MINIMALLY INVASIVE CORONARY ARTERY BYPASS FEATURING DA VINCI ROBOT TRINITY MOTHER FRANCES HEALTH SYSTEM TYLER, TX November 2, 2006

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1 MINIMALLY INVASIVE CORONARY ARTERY BYPASS FEATURING DA VINCI ROBOT TRINITY MOTHER FRANCES HEALTH SYSTEM TYLER, TX November 2, :00:15 ANNOUNCER: Over the next hour, live from Trinity Mother Frances Health System's Center for Advanced Surgery and Technology in Tyler, Texas, you will learn now surgeons use the da Vinci robot to perform a minimally invasive coronary artery bypass. The da Vinci is a laparoscopic surgical system that integrates the skills of the surgeon with the precision of the robot. The surgeon makes all the movements, but the robot makes those movements more precise. It allows the surgeon greater range of motion in very small places within the body. You may questions at any time during the program by clicking the MDirectAccess button on your screen. You can also make an appointment or make a referral. This program represents Trinity Mother Frances Health System's Center for Advanced Surgery and Technology's ongoing efforts to bring the latest developments in health care to the community. 00:01:05 WILLIAM E. COHN, MD: Welcome to the Center for Advanced Surgery and Technology here at Mother Frances Hospital in Tyler, deep in the heart of Texas. Thanks a lot for joining us. Tonight you'll see the third in a series of live surgical broadcasts. Tonight's broadcast is a minimally invasive coronary artery bypass done with surgical robotics without splitting the breastbone and without stopping the heart. I'm Dr. Billy Cohn. I'm a heart surgeon and the director of minimally invasive surgical technology at the Texas Heart Institute in Houston. I'll be moderating. Behind these doors, the surgeon, Dr. William Turner, who's been a good friend and colleague for 20 years, is doing the operation. He started about an hour ago. We're going to go and see what he's doing, but before we do, for those of you at home who have good questions or comments, we encourage you to send them to us. Simply type your question and hit the MDirect button on your screen, and we'll try to get to it during the broadcast. Okay? So let's go in, see what Bill's up to and how he's doing. Put your masks on and let's go. Hey, Bill. 00:02:10 WILLIAM F. TURNER, JR, MD: Hi, Billy. 00:02:11 WILLIAM E. COHN, MD: Hey, how's it going, man? 00:02:13 WILLIAM F. TURNER, JR, MD: It's going very well. 00:02:14 WILLIAM E. COHN, MD: Now, you've been at this for about an hour, right? 00:02:16 WILLIAM F. TURNER, JR, MD: That's right. We've been -- 00:02:17 WILLIAM E. COHN, MD: Why don't you tell us a little bit about your patient and what you're doing, what's gone on so far.

2 00:02:21 WILLIAM F. TURNER, JR, MD: Our patient is a 69-year-old gentleman that has a very complex blockage in the artery on the front wall of the heart. It's a type of blockage that's going to best be managed with a coronary artery bypass operation. Thus far, what we've done is we've taken an artery down from below the chest wall and we're going to use that vessel to bypass the blockage on the front wall of the heart, thereby restoring blood supply to that area of the heart that previously was not getting enough. 00:02:47 WILLIAM E. COHN, MD: All right, great. And you've used the robot for that, so you haven't had to make a big cut on this patient's chest at all. In fact, I see you've made no cut. 00:02:53 WILLIAM F. TURNER, JR, MD: That's right. So far, we've not made any incisions in the patient's chest, and we've done everything with the robot. Now, the robot, as you can see here, consists of three different parts. The first part is the console, which I'm looking at right now, and it has two separate hand motions which I'm moving on camera. Can the audience see that? 00:03:14 WILLIAM E. COHN, MD: Yeah, that's a beautiful image. 00:03:15 WILLIAM F. TURNER, JR, MD: Okay. The hand motions are transmitted to a computer processor, where they're digitized, and then they're relayed in real time to the telemanipulator of the robot, so the robot actually replicates all of the motions that I make with my left and right hand. 00:03:32 WILLIAM E. COHN, MD: And for those people watching at home, those little jaws of that robotic hand are about a quarter of an inch. They're very, very small. 00:03:38 WILLIAM F. TURNER, JR, MD: And therein lies the beauty of the technology. It allows us to get into small cavities, particularly the pericardium, where you can see the heart here, without putting our big hands in there and thus allows us to operate through very small incisions. Billy, let me show you a little bit of the anatomy here before we get started with the operation. 00:03:56 WILLIAM E. COHN, MD: All right, great. 00:03:57 WILLIAM F. TURNER, JR, MD: This big vessel right here is called an internal mammary artery, and that's going to be our conduit, or the material that we use to bypass the blockage in the anterior wall of the heart. Now, the heart you can see at the bottom of the screen here, will be beating throughout the operation, and I think you can appreciate this glistening -- kind of this straight line that you can see -- 00:04:23 WILLIAM E. COHN, MD: On the surface of the heart there. 00:04:25 WILLIAM F. TURNER, JR, MD: -- in the center of the screen right here. 00:04:26 WILLIAM E. COHN, MD: Sure. 00:04:27 WILLIAM F. TURNER, JR, MD: Now, that's called the anterior descending artery. That's the most important artery on the heart, and when we effect the bypass there, we're going to restore the blood supply to the anterior wall. 00:04:36

