In a bold move that could transform the current landscape of vascular surgery, Houston Methodist's DeBakey Heart and Vascular Center recently launched a robotic vascular surgery program that's the first of its kind in the U.S.

Spearheaded by vascular surgeon Dr. Charu Bavare, and supported by Dr. Alan Lumsden, chair of Cardiovascular Surgery, the new program aims to combine the strengths of open vascular surgery with the benefits of minimally invasive procedures to provide the most durable interventions and best outcomes for patients.

Best of both worlds

The longest-lasting fix for vascular rupture is a Dacron graft, developed by Dr. Michael DeBakey some 50 years ago. Until recently, the only way to perform it was through open surgery.

"While endovascular procedures are currently more popular because they are less invasive, they have some tradeoffs that make them less effective in the long run," said Dr. Bavare. "Robotic surgery enables the longevity of a Dacron graft with a minimally invasive approach."

Despite the obvious payoff, vascular surgeons in the U.S. — and elsewhere — have been slow to adopt the new technology due to a lack of training in robotic and laparoscopic techniques.

The catalyst for the Houston Methodist program came in 2019, when Dr. Lumsden's interest was piqued during a presentation about robotic renal vein transposition surgery.

"I was so impressed, but then the surgeon mentioned he hadn't performed the procedure himself — he'd asked a urologist colleague to perform it because he was the only one familiar enough with robotic surgery," Dr. Lumsden recalled. "That was the first time I realized vascular surgeons might be missing the boat on this vital skill."

A heavy lift

Luckily, Dr. Lumsden knew one surgeon who might have the right combination of skills. Dr. Bavare performed laparoscopic general surgeries in his practice prior to joining Houston Methodist, giving him significant exposure to laparoscopic, robotic and vascular surgery techniques.

"Unfortunately, there's zero training or technical support available for robotic vascular surgery in the U.S., so we quickly realized we'd have to go to some fairly heroic efforts to get our program off the ground," Dr. Bavare said.

Dr. Bavare started the process by talking to surgical robot manufacturer, Intuitive, who said they would support initial training requirements, case observations and simulation but stressed that they don't support vascular robotics. Dr. Brian Miles, vice chair of Urology and medical director of Robotic Surgery at Houston Methodist, was Dr. Bavare's next call. He was instrumental in outlining the steps necessary to start doing vascular robotics procedures at Houston Methodist.

Finally, Dr. Bavare reached out to Dr. Peter Stadler, one of the few vascular surgeons globally who specializes in intra-abdominal vascular procedures using the DaVinci Xi robot platform.

Learning the ropes

In September of 2023, Dr. Bavare underwent a three-day case observation program in Prague with Dr. Stadler and his team, an important step before the Houston Methodist program's launch.

"The main goal of this training session was to learn how to set up the procedure," Dr. Bavare said. "Planning and setup are critical. Proper positioning, port placement and meticulous planning minimize risks."

The well-organized hospital set-up and the efficiency of having a dedicated robotic vascular surgery team were illuminating, Dr. Bavare said.

"There's a lot of potential to replicate this in the U.S." Dr. Bavare explained. "Our goal is to create a comprehensive program, initially focusing on low-risk cases while we work up to aortic aneurysms and the like, and eventually serving as a training hub for a generation of future robotic vascular surgeons."

Benefits of the approach

Dr. Bavare is confident that robotic surgery will eventually change the landscape of open vascular surgery, like endovascular surgery did many years ago.

"You get a decreased length of stay, faster recovery, decreased post-op pain and use of opioids, occasionally shorter operating time and reduced risk of infection — while still getting the gold standard treatment," Dr. Bavare said. "This is a huge game-changer, make no mistake."

On top of that, it's easier for the surgeon, reducing fatigue and enhancing visibility, accuracy and resolution beyond what a human eye can see. The surgeons also get the benefit of an extra hand to hold clamps and clear extraneous tissue out of the surgical field.

"I think this is what's best for the patient, and that always wins out in the end," Dr. Bavare said.

It also helps that the institutional barriers that stopped vascular surgeons from learning robotic surgery techniques may soon be a thing of the past.

"The general surgery trainees that apply for our fellowships these days have all logged a significant amount of time on a surgical robot and have a vested interest in continuing to develop that skill set," Dr. Bavare explained. "The older surgeons can either learn it — or not — and that's okay. But I think the newer generations will come well-equipped to leapfrog over the hardest parts of that learning curve."

Next steps

Dr. Bavare is focused on beefing up his vascular surgery skill set while seeking to build his own dedicated robotic vascular surgery staff.

"I anticipate that within six to twelve months, we will be ready to perform the most complex vascular procedures with the robot," Dr. Bavare predicted. "And we will be tracking each case carefully to see if the outcomes are indeed better for the patients in both the short and the long-term."