Bonatti is recognized as one of the world’s most experienced surgeons in minimally invasive heart operations using the da Vinci robot.
He has performed more than 300 of these surgeries without incisions.
You moved to Baltimore from Austria. What has that change been like?
This has, of course, been a big change for me, but I [made] the decision with my family. I like the University of Maryland especially and my work and the team there. It is exciting to be in the United Sates. It gives me the opportunity to expand on my work. I have the newest generation of da Vinci robots, which is what [are used in the surgery]. I have an operating room that is equipped with an angiography unit, which makes the development of my hybrid programs feasible.
What are the hybrid programs?
We are working on concepts where I, as the heart surgeon — a minimally invasive heart surgeon — would place the grafts [where a section of blood vessel bypasses the blocked coronary artery] completely endoscopically, and in the same session a cardiologist would place stents [small tubes placed in weakened arteries to improve blood flow]. It’s a new concept of treatment of coronary artery disease that we want to further develop here.
That was a big draw for you?
That was one of the draws. I like Baltimore and Maryland, and it’s very central in the East Coast. It’s a harbor city, and that’s new for me.
In Austria, you were more into skiing?
As an Austrian, I grew up on skis. My hometown is Innsbruck, where the famous downhill ski races [are held], and I was a member of the Austrian freestyle ski team. I competed in some national championships and Eurocup also. I learned a lot about how to develop new ways of skiing and that has translated a little bit in how I am able to develop new methods in surgery.
Tell me about the minimally invasive endoscopic heart bypass operations.
That means you perform a coronary bypass grafting procedure without any opening of the chest. Through tiny port holes only. You have a camera that goes inside the chest and two working ports where you put in your instruments. And the camera and the instruments are controlled from the console where I sit as the surgeon [and] have joysticks and foot pedals.
My movements are translated from the console to the robotic arms by cables. There are four arms so I can use an additional one for stabilization of the heart or bringing it into the right position.
In general surgery, it is possible to remove the gall bladder totally endoscopically, but this did not work for heart surgery. Our vision is to be able to one day perform coronary bypass grafting procedures on a routine basis using the robot.
What is it like working with a robot?
It is a great feeling working with that machine. You sit there very comfortable. You don’t have to wear a headlight and you don’t need to stand. The view you have on the operating field is fascinating. You have 3-D vision, which is very important compared to the tradition endoscopic methods. You are feeling more or less immersed into the operating field, and you have up to tenfold magnification. That makes the work very precise, in addition to the fact that you have tremor-free work. The instruments are completely still, which gives the technology the highest level of precision.
In conventional endoscopic surgery, an assistant would have to hold the camera and you would tell them, ‘Go that way,’ and now you can do that yourself.
What are the benefits?
It’s reduced surgical trauma, instead of having a large incision or many incisions. That translates into a much quicker recovery time.
What is the patient recovery like?
Usually when we send a patient home after a regular coronary heart bypass surgery grafting operation with a big incision, we tell them don’t lift heavy things 10 weeks from now. This is not at all the case with the endoscopic surgery. The usual recovery time after conventional coronary surgery is in the three month range, but with this type of surgery patients would go back to their normal activities two to three weeks after the surgery. The big advantage is in the early rehabilitation phase.
We have discharged patients already three days after the operation.
Why is it still rare?
It’s rare because the situation that you have one or two bypass grafts is not so common [because many patients need more grafts]. [Procedures] will increase when you can do three or four grafts.
What are the limitations to it?
It’s a more complicated procedure and takes longer. And the limitations at this point are the number of bypass grafts. We can do one or two at this point in a reasonable manner. But we are doing research on expanding the number of grafts. And other than that, the patients have to complete certain requirements. If the patient has had a severe chest trauma and there are scars in the chest, you would have to exclude them.
The majority of coronary artery bypass grafting procedures we do these days is three, four, even five grafts. We have to come to a point where we are able to do that [with the endoscopic procedure.] That is our goal.
Dr. Johannes Bonatti
Job title: Cardiac surgeon at the University of Maryland Medical Center and surgery professor at the University of Maryland School of Medicine
Hometown: Innsbruck, Austria
Current home: Lutherville
Family: Married, three chidren
Education: Graduated from Innsbruck University Medical School in 1986 and completed part of his surgical residency at the Medical College of Virginia in Richmond in 1989.
Background: Bonatti was an attending cardiac surgeon and associate professor of surgery at Innsbruck Hospital since 1998 and started a minimally invasive cardiac surgery program there in 2001. He has trained surgeons in the use of the da Vinci robot at hospitals in Germany, the Czech Republic, Greece, Turkey, India and Australia.