3 WILLIAM E. COHN, MD: That's the artery that has a blockage in this gentleman. 00:04:38 WILLIAM F. TURNER, JR, MD: That is correct. 00:04:40 WILLIAM E. COHN, MD: And it's amazing. You've gotten to this point in the operation, again, to reiterate, without making an incision on the patient's chest. 00:04:44 WILLIAM F. TURNER, JR, MD: That's right. Thus far, it's completely a closed chest procedure. So what I thought we'd do right now is we're going to divide the mammary artery and kind of make our preparations, our initial preparations if you will, to do the bypass. So if I could get a clip in my left hand, please. 00:05:03 WILLIAM E. COHN, MD: So the different instruments can be changed out rapidly. There you've taken the cautery, the little spatulated tip that allows you to cut with electricity, and replaced it with a clipping instrument. You've got scissors and graspers and a variety of tools. 00:05:16 WILLIAM F. TURNER, JR, MD: And forceps. And all of these are scaled down to...i would estimate about the size of a dime or maybe a little bit smaller. 00:05:24 WILLIAM E. COHN, MD: Truly amazing technology. And can you comment for the people at home about the 3-D videoscopic visualization? 00:05:30 WILLIAM F. TURNER, JR, MD: The visualization that I can see, and the people in the audience can't really appreciate it on a two-dimensional screen, but I have threedimensional vision, so I can appreciate depth between two different structures. That greatly facilitates the precision of the operation and the mechanisms and motions that I'm able to do with the robot. In addition, you've got 32 times the magnification that you would normally see. Now, this here is a clip, and it's just called a Hemoclip, and basically what we're going to do is we're going to put one here and then we'll take two more. We're going to divide the mammary artery, and I think it'll be pretty obvious to the audience once we do where the rest of the operation is going to go. 00:06:17 WILLIAM E. COHN, MD: Okay, great. Now, this particular robot is the latest and greatest by Intuitive Surgical. This is the da Vinci S. 00:06:27 WILLIAM F. TURNER, JR, MD: This is -- Mother Frances Hospital was one of the first in the country to obtain this particular robot, and it is a much streamlined version from the earlier prototype. The arms are smaller, the motions are much more precise, they're more streamlined. And it's much easier to use this robot than the previous generation was. Let me get one more clip, please. 00:06:53 WILLIAM E. COHN, MD: And this robot, like every generation of Intuitive Surgical robots, has tremor filtering. Can you tell us a little bit about that? 00:06:58 WILLIAM F. TURNER, JR, MD: Well, what this does, it has built-in mechanisms whereby a patient or a human being's natural tremor is filtered out so that every motion I make is very precise, and it filters out the natural human element, if you will. So every move that I make, as you can see, are very precise, and they're without any type of natural tremor whatsoever. 00:07:21 WILLIAM E. COHN, MD: Yeah, it's beautiful. 00:07:23

4 WILLIAM F. TURNER, JR, MD: Okay, may I have the scissors, please? 00:07:26 WILLIAM E. COHN, MD: Now, see here you pull out the clipping instrument and replace it with a -- with a pair of scissors. It's like a Swiss Army robot, isn't it? 00:07:34 WILLIAM F. TURNER, JR, MD: Something like that. There we go. Okay, so here's our scissors, and we're going to divide this mammary artery. 00:07:47 WILLIAM E. COHN, MD: Beautiful. 00:07:51 WILLIAM F. TURNER, JR, MD: Okay, let me get another clip, please. 00:07:54 WILLIAM E. COHN, MD: Actually, we're already starting to get some questions from some of the viewers. Is now an opportune time? 00:07:58 WILLIAM F. TURNER, JR, MD: Sure, Billy. 00:08:01 WILLIAM E. COHN, MD: Actually, Mark Lanue wants to know: how much does one of these robots cost? That's an interesting question. 00:08:07 WILLIAM F. TURNER, JR, MD: I'm going to defer that to our administrators, and they're quite expensive. 00:08:11 WILLIAM E. COHN, MD: Yeah, let's forgo that one. Maybe he's in the market for buying one, I don't know. 00:08:20 WILLIAM F. TURNER, JR, MD: Okay, so we're going to put this mammary artery close to where we're going to be doing the operation. 00:08:26 WILLIAM E. COHN, MD: I see, so you use the clip just to stabilize it's position to keep it from twisting. 00:08:30 WILLIAM F. TURNER, JR, MD: Exactly. 00:08:31 WILLIAM E. COHN, MD: I see. 00:08:40 WILLIAM F. TURNER, JR, MD: That also is going to help us locate the mammary artery when we go open. So now what we'll do is we're done with the actual robot part of the operation. This is the bed of the mammary artery. This is what we dissected free earlier. This is where it lies in its natural state. 00:08:55 WILLIAM E. COHN, MD: That's where you peeled the artery from. 00:08:56 WILLIAM F. TURNER, JR, MD: That's exactly right. So now we're done, and Billy, I'm going to go wash my hands and we're going to proceed to the open part of the operation. 00:09:03 WILLIAM E. COHN, MD: All right, great. Well, while Dr. Turner's scrubbing for the operation, I'm going to keep asking the questions. you'll be able to hear me, I suspect, right? So, Bill, can you still hear me? 00:09:15 WILLIAM F. TURNER, JR, MD: Yes, sir. 00:09:16

5 WILLIAM E. COHN, MD: All right. Well, here's a question from Janet Torpy. She says she's seen infomercials -- she must be a local -- local person. She's seen infomercial about robotic heart surgery at Mother Frances Hospital and wants to know if you did the operations on these patients. 00:09:32 WILLIAM F. TURNER, JR, MD: I did. Both of those were my patients. The first one was a patient of Dr. Bob Karny, who's the cardiologist on this particular case. The second one's a gentleman from Fort Worth who found me on my website, heartsurgery-tyler.com. He called me on a Friday, we had him in to Mother Frances on a Monday. He was able to go home three or four days after surgery. I'm having a little bit of audio trouble here, so -- 00:09:56 WILLIAM E. COHN, MD: All right, why don't you go scrub your hands and -- 00:09:58 WILLIAM F. TURNER, JR, MD: And I'll be back. 00:10:02 WILLIAM E. COHN, MD: If you want to get some good footage of perhaps the robotic setup at the bed, if you could swing over and show that. And here's the robot being moved away from the patient. You can see, it's -- it's on wheels, so you can bring it in when you need to use it and then roll it away for the second part of the procedure, which will be done through a small incision between the ribs. Now, can Dr. Turner still hear me? Billy, can you hear me? No, okay. Now, you sort of regroup here and get everything set up for the open phase of the operation. With the robot out of the way, they prep the field just for a re-- as for a regular procedure, but now, when he opens the patient, half the operation's already been done. And based on where his ports were -- you can see the -- I don't know if you can appreciate the port incisions on the patient's chest. Can you get a good zoom-in shot on that on camera one? Can you get tighter on those? Every one of those is going to be covered by a regular Band-Aid. These incisions are about a half of an inch. The really uncomfortable thing about an operation isn't so much the skin incision, it's banding and moving muscles around and spreading ribs and whatnot. And you can see that the ribs haven't been spread, the muscles haven't been disrupted. It's just these small, little incisions that we cover with a Band-Aid. And that's one of the beautiful advantages of surgical robotics. Now, Bill won't say this because he's too modest while he's in the room, so I'll talk about it while he's gone. He's been a real leader in this field in this part of the country and actually in the world. Not only this but also in beating-heart bypass. Bill's been doing beating-heart coronary artery bypass -- that's coronary artery bypass without stopping the heart -- for a number of years and has published recently I saw a paper saying he's done 1,700 of them, so he's definitely one of the most experienced off-pump bypass surgeons in the country. And he's really contributed significantly to this field. And combining that technology and robotics, you get a really nice approach and a really nice solution for patients just like this. The patient has the mammary harvested with the robot, then gets a small cut and has the two arteries sewn together without the heart-lung machine, without having the heart stopped, and without some of the ramifications of going on the heart-lung machine. I'm sure Dr. Turner will address those issues when he comes back in the room. Talking to Bill, apparently he's done 130 of these. We'll get him to comment on his learning curve as soon as he gets back in the room. But I know that he's come quite -- advanced the technique significantly to now, where the procedure takes dramatically less time. This mammary harvest took him about 30 minutes to do, which is about the same amount of time that it takes to do an open mammary harvest. And surgical robotics has varying adoption around the United States. There are some centers that don't do it, some centers that dabble in it. Clearly there's a

