Anatomical and Physiological Basis for cardiac …Anatomical and Physiological Basis for cardiac...
Transcript of Anatomical and Physiological Basis for cardiac …Anatomical and Physiological Basis for cardiac...
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Anatomical and Physiological Basis for cardiac robotic surgery
Nicolas BonnetLa Pitié-Salpêtrière, Paris, France
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The thorax is the upper part of the trunk
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Thorax
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The Thorax…
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The heart is in a jail, the thoracic skeletton
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How to work on the heart
• Go inside
• Reach the target(s)
• Do the cardiac procedure
The procedure is a choice of the best approach regarding the cardiac target, the tools avaliable designed for the procedure and the predictable and unpredictable difficulties.
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Sternotomy• Full acces in direct
vision• Redo surgery• Combined surgery
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Ministernotomies are sternotomies
• General anesthesia, surgeon, saw…
• Direct but limited vision to some parts of the heart
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Classical subxyphoid –Marfan-
• Easy• Fast• Direct vision
– Pericardium– RV
• Improvment of vision with video• Difficult in obese or
redo patients
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Old incisions– Larrey Rehn-,- Parsonnet-
• Real surgery
• Best vision on the RV
• Difficult to close
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New subxyphoid aproach
• Blind technic: Percutaneous
• Safe technic:Videoscopic approach with a translucent self-cuting trocard -Ethicon™-
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Left minithoracotomy
• Easy and Fast
• Direct vision– Pericardium– LV ± LA
• Improvment of vision with video
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Anterior minithoracotomy, pericardium, pleura and lung
• Pericardium is « under skin »
• Lung is away –no selective intubation-
• Pleura can be avoided• Take care to the ITA
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Right minithoracotomy• Easy and Fast• Direct vision
– Pericardium– RA ± LA
• Improvment +++ of vision with video
• Rescue for endocardial access through RA or LA
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Thoracoscopy
Click on image to start videoCourtesy of Dr. Omar Lattouf
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Target and entry point, a geometrical problem
If the tools are rigid,
the pericardial approach
depends on the target
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More degree of freedom (dof)new tools and robotic surgery
Click on image to start videoCourtesy of Dr. Omar Lattouf
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Surgical approach, a geometrical problem.
Inside - Outside
Target / tangential
Target / orthogonalEntry point
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Planification, Virtual Reality• Preoperative data• Simulation• Multimodal vision• But what about:
– Motions (heart, ventilation…)
– Deformations (patient on the right side…)
• To directions– Real time
reconstructions– modelisations
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How to see the target(s)and the danger(s)
• Direct vision• Videoscopy
– Rigid– Flexible
• X-ray• Echo• EP, magnetic
navigation• NMR…
• In the futur– Multimodal vision– Enhancement of
the reality (recalage)
Multimodal operating room and team
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Wath is surgery, wath is not?
• Surgery– General
anesthesia– Surgeon– Operative room– Incision
– Direct vision of the target and the danger
• The future– Anesthesiologist
choice– Trained
physician– Multimodal
room– The best
approach• Safe• Fast..
– Multimodal vision
• No surgery– Local
anesthesia– Cardiologist– EP lab– Percutaneous
– X-Ray, Ultrasound… no direct vision of the target
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Heart-Lung
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Heart
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Heart
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Heart
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Heart
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4 Chambers
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4 valves
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Diastole
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Systole
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Aortic Valve
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Mitral Valve
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Mitral Valve
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Aortic root
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Valvulopathy• Stenosis
• Insufficiency
• Valvuloplasty
• Valve Replacement
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LV
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LV
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RA
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RVTricuspide
Valve
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Left main
coronary rtery
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Left Anterior Descending
Artery
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Fat, grooves and coronary arteries
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Coronaropathy
• Etiology: atherosclerosis
• Symptoms:– Angina pectoris– Myocardial Infarction– Heart Failure
• Revascularization– Percutaneous angioplasty– Coronary artery bypass grafting
(CABG)
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HisBundle
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Left Bundle Branch of theHis
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Atrio-Ventricular Block, Cardiac pacing
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Pericardium
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Physiology – W Harvey
OD
VD VG
OG
AP
Ao
TricuspideTricuspide
PulmonairePulmonaire
MitraleMitrale
AortiqueAortique
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Bloc CP
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