Robert Binford, a heart surgeon at Overlake Medical Center in Bellevue, remembers a patient, on whom he had performed a minimally invasive heart valve procedure, putting on a shirt and tie three days later and interviewing for a job via Skype from his hospital room overlooking downtown.

The story demonstrates improved recovery time from a minimally invasive mitral valve repair, Binford’s area of focus for minimally invasive surgery (MIS). That’s one of the benefits of minimally invasive procedures, which are growing in popularity across numerous specialties.

Binford can do the procedure, using instruments about 12 to 16 inches long, through a less-than-2-inch incision between a patient’s ribs. He also does minimally invasive tricuspid valve repairs. He estimates mitral and tricuspid surgeries are about a third of his cases and that he does about 85 percent of those using minimally invasive techniques.

He also does transcatheter aortic valve replacement, another minimally invasive procedure seeing growth. Between that and mitral and tricuspid procedures, Binford estimates about half his cases are minimally invasive. In a standard heart surgery, most patients go home in four to five days and recovery is three months. But with a minimally invasive mitral valve repair, patients typically go home on the third or fourth day, with recovery in three to four weeks, he said.

“People can go back to work in four weeks if they’re driven to and they want to,” Binford said. Less recovery time and smaller scars are just a couple reasons such surgery is increasingly popular.

RISING SCALES

A surgeon uses the da Vinci Xi console to operate the robotic limbs of the device. Photo ©2020 Intuitive Surgical, Inc.

BIS Research, a California-based global B2B market intelligence and advisory firm, which says it focuses on emerging technological trends likely to disrupt the dynamics of the market, issued a market study this year forecasting the sales of minimally invasive surgical systems/ instruments and related technologies to reach a market value of $55.64 billion by the end of 2030. That would be up from $24.76 billion in 2018. BIS forecasted a compounded annual growth rate of 6.51 percent from 2020 to 2030.

The market value is estimated from technologies including conventional minimally invasive surgical systems such as rigid endoscopes, flexible endoscopes, capsule endoscopy, video and visualization systems, instruments and accessories; and others in reprocessing and sterilization; and surgical robotics such as robotic systems, instruments and accessories, and services.

A similar BIS report in 2018 noted strong growth in North America due to patient demand for MIS; technological developments; and perceived benefits of MIS, including the quick recovery, fewer scars and pain, and fewer postoperative complications.

For some procedures, MIS also can lower overall cost. According to the Mayo Clinic’s website, laparoscopy — surgery done through one or more small incisions, using small tubes and tiny cameras and surgical instruments — was among the first types of MIS. Another type is robotic surgery, which provides a magnified, 3D view of the surgical site and helps the surgeon operate with precision, flexibility, and control, the website says.

MIS procedures are used in a wide array of surgeries. At Overlake, for example, MIS, including those using robotics and other minimally invasive techniques, are used in urology, thoracic surgery, general surgery, bariatric surgery, gynecologic surgery, and urogynecology, among others, according to Morgan Brice, Overlake’s senior media and public relations specialist.

Between 2017 and 2019, robotic procedures increased 40 percent at Overlake, she said.

Overlake purchased two da Vinci Xi robotic systems in 2019, allowing it to expand the robotic program in general surgery, Brice said. It also purchased the Mako robot for orthopedic total joint procedures in 2019. And in neurosurgery, Overlake is utilizing navigational equipment for minimally invasive cranial and spine surgery.

EASTSIDE DESIGNED

Siemens Healthineers angiography system technology and ultrasound technology are used in an image-guided surgical procedure. Specifically, this image features the ACUSON SC2000 PRIME 5.0 ultrasound system and the ARTIS pheno robot-assisted angiography system, both manufactured by Siemens Healthineers North America. Photo courtesy of Siemens Healhineers North America.

The Eastside also plays a role in design and manufacturing of devices used in MIS. For Germany-based medical technology company Siemens Healthineers, Issaquah is the global headquarters for its ultrasound division, which makes imaging equipment critical to MIS, with doctors using real-time imaging to help steer surgical tools. The Issaquah site — which does all of Siemens’ ultrasound research and development, and some ultrasound manufacturing — has more than 300 employees.

In Redmond, a specialized team of the Pennsylvania- based medical technology company Olympus Corporation of the Americas researches, develops, and manufactures medical devices that utilize Olympus endoscopes and bronchoscopes for minimally invasive diagnosis and/or treatment of multiple diseases, including the Spiration Valve System to treat advanced emphysema through bronchoscopic lung volume reduction, and needles for sampling tissue that can be accessed through a bronchoscope for diagnosis and staging of lung cancer. The office has about 100 employees. While the medical device hubs in Minneapolis and Boston are larger, there have been a number of successful companies that have their roots in innovative technologies developed in the Greater Seattle area that have addressed minimally invasive treatments in the cardiovascular, pulmonary, and oncology fields, H. Xavier Gonzalez, vice president and chief scientific officer for Olympus in Redmond, said via email.

Redmond’s Olympus building.