6 learning curve, but when you get to the point where you can take the mammary down in 30 minutes, arguably it's not adding anything to the length or complexity of the procedure and really does provide some real patient benefit. Elsewhere in the country and in the world now, there are people that are trying to do the entire procedure without doing an incision. We'll get Dr. Turner to comment on that. Bill, tell me about the evolution of this and -- and where you are in that evolution, where you see it all headed. 00:13:26 WILLIAM F. TURNER, JR, MD: About 10 years ago, Billy, as you know, we started to approach these operations without the use of cardiopulmonary bypass. Cardiopulmonary bypass itself can be responsible for as much as 70% of the complications associated with the coronary artery bypass procedure. Once we'd eliminated that -- and we've got a series now of over 1,700 patients -- we needed to address what we call access trauma. Taking the vein out of the leg, we've addressed that with what we call endoscopic vein harvesting, but with the chest, we needed to do away with the sternotomy. In other words, that sternal saw whereby you make about a foot-long incision down the front and transect the breastbone. So the next step is if we can do these operations through a small thoracotomy incision over on the side, that eliminates the sternotomy incision and allows people to get back to their regular activities in a much shorter timeframe. I think some of our patients have actually gone square-dancing the third day after surgery. One of our more famous ones that made the infomercial. But either way, if you have a sternotomy incision, we'd recommend that the patients don't lift anything heavier than a telephone or a soup spoon for about six to eight weeks. 00:14:39 WILLIAM E. COHN, MD: Or even drive a car for that matter. 00:14:41 WILLIAM F. TURNER, JR, MD: Exactly. WILLIAM E. COHN, MD: Sure. Well, I think it's true to say -- it's true to say that the conventional operation works very, very well for many patients, however. 00:14:51 WILLIAM F. TURNER, JR, MD: Absolutely. Absolutely. 00:14:52 WILLIAM E. COHN, MD: But avoiding the heart-lung machine is very advantageous in some of the older and sicker patients and may offer some subtle benefits in just about every patient. Okay, how are you going to decide where to make the incision here? 00:15:06 WILLIAM F. TURNER, JR, MD: Where we make our incision, Billy, is going to be in the left lateral chest. This gentleman has had a previous mastectomy, and we'll go -- can you raise the table a little bit, please, Peter? Below where the left breast was, if you will. That's great. 00:15:30 WILLIAM E. COHN, MD: It's almost like opening a Christmas present and you already know what it is. You've already looked inside his chest and know what everything looks like, so no surprises when you make your incision, huh? 00:15:38 WILLIAM F. TURNER, JR, MD: Well, we have the advantage of knowing what the anatomy is, where the coronary artery is, and also the length and status of our conduit. I think you can appreciate it that it was a rather nice size internal mammary artery. So we're going to take this a layer at a time. Here we're going through some muscle. 00:16:06

7 WILLIAM E. COHN, MD: Just go ahead. Don't worry about it. He'll position himself around you. Okay, so the incision is really not much longer than your finger. 00:16:19 WILLIAM F. TURNER, JR, MD: That's right. 00:16:21 WILLIAM E. COHN, MD: Can I ask you some questions that people have submitted while you're doing this portion? 00:16:24 WILLIAM F. TURNER, JR, MD: Sure. Sure. 00:16:26 WILLIAM E. COHN, MD: All right. Here's a question from Louie in Austin. He wants to know: how extensive is the training necessary for this robotic equipment? 00:16:36 WILLIAM F. TURNER, JR, MD: The way that we approach this, Billy, is there are various training centers around the country, which I'm proud to say that Mother Frances is now one. We've been designated a center of excellence. And what one do- - what one does, rather, is attend a series of didactic lectures followed by laboratory studies, working on cadavers, and then most surgeons have extensive experience taking down a mammary artery, so part of it is -- we've already been trained to do. 00:17:12 WILLIAM E. COHN, MD: Here's a question maybe from a heart surgeon. He wants to know: can you show us where your ports are located and explain how the robot's moved into position? And that's from Mark. I actually have -- if you can cut to that PowerPoint slide, there's a little picture that you prepared, Bill. You can see there, with the pink lines on the patient's chest in this photograph, where the left and right internal mammaries, or LEMA and REMA are. The X's are where the ports went in for the mammary harvest. You can see just three lines straight in a row, and it actually was very, very slick how your team set that up. In fact, if I may say so, I've been really impressed with the whole system here of the hospital and this program and team that you've put together. Is now an opportune time to -- to name a few of them and point them out or would you like to do that later? 00:18:04 WILLIAM F. TURNER, JR, MD: Sure, Billy, I think this is a great time while we get set up with our equipment at the head of the table. We're very proud of what we've done here at Mother Frances Hospital, which was the first institution to bring heart surgery to east Texas. We started our robotics program in February of 2004, and a lot of these people have been with me for about 15 years. Terry Krause is helping set up the stabilizer here. We've got Shelly, who's my first assistant. We've got Chris, who is the first scrub to my left. The head -- 00:18:41 WILLIAM E. COHN, MD: Wave when they say your name, okay? Wave when Bill introduces you so we can see at home. 00:18:47 WILLIAM F. TURNER, JR, MD: At the head of the screen, we have our anesthesiologist, the baddest guitar player on the planet, Peter Ciriani. And we've got one or two of our best standby profusionists, Darryl Miller, in the back. We do a lot of off-pump, but when we do go on pump, they do a really nice job for us, and we're glad to have them. 00:19:09 WILLIAM E. COHN, MD: All right, great. 00:19:16 WILLIAM F. TURNER, JR, MD: Okay, so we're making our initial preparations to -- to do the operation. This is a little retractor that we're going to use to spread the ribs,

