Da Vinci is an enormous box fed by cables that directs a 7-foot tall, spider-like assembly of arms, hinges, lights and gears. Despite its bulk, the da Vinci Surgical System powers two small wrists that perform with the sensitivity of a human hand. Yet while it is remarkable, it is only an instrument, leaving the physician responsible for the perfect execution of each step of a complex operation.

The robotic system’s name reflects the inspiration of the Renaissance innovator Leonardo da Vinci. Among physicians, da Vinci is known for his groundbreaking discoveries of heart anatomy; he gave the mitral valve its name after the peaked hat worn by church bishops.

The miracle of the robotic da Vinci is that it translates the surgeon’s hand movements to miniature mechanical arms able to thread their way into a patient’s heart and operate from the inside.

Traditional open-heart surgery requires surgeons to make an 8- to 10-inch incision by sawing through the sternum and opening the rib cage to gain access to the heart. This method is painful for patients and requires several weeks of recovery.

With the da Vinci Surgical System, surgeons make a 3-inch incision between ribs on the right side and two other incisions of less than a half-inch on the top of the chest before inserting the robotic arms. One arm holds a slender camera that projects 3-D images onto a monitor in front of the surgeon, seated at the console. The lens system magnifies filament-sized arteries and veins to the size of drinking straws. The other arms hold the instruments, whose mechanical wrists are operated by complex cables and can transmit the dexterity of the surgeon’s forearms and wrist into the chest.

Seated at the computer console several feet from the operating table, the surgeon views the magnified, 3-D image and moves the robotic arms using two mechanical levers.

Da Vinci’s robotic arms are steadier than the coolest surgeon’s, eliminating tremor in the critical heart spaces where millimeters matter. The robotic wrist holds the curved needle while the surgeon moves it to reinforce the valve flap with sutures.

Minimally invasive, robotically assisted valve repairs mean patients avoid sternotomy. They recover faster and with less pain.

“The robotic arm has vision, accuracy, precision and dexterity that allow us to do a better operation,” Nifong said. “It’s the only way to operate inside the heart laparoscopically.”

Years of diligence in developing the robotic arm have enabled ECU to lead successful studies for the U.S. Food and Drug Administration, under the leadership of Dr. W. Randolph Chitwood Jr., chairman of the department of surgery and chief of cardiac surgery. He is also director of the Heart Center of University Health Systems of Eastern Carolina.

Today, the ECU medical school is a leader in robotics and one of only a few sites training surgeons to use da Vinci for other procedures, such as appendectomies, hysterectomies and gastric surgery for obesity. The Brody School of Medicine is the only place in the world training physicians to perform the robotic heart valve operation.

Two da Vinci systems are in use at the medical center. One is at ECU’s surgical training center and the other is used for operations at Pitt County Memorial Hospital. The units cost about $1.3 million each.

Heart murmur, leaky valve
Most people never hear of the mitral valve until they have a problem with it. But it’s the workhorse of the heart valves, blocking the lower left chamber shut every second or so while freshly oxygenated blood rushes out to the rest of the body.

The valve, a veil of skin about 2 inches wide, also opens with each heartbeat to shepherd newly oxygenated blood into this chamber, or ventricle, from the lungs.

A working mitral valve prevents blood from seeping back into the upper left chamber, or atrium, from where it would have to be pumped out, again — inefficient for the heart and exhausting for the person.

Doctors detect mitral valve bulges or leaks when they hear a heart murmur, or a strange heart sound. Valve leakage can appear at birth or occur as a result of disease. Other malfunctioning valves occur when the skin becomes hardened by disease such as rheumatic fever.

Traditionally, the valve was replaced with a pig valve or other suitable substitute during an open-chest procedure that left patients with an incision several inches long closed by a row of staples down their chest.

“It’s a totally different operation than we were taught,” said Nifong, 40, assistant professor of cardiothoracic surgery. “Our incisions are smaller, only 4 centimeters. At first, you had to believe in the technology, but once you saw how well the patients did, you got the energy to keep pushing forward.”

In November 2002, the FDA granted full approval for da Vinci’s use inside the heart. Cardiac surgeons at ECU led the national multi-center clinical trial; Chitwood served as principal investigator, performing 51 mitral valve surgeries using the da Vinci system, more than any other cardiac surgeon in the world.

With the FDA approval, doctors across the nation have the green light for adopting robotics for heart valve surgeries. Soon, they will likely start performing other heart surgeries, such as to repair septal defects, or holes, between heart chambers.

A separate FDA trial is now studying da Vinci’s use for coronary artery bypass grafting, or CABG. The ECU medical school is also participating in these studies.

The da Vinci Surgical System is made by Intuitive Surgical of Sunnyvale, Calif., a medical technology company. Other companies, convinced of robotics’ strong future, are pursuing their own surgical robotic devices.