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A surgeon for life: Pioneer in robotic enhanced and minimal access surgery

An interview I did for Student BMJ


Roberto Casula studied at Padua medical school in Italy, graduating in 1989. He came to the UK in 1993 and has worked in Glasgow, Cambridge, and London. He has a European qualification in cardiac and thoracic surgery and is a fellow of the Royal College of Surgeons. He is a consultant cardiothoracic surgeon and honorary senior lecturer at Imperial College London and a UK pioneer of minimal access and robotic cardiac surgery.

What first attracted you to cardiac surgery?

As a child I was told about the first heart transplant. This never left my mind and I was fascinated by the whole story. Since then I never considered any other path in life apart from studying medicine and then training in cardiac surgery.

What do you value about your job?

You hear about successful people being bored with their highly remunerated job after 10 years. I don’t think that this will happen in a specialty like mine. The technical improvements and technological refinements in cardiac surgery continue to stimulate me and remain challenging on a daily basis.

It is also rewarding to see that we can provide somebody’s problems with a solution and hear from them about how much they have improved after surgery and minimal invasive procedures.

What’s different about cardiac surgery compared with other sorts of surgery?

Dealing with the heart is challenging and fascinating: having to stop it and then restart it and—even more challenging—sometimes having to operate it while it’s moving. Performing microsurgery on a beating heart requires dexterity and skills that have developed in cardiac surgery to a high level.

What’s a normal day like for you?

There are days when I spend most of the time in the operating theatre. This is usually physically demanding. In a day I typically do one, two, or three operations and I often organise my meetings and do paperwork in between cases.

Some days I attend multidisciplinary team meetings or see outpatients. Regardless of the extensive use of technology in my clinical practice I enjoy talking and listening to my [out] patients because it allows me to ensure they continue to progress to our expectations.

I also spend some of my time reading, reviewing, or writing academic papers.

What does robotic enhanced minimal access surgery involve?

When we say “robotic enhanced” obviously it is not an independent intelligence that performs the operation. The system is guided by a surgeon, and moves pencil sized surgical effectors inside the chest that are positioned at the beginning of the operation.

The operation takes place through small incisions. This avoids opening the sternum, which is always required with traditional surgery, and this is what we mean by “minimal access.” The advantage is that we can reproduce traditional surgical techniques with reduced surgical trauma. We also do not use the cardiopulmonary bypass machine, and therefore we do not expose these patients to side effects [associated with the machine].

Usually patients treated with less invasive or robotic surgical techniques recover faster and return to their normal daily and professional activities sooner than the traditional patient.

What sort of operations are you doing using these techniques that other people are doing via traditional surgery?

The most common operation performed with robotic technology is a single bypass to a blocked coronary artery. We also undertake mitral valve repairs. Several other minimal access procedures are routinely performed to change or repair the aortic valve, remove heart tumours, or reset the normal sinus rhythm in patients with atrial fibrillation. These do not necessarily require robotic technology.

Why are so few surgeons offering robotic cardiac surgery in the UK?

The techniques are time consuming and require specific training. The set of skills needed for robotic surgery are different from those acquired when training for traditional cardiac surgery.

Another limitation is that several medical specialties offer treatments for cardiac disease. As a result, we don’t treat a sufficient number of patients surgically to reproduce robotic technology in large volumes.

What’s the best way to choose the most appropriate treatment for a patient with a cardiac problem?

In an ideal world the specialists discussing the case would be a conventional cardiologist who can do an angioplasty, a non-interventional cardiologist who is untrained in either angioplasty or robotic surgery, and a cardiac surgeon capable of performing minimal access/invasive surgery. This is what is suggested by European guidelines. Between the three of them they will be able to reach the best decision for the patient.

What innovations do you think we’ll see in cardiac surgery in the future?

I would like to see better integration between present technologies with better collaboration between groups of specialists. The best treatment is “hybrid treatment,” which means being able to offer a bespoke treatment to a patient according to his or her needs. An example of this might be a patient with multivessel coronary artery disease who has a robotic operation on the most important vessel, such as the left anterior descending, and angioplasty to a further vessel of lesser importance.

What advice would you give a student thinking of training to be a cardiac surgeon?

The best approach is to arrange to visit an operating room and watch an operation. If possible they should also see a minimal access operation, and perhaps even a robotic operation. If they are caught by this bug that caught me many years ago I think they will never regret entering into a career in cardiac surgery.

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