8 and it's important to note that we have not broken any bones here or transected any bony structures. There's no disruption of the thoracic skeleton, if you will. 00:19:43 WILLIAM E. COHN, MD: And there your incision is right over the place where you opened the pericardium, or the heart sac, so it seems to be in perfect position. Can you see the mammary through that incision, where it was? 00:19:52 WILLIAM F. TURNER, JR, MD: Yes, we can. And hopefully, when we get set up here, the rest of you will be able to see it as well. 00:20:00 WILLIAM E. COHN, MD: So you can see, just relative to his hands, how small that incision is and how little you have to spread the ribs. You hardly spread them at all. It used to be -- remember, in the '90s, when we were doing the mid-calf operation, we'd make the same cut, but then we would spread it widely to be able to take the mammary down, and the robot's really taken away all that, hasn't it? 00:20:21 WILLIAM F. TURNER, JR, MD: Well, we had to, Billy. And I know a lot of surgeons have got a lot of neck and back trouble from trying to take the mammary down through this small incision, and I know that the robot, this technology, has made it much easier, and I really think we get a better conduit and a better grasp by taking it down with the robot because we know it's longer, and I think you can see that it's going to be a better size and caliber. 00:20:46 WILLIAM E. COHN, MD: Yeah, we were just talking about before -- before we came on about how -- we could take it down, take the mammary off the back of the breastbone from the incision to the head relatively easy without the robot, but doing it before -- below the incision was almost impossible. And again, the patients had so much discomfort from how hard we had to tug on the chest wall. 00:21:05 WILLIAM F. TURNER, JR, MD: Exactly. Okay, how are we doing on the visualization there? Will you hand me the other towel, please, Chris? 00:21:13 WILLIAM E. COHN, MD: See if you can get that thoracoscope in there. Do you have the image from that? Okay. There you go. If you can see that monitor and position it. Well, we'll get that working in a second. So how's the visualization of the LAD through that incision, Bill? 00:21:35 WILLIAM F. TURNER, JR, MD: Well, I can see beautifully. I don't know if you're attuned to my camera or my head cam... 00:21:41 WILLIAM E. COHN, MD: Can you wipe off the thoracoscope? You've got some slime on the end of it. And -- Boy, but you got a great view of the LAD there, it's right in the center of the field. 00:21:53 WILLIAM F. TURNER, JR, MD: It is. It's -- 00:21:56 WILLIAM E. COHN, MD: Now, it's wiggling a lot, so tell me about the evolution of cardiac stabilization and coronary stabilizers. 00:22:04 WILLIAM F. TURNER, JR, MD: Well, as you know, Billy, many of us in the very beginning took, oh, I guess cooking instruments. I know that I did. I took a barbecue fork and cut out the middle wing of it out in my garage, and we fashioned that into a stabilizer to hold the anterior descending artery still. And fortunately, as result of a

9 lot of the work that you have done, we now have what we call commercially available stabilizers that do a much better job and are reusable, so it's really made our life a lot easier. But as you mentioned, we're going to need some type of device to hold this artery still because as you can readily appreciate, it's going to be diff-- difficult to sew that on a moving heart without some type of stabilization. 00:22:55 WILLIAM E. COHN, MD: So the -- for those of you that aren't medical, you know, these arteries are about 2 mm in diameter, and they're very, very delicate, almost like cooked pasta. And to sew that artery peeled off the back of the breastbone to that little artery you see wiggling there would be almost impossible to do with the kind of precision necessary. So traditionally in heart surgery, you put the patient on the heart-lung machine, pack the heart in ice, and so the heart's actually stopped and immobile to allow you to do a precise anastomosis. Here, rather than stopping the heart, Bill's going to put a stabilizer on it just to hold that one portion of the heart still, the coronary artery, to allow him to sew with precision. You can see how big the artery is, it's just a little, stringy thing when not looked at under magnification. He's got to sew that to the little artery on the surface of the heart with about 10 teeny, little stitches. And it really takes some additional technology, but you'll see that technology now. Can you try wiping off the end of the thoracoscope one more time? Maybe put some anti-fog on it, see if we can optimize that image. It still looks really blurry. Is it a focus problem or is it blurred? Do you have a monitor that you can see it on? I don't see it either. Well, anyway, we've got really good views from -- from your head-cam there, Bill, and also from the overhead cam. We'll keep working with that scope to see if we can get a tighter shot. Of course, it worked great in rehearsal, but that's the way it always goes. But that's a beautiful view there. and those little green plastic things are spring-loaded clips to temporarily stop flow down the mammary artery. Because remember, the mammary artery's a branch of the subclavian, and it's got brisk pulsatile bright red flow through it. Without those little plastic clamps on it, it'd be spraying blood all over the place, wouldn't it? 00:24:54 WILLIAM F. TURNER, JR, MD: Which is obviously what you want if you're going to restore the blood supply to the front wall of the heart. Can I have this attachment, Chris? 00:25:00 WILLIAM E. COHN, MD: Do you want comment on how mammaries to the LAD do over time and why it's such a superb technology? 00:25:05 WILLIAM F. TURNER, JR, MD: I think that's an excellent point. In the beginning of coronary artery bypass surgery, about 30 years ago, we used saphenous vein, or the vein from the leg, which we still use today for arteries on the back of the heart and also for the right side. Now, with the front of the heart, that artery is the most important one, so obviously, if you can put a conduit there that's going to stay open longer, you're going to improve a patient's long-term survival and freedom from what we call adverse cardiac events or recurrent chest pain. Now, we know from studies done at the Cleveland Clinic that this internal mammary artery, which I'll try to show you right here, when you use that as a bypass material, it has about a 92% chance or greater of being open 10 years after the operation. So obviously, that's the material that you want to use as opposed to the -- to the saphenous vein. Now, what we're doing now is we're going to try to get our little stabilizer in this little hole, and it's going to kind of help us hold the heart still. 00:26:09 WILLIAM E. COHN, MD: So this is the Guidant stabilizer, right? The Acrobat? 00:26:12

10 WILLIAM F. TURNER, JR, MD: Actually, this is the Medtronic device. 00:26:14 WILLIAM E. COHN, MD: Oh, Medtronic, okay. My bad. Sorry, Medtronic. Sorry, Guidant. Okay, and so you've tightened it into position. 00:26:27 WILLIAM F. TURNER, JR, MD: Now, you'd never eliminate all the motion of the heart, but I think you can appreciate, through my head-cam, that we've got pretty good stability here. This is where we're going to sew. 00:26:37 WILLIAM E. COHN, MD: Let's see. Yeah, that's really nice. That's really nice. 00:26:40 WILLIAM F. TURNER, JR, MD: That's a nice section of artery. Now, the next thing we're going to do is we're going to clean this artery off a little bit. 00:26:46 WILLIAM E. COHN, MD: And for the non-surgeons who are watching, that stabilizer, a version of the Octopus, uses suction to grip the surface of the heart, the epicardial surface, and really holds it quite still. In fact, that's beautiful. I've never seen one work better. 00:27:03 WILLIAM F. TURNER, JR, MD: And again, you're going to get some motion here, but it's -- it's much, much less than what you would do if you had no stabilizer, and it's very -- it's very workable. We can do this with a very high degree of precision. 00:27:17 WILLIAM E. COHN, MD: Now, these are just like rubber bands on a -- on a blunt metal needle, silicone elastic tape. 00:27:21 WILLIAM F. TURNER, JR, MD: Right. We're going to temporarily occlude the flow of this vessel so that we can have a relatively dry field to sew this graft on. Now, another thing we're going to do, Billy, which I think is very important, is we're going to use an intraluminal shunt that will maintain blood flow down to the anterior wall of the heart. In other words, we're not going to completely occlude this for an extended period of time. 00:27:50 WILLIAM E. COHN, MD: I see. 00:27:51 WILLIAM F. TURNER, JR, MD: And I'll show you what we mean here. 00:27:53 WILLIAM E. COHN, MD: See if you can move the thoracoscope to center the field and get a really nice shot of that. The thoracoscope image is now good. Wow, look at that. So you can see, the silicone elastic tape is around the artery now. 00:28:10 WILLIAM F. TURNER, JR, MD: Okay, Billy, we're going to prepare the mammary artery now and kind of get it ready for -- for bypass. Okay, you have blues. Just scissors. 00:28:25 WILLIAM E. COHN, MD: And so you're just going to cut off those last clips and just sort of splay it open to make a hood, right? 00:28:29 WILLIAM F. TURNER, JR, MD: That's correct. Okay, if I could have the Castroviejo. Good. 00:28:44 WILLIAM E. COHN, MD: You know, it's interesting, I've never heard a good explanation for why the mammary artery doesn't develop atherosclerosis because

11 blockages plague vessels all over the body: the coronary arteries, the arteries to your brain, the carotid arteries, the leg arteries, never seems to involve this mammary artery. Oh, there you can see, it's got brisk, beautiful flow. 00:29:02 WILLIAM F. TURNER, JR, MD: Yeah, I want to show you -- I'm going to flash this bulldog and -- 00:29:05 WILLIAM E. COHN, MD: Yeah, look at that. 00:29:06 WILLIAM F. TURNER, JR, MD: -- I think you can see that -- 00:29:07 WILLIAM E. COHN, MD: That's just what the heart needs. 00:29:10 WILLIAM F. TURNER, JR, MD: There's a lot of theories advanced for that, Billy. I think one of the reasons is it's a completely elastic artery as opposed to some of the others that are -- have a muscular content. It has a completely continuous internal elastic lamina which is very fancy terminology but basically, it's virtually resistant to atherosclerosis for at least 10 years. 00:29:32 WILLIAM E. COHN, MD: And unlike a stent, it not only treats the lesion that you're there to bypass but it protects against the formation of new lesions over the life of the graft, doesn't it? 00:29:43 WILLIAM F. TURNER, JR, MD: That's correct. Okay, we're going to go ahead and open this artery. 00:29:49 WILLIAM E. COHN, MD: Okay. 00:29:51 WILLIAM F. TURNER, JR, MD: And you may see some blood here in the field, and then we're going to put in our intraluminal shunt. 00:29:59 WILLIAM E. COHN, MD: And so the tape is still loose right now, or is it down a little bit? 00:30:02 WILLIAM F. TURNER, JR, MD: I've got it snug. 00:30:03 WILLIAM E. COHN, MD: Okay. All right. And again, this blood vessel's one and a half, two millimeters in diameter. Very teeny. And you're just going to make a slit in it. 00:30:32 WILLIAM F. TURNER, JR, MD: Sure. 00:30:36 WILLIAM E. COHN, MD: Could you clean off the fluoroscope -- the endoscope one more time? Thanks. Okay, now you're just lengthening the incision. You've got pretty good blood control already, don't you? 00:30:48 WILLIAM F. TURNER, JR, MD: Yeah, we do. 00:30:49 WILLIAM E. COHN, MD: Are you going to put a shunt in? 00:30:51 WILLIAM F. TURNER, JR, MD: How are we doing at the head of the table, Peter? 00:30:53 PETER CIRIANI: Doing just fine. Blood pressure is 120/50. 00:30:57

12 WILLIAM F. TURNER, JR, MD: Would you rotate it towards Shelly a little? Yeah, that's fine. No, that's perfect. 00:31:08 PETER CIRIANI: Saturation is 99%. 00:31:10 WILLIAM F. TURNER, JR, MD: Okay, let's -- 00:31:11 WILLIAM E. COHN, MD: So the patient's doing beautifully. The LAD's temporarily occluded now and you've got it open. And here goes the shunt. You want to tell us a little bit about when you shunt and when you don't? 00:31:23 WILLIAM F. TURNER, JR, MD: I like to shunt if -- let me get this in and I'll tell you. 00:31:33 WILLIAM E. COHN, MD: Just a little plastic tube that just goes into the coronary artery so you can let up on the tape and let the blood flow yet still not have blood coming out through the incision. 00:31:43 WILLIAM F. TURNER, JR, MD: I think, Billy, paradoxically enough, the worse the lesion, the less you need a shunt. 00:31:47 WILLIAM E. COHN, MD: Right. Sure. Because they're used to not having blood supply. 00:31:50 WILLIAM F. TURNER, JR, MD: That's right, the heart is conditioned, if you will. 00:31:52 WILLIAM E. COHN, MD: Preischemic conditioning. 00:31:53 WILLIAM F. TURNER, JR, MD: If -- if your blockage is 60% or 70%, those are the lesions that get you into trouble. Okay, so we've got our shunt in place now. 00:32:03 WILLIAM E. COHN, MD: Now you're going to release the tape. How's it look? 00:32:06 WILLIAM F. TURNER, JR, MD: It looks like we've got pretty good control here. 00:32:08 WILLIAM E. COHN, MD: Boy, that's beautiful. 00:32:09 WILLIAM F. TURNER, JR, MD: Now, the shunt serves two important purposes. It facilitates some of the technical aspects of the operation -- I'm ready to sew -- in the sense that if you've got that in the lumen, you're not going to sew the lumen shut and you're less likely -- 00:32:24 WILLIAM E. COHN, MD: Right, if you can take it out after you finish sewing, it must be okay. 00:32:27 WILLIAM F. TURNER, JR, MD: Exactly. You're less likely to make a technical error. 00:32:29 WILLIAM E. COHN, MD: Sure. 00:32:33 WILLIAM F. TURNER, JR, MD: So here's our mammary artery. Here's our coronary artery. 00:32:37 WILLIAM E. COHN, MD: What's -- what's the endoscope view look like now? Still blurry. Still blurry, they tell me. Yeah, I don't think it's a blur -- it's a focus problem.

13 Do you see a focused image on the screen here? Try to push the focus button there. it's a shame, because it gives a beautiful, beautiful close-up image. Although we can see fine. The images you have from your head-cam, Bill, are really nice. 00:33:07 WILLIAM F. TURNER, JR, MD: Okay, squirt in the mammary there. 00:33:10 WILLIAM E. COHN, MD: So that's the mammary artery, and you're using a little cannula that delivers carbon dioxide, a CO2 blower. 00:33:16 WILLIAM F. TURNER, JR, MD: It's humidified carbon dioxide. I -- as you know, in the beginning, Billy, we used carbon dioxide, it was not humidified, and I think some of the studies that you put in the literature showed that it dried these arteries out and it decreased the patency of our bypass grafts, so it's very important these are humidified. 00:33:36 WILLIAM E. COHN, MD: And through your loops, you know, it looks pretty much like it would for a stopped heart. The area that you're working on's not moving, or not moving much. All right, here's some more questions. Can you sew and answer questions at the same time? 00:33:50 WILLIAM F. TURNER, JR, MD: Sure. 00:33:51 WILLIAM E. COHN, MD: Mark Boslum wants to know -- he says: an open heart surgery's very stressful on the patient after the operation. Just how stressless is the minimally invasive operation during and after the procedure? 00:34:05 WILLIAM F. TURNER, JR, MD: I think it's less stressful for several reasons, the first of which, as we talked about, we avoid heart-lung machine, so there's less of what we call inflammation or just overall soreness. And again, with a smaller incision here, it's less traumatic to the patient, and there's less in the way of tissue that -- to heal. Because you don't break that bone and there's also a lot less bleeding. Because when you do open the sternum -- 00:34:34 WILLIAM E. COHN, MD: There's a beautiful image. 00:34:35 WILLIAM F. TURNER, JR, MD: -- a lot of -- a lot of bleeding from the marrow. 00:34:39 WILLIAM E. COHN, MD: Well, here's a question from Dennis Raleigh, who's apparently a doctor of osteopathy, and he personally has atrial fibrillation. He wants to know if there's a less invasive robotic-assisted therapy for the treatment of atrial fibrillation. 00:34:53 WILLIAM F. TURNER, JR, MD: Actually, there is, Billy. And we started doing that operation a couple of years ago whereby patients with certain types of atrial fibrillation can have a procedure using the robot, and we can isolate that area of the heart that's responsible for the irregular rhythm, and we've done about 10 patients and have about an 80% success rate of curing people with atrial fibrillation, and it's interesting that -- is it Dr. Raleigh? Dr. Raleigh? Yeah, it's interesting, because we have a case tomorrow. 00:35:34 WILLIAM E. COHN, MD: Oh, great. 00:35:36 WILLIAM F. TURNER, JR, MD: Of a patient that has atrial fibrillation.

14 00:35:38 WILLIAM E. COHN, MD: Well, maybe we'll stick around. Well, right now we've got the endoscope image up, and it's just beautiful. In fact, I can see clear enough, I think I could do it from here. 00:35:49 WILLIAM F. TURNER, JR, MD: You're doing a great job where you are, Billy. Okay, now we're going to transect that part of the artery that we're not using. Let's have the Castroviejo would be good. 00:35:59 WILLIAM E. COHN, MD: Oh, I see, you use it sort of as a handle to hold it while you're sewing. That's clever. 00:36:04 WILLIAM F. TURNER, JR, MD: Kind of developed tricks along the way. We've done about 100 of these, and we've made some progress, which I'm very happy to say. 00:36:14 WILLIAM E. COHN, MD: Yeah, that was a question that was asked earlier about the learning curve. How long is it -- did it take you to do these when you were first starting, and how rapidly did you advance through that process? 00:36:28 WILLIAM F. TURNER, JR, MD: Well, the first case, there was no robotic surgery, so we really kind of learned a lot as we went, and the first case took about six hours. And on that case, we did three-vessel bypass. And that patient did very well. Now, with each 10 patients that we've done, we've made various little tricks and maneuvers that have greatly shortened our time, and the last 10 cases that we've done have been right at three hours total. And I can't say enough for the patience that our team has displayed in our progress here because we really had some difficult times in the early going. 00:37:19 WILLIAM E. COHN, MD: Okay. Oops. There we go. Now here's a question from Dimitri Keriazis, who apparently is a physician, and he says he's impressed with the procedure and wants to know if you've submitted your results for publication in any of the cardiac surgical journals. 00:37:37 WILLIAM F. TURNER, JR, MD: We have, and in fact, we presented our data at the Southern Thoracic Surgery Association about a year ago, and our results were published in the annals of Thoracic Surgery. In the September issue. 00:37:54 WILLIAM E. COHN, MD: Okay. Here's a question from Anne Gibson. She wants to know: is cardiac rehabilitation programming for the robotic assisted CABG patient similar to that received by PTCA patients? 00:38:07 WILLIAM F. TURNER, JR, MD: Yes, it's very similar, and we have a very active rehab program here at Mother Frances, and I personally recommend it to all of the patients because it's a structured environment, they can monitor their progress, and they -- the patients really seem to do a lot better when they've got a little guidance and a little routine, so to speak. 00:38:28 WILLIAM E. COHN, MD: I see. Well, here's an interesting question from a Shawn Dreaver. She asks: why couldn't you do this operation with the patient awake? Maybe you can, who knows. 00:38:41 WILLIAM F. TURNER, JR, MD: Well, some people have done that. I think that that's a big step, and our anesthetic techniques are so good --

15 00:38:48 WILLIAM E. COHN, MD: I'll tell you what, Bill, when you do me, wake me up when it's over. 00:38:52 WILLIAM F. TURNER, JR, MD: Right. 00:38:54 WILLIAM E. COHN, MD: All right, great. Well, it looks like the anastomosis is coming along nicely. The tissue sews pretty nicely? 00:39:01 WILLIAM F. TURNER, JR, MD: It is. 00:39:02 WILLIAM E. COHN, MD: I see you use a rider. Do you use Castros for anything? 00:39:07 WILLIAM F. TURNER, JR, MD: Actually, I'm using Castros. 00:39:09 WILLIAM E. COHN, MD: Oh, are they Castros? Good. 00:39:10 WILLIAM F. TURNER, JR, MD: Right. We use riders to close the chest in the -- 00:39:14 WILLIAM E. COHN, MD: Yeah, because I was going to say, when you taught me to do a coronary artery bypass when we were residents together, I thought you insisted that I use Castros. Oh, yeah, there you go, they're Castros. They're -- Bill actually was my senior resident all through training and was my resident when I was a medical student. In fact, I think, Bill, I helped you with an appendectomy once when I was a second-year medical student, didn't I? 00:39:37 WILLIAM F. TURNER, JR, MD: Yeah, and I never got over it. 00:39:40 WILLIAM E. COHN, MD: Okay, here's a question from RJ Madden. And RJ wants to know if the reason that the patient's having coronary bypass is occlusion of the LAD by plaque, do you do anything with the LAD after bypassing it with the internal mammary artery? I guess he wants to know: do you take the plaque out or do anything about that? 00:39:57 WILLIAM F. TURNER, JR, MD: No, we don't. We leave all of that, what we call, in situ, just where it is. I think to try to -- to do that, Billy, would cause a lot more harm than good. 00:40:10 WILLIAM E. COHN, MD: Yeah, I think Dr. Sabiston tried that in the 1960s, and as soon as they came up with the idea of a bypass, they quickly abandoned it. It was just technically too hard to do because the arteries were too small and too fragile. Well, that's coming together quite nicely. Do you finish the whole anastomosis before you take the shunt out? 00:40:34 WILLIAM F. TURNER, JR, MD: What we'll do is we'll put in all of our sutures -- 00:40:37 WILLIAM E. COHN, MD: And leave them loose. 00:40:38 WILLIAM F. TURNER, JR, MD: Leave them loose, and then we'll take the shunt out. 00:40:41 WILLIAM E. COHN, MD: Well, while you're doing that, if you could cut to this slide here that you've prepared on the PowerPoint, this off-cab to robo-cab to T-CAB. Now right now, you're doing a robo-cab. It's a small incision. It's the middle one

16 there. You take the robot, use it to take the mammary down videoscopically, then make a small incision and do the anastomosis, like you're doing now. Over on the right, though, T-CAB, that's a fascinating concept that you would actually do the part you're doing now robotically. Do you think it's got a future, and what do we need to get there? 00:41:13 WILLIAM F. TURNER, JR, MD: I really do, Billy. I think we're going to need a little improvement in what we call enabling technology, and by that, I mean we'll need a little improvement in our stabilizers, perhaps a little better improvement in our visualization and also the instruments that we use. 00:41:28 WILLIAM E. COHN, MD: Sure. 00:41:29 WILLIAM F. TURNER, JR, MD: I think it's very doable. Our good friend Sudhir Srivastava in Odessa has had great success with it. Sudhir is really a true pioneer and probably the world's preeminent robotic surgeon. 00:41:39 WILLIAM E. COHN, MD: Well, I think he's probably done more of them than anybody on the planet. But I think, you know, he's -- he's expressed a willingness to teach anybody that wants to learn, so I'm -- I'm actually going to go down and learn how to do it from him. 00:41:51 WILLIAM F. TURNER, JR, MD: He was kind enough to come out when we started our program. Our coronary program, but also our atrial fibrillation as well. 00:42:04 WILLIAM E. COHN, MD: Uh-huh. And for those of you who are just tuning in, this is Dr. William Turner here at Mother Frances Hospital in Tyler, Texas, and he's doing a coronary artery bypass on a beating heart through about a two and a half inch incision. The mammary artery was actually taken down using a robot without opening the patient up, so really, there's very little in the way of muscular spreading or bone spreading. This patient is going to have very little discomfort postop. His heart's not stopped, he's not put on the heart-lung machine, and he'll be able to go home in, what, a couple of days, right, Bill? 00:42:39 WILLIAM F. TURNER, JR, MD: We're hopeful. 00:42:41 WILLIAM E. COHN, MD: Yeah. And how about these new anastomotic devices? You know, a number of companies have tried to develop sort of one-shot clips for catching the mammary artery to the LAD which would obviate the need to put in all these precise sutures. I know they're still very experimental. The first one has just recently been approved by the FDA for use, and it's sort of in its early, early stages of adoption. Do you think it's got a future or you're waiting to see? 00:43:15 WILLIAM F. TURNER, JR, MD: Well, we're all very intrigued with that concept thus far. I haven't seen anything available as of yet that I would want to use on a distal anastomosis. Now, we had a lot of experience with the -- the St. Jude device, the connector, and actually, it was quite good, but as you know, the problem was with long-term patency. 00:43:42 WILLIAM E. COHN, MD: Right. 00:43:43 WILLIAM F. TURNER, JR, MD: And it's since been taken off the market. 00:43:45

17 WILLIAM E. COHN, MD: Bill, I'm not sure if that was a problem with the device per se or just the way it was being used. 00:43:50 WILLIAM F. TURNER, JR, MD: I think it was a combination of both. 00:43:54 WILLIAM E. COHN, MD: Yeah, perhaps it was. So you've taken the shunt out. 00:43:56 WILLIAM F. TURNER, JR, MD: We've taken the shunt out. 00:43:58 WILLIAM E. COHN, MD: You're going to put one more stitch in there. and now you've re-tightened your tape, have you? 00:44:05 WILLIAM F. TURNER, JR, MD: Yes. 00:44:12 WILLIAM E. COHN, MD: And just trying to get good visualization of that -- 00:44:17 WILLIAM F. TURNER, JR, MD: Okay, we loosened the tape just a little bit. 00:44:20 WILLIAM E. COHN, MD: Okay. 00:44:21 WILLIAM F. TURNER, JR, MD: And now we're going to flash the mammary artery. 00:44:23 WILLIAM E. COHN, MD: All right. 00:44:25 WILLIAM F. TURNER, JR, MD: You can take that out now. Let's have a heavier forcep. 00:44:29 WILLIAM E. COHN, MD: Well, here's a great question from Israel K. And Israel K. wants to know -- well, here, let's let you finish this. 00:44:37 WILLIAM F. TURNER, JR, MD: That's the mammary -- 00:44:38 WILLIAM E. COHN, MD: Now, with the tape loose, you can see it's bleeding quite a bit. 00:44:40 WILLIAM F. TURNER, JR, MD: And I think you can see, there's excellent flow there. 00:44:42 WILLIAM E. COHN, MD: You snug up the suture. And there you go. Bill, that looks great. 00:44:52 WILLIAM F. TURNER, JR, MD: We'll tie this down and check for any leaks and then we'll be done. 00:44:59 WILLIAM E. COHN, MD: You know, it's hard to tell under this magnification, but that's 7-0 prolene, is it? 00:45:03 WILLIAM F. TURNER, JR, MD: Yes, uh-huh. 00:45:04 WILLIAM E. COHN, MD: That's a suture that's about as big around as a human eyelash. And I don't think you could catch a quarter-pound trout on this stuff, and -- 00:45:15 WILLIAM F. TURNER, JR, MD: Okay, when we started the operation, we gave a blood thinner called heparin so that none of the arteries would develop clot while we worked, so now we're going to reverse that. Peter, if you could give the protamine.

18 00:45:30 WILLIAM E. COHN, MD: All right, great. Boy, that really looks nice, Bill. Now you going to let up on your silicone elastic tape here? 00:45:38 WILLIAM F. TURNER, JR, MD: We're about to right now. 00:45:41 WILLIAM E. COHN, MD: And now the graft is open, and now this area of this poor man's heart that hasn't been getting enough blood for the last several years is getting a cool breeze of fresh air. Suddenly bright red blood is going down there, and he's -- he's fixed. 00:45:57 WILLIAM F. TURNER, JR, MD: And I -- Peter, is he -- tolerated things pretty well? 00:46:00 PETER CIRIANI: Perfect. 00:46:02 WILLIAM F. TURNER, JR, MD: Okay. Suction off. 00:46:07 WILLIAM E. COHN, MD: And now the stabilizer's removed, and you want to get a wide view of that with the head-cam? So point out the graft and the coronary artery and... 00:46:18 WILLIAM F. TURNER, JR, MD: Let me have two long forceps. Okay, which view are you looking at, Billy, is it the head-cam or the -- 00:46:27 WILLIAM E. COHN, MD: Yeah, we're going to switch to the head-cam right now. There we go, we're on the head-cam. 00:46:30 WILLIAM F. TURNER, JR, MD: All right. This fat thing here is the internal mammary artery. And I'm very gratified with the size of this and the flow that it has. Can I have some irrigation, please, Chris? 00:46:39 WILLIAM E. COHN, MD: And you can see it going right down to the LAD, to the coronary artery that had the blockage. And those little bruises on the surface of the heart are just like -- we call them suction hickeys. Those will all go away with no consequence, right? 00:46:50 WILLIAM F. TURNER, JR, MD: Exactly. That's going to go away. Those are only on the epicardium. And I think you can appreciate we don't have any leaks here, so -- 00:46:57 WILLIAM E. COHN, MD: Yeah, it looks beautiful. And you haven't even reversed the heparin yet. 00:46:59 WILLIAM F. TURNER, JR, MD: Well, we're about to do it right now. 00:47:02 WILLIAM E. COHN, MD: In the process of it. 00:47:03 WILLIAM F. TURNER, JR, MD: So we're in good shape. 00:47:05 WILLIAM E. COHN, MD: Bill, do you know where protamine comes from? 00:47:11 WILLIAM F. TURNER, JR, MD: Why don't you educate us on that, Billy. 00:47:13