Gonzalez attributed much of the success to collaborations with strong academic and research institutions, such as the University of Washington and Fred Hutch. He places the Spiration Valve System (SVS) among the more significant minimally invasive devices to originate in Olympus’ Redmond office. “The primary indication for SVS is for the treatment of adult patients with shortness of breath and hyperinflation associated with severe emphysema in regions of the lung that have evidence of low collateral ventilation,” he wrote. “SVS was designated and approved by the FDA as a breakthrough medical device.”

Added Gonzalez, “Placed in targeted airways of the lung during a short bronchoscopic procedure, the Spiration Valve is an umbrella-shaped device that improves breathing by blocking airflow to the diseased portion of the lung. SVS therapy leads to volume reduction in the treated part of the lung, allowing the healthier tissue in the remaining portion of the lung to function better.”

Joseph Riley, vice president of interventional radiology and cardiology at Siemens’ Healthineers North America office in Malvern, Pennsylvania, said the minimally invasive treatment market has seen strong growth over the past decade on the surgical instruments side and imaging equipment side — whether it be angiography, ultrasound, or other modalities, like interventional CT or magnetic resonance.

“So the trend for us is expected to continue for growth here, really driven by novel procedures that are reducing the need for open surgery and that, quite frankly, drive better outcomes,” Riley said.

Siemens focuses largely on the imaging side of the medical procedures, but last year acquired Corindus Vascular Robotics Inc., which makes a robotic system for endovascular coronary and peripheral vascular interventions. The system helps physicians to precisely control guide catheters, guide wires, and balloon or stent implants via integrated imaging, according to a news release announcing the deal.

Riley’s interventional radiology and cardiology imaging systems division is closely connected to Issaquah’s ultrasound division. It has to be, because of the need to orchestrate different imaging technologies during minimally invasive procedures to ensure physicians have all the information they need to see inside the body, he said.

“Ultrasound gives physicians the ability to look inside of the patient without use of radiation,” Riley said. “That’s a really powerful modality, and ultrasound is also excellent at visualizing moving tissue.”

For example, consider a tumor in a tough-to-reach spot like a lung — ultrasound allows a physician to look inside without X-ray, Riley said. The physician, perhaps using a needle to ablate and kill the tumor without cutting open the patient, can use ultrasound to precisely guide the needle without hitting other good organs, while also seeing tissue movement around the tumor as the needle advances, he said.

USE TRENDING UP

Scott Thielman. Courtesy of the subject.

Scott Thielman, chief technology officer at Seattle-based Product Creation Studio, which does product design and development for clients in medical, consumer, and industrial applications — everything except manufacturing the products — sees the trend toward more MIS firsthand, especially as technology improves.

He points to transcatheter aortic valve replacement (TAVR) as an example of a procedure that pushed the boundaries when it was introduced but is now commonplace. The idea of sending a new valve to the heart through a catheter in the femoral artery in the leg, deploying the valve without opening up the chest, and then removing the catheter “would have been on the edge of borderline crazy” when it was considered almost 20 years ago, he said.

TAVR’s success opened a lot of minds toward innovation, he said. “If we can do that … what can’t we do?” he said of how innovators in the industry think.

Thielman said robotic surgeries go hand in hand with the emphasis in MIS and also are growing in interest. He doesn’t believe all the potential benefits of robotic surgery have yet been realized.

“I think this next decade is (the) robotics decade, not heretofore, even though da Vinci’s kind of become a household name,” he said of the robotic surgical system. “I think we have so much more to do, and to me that’s a really exciting aspect.”

Dr. Binford. Courtesy of the subject.

Back at Overlake Medical Center, Dr. Binford is comfortable with his minimally invasive mitral and tricuspid valve surgery techniques, choosing not to use robots that are often booked for other surgeries. Also, robotic heart procedures include more incisions that, while small, aren’t as well-hidden as he said he can do on women, for example, with a small 2-inch incision hidden at the breast crease, with only a small 1-centimeter incision about two ribs below for a drainage port that’s required for all surgeries.

Binford, though, is no stranger to robots, starting robotic-assisted surgery in 2003 in Nashville and going on to train other doctors on the da Vinci system until coming in 2011 to Overlake, where, because there wasn’t a hear-procedure room then big enough for a robot, he began his current minimally invasive technique using long instruments.

Additionally, he estimates his minimally invasive TAVR procedures — which require a surgeon and cardiologist working together, per FDA regulations — number about 60 to 70 a year.

Overlake’s spokesperson, Brice, said the hospital saw 11 percent growth in TAVR procedures from 2017 to 2019, but it was expecting about a 54 percent increase this year over last. Binford said there’s a lot of minimally invasive work being done between cardiologists and surgeons.

“Some of those aren’t classic surgery — we’re not making an incision or anything — but they’re still addressing these problems that used to require surgery that may not even require surgery anymore,” he said. “And this is only going to get more and more common. And I would say within the next 10, 15 years, a large part of what we call structural heart valves and stuff will be done either minimally invasive like I do, or with a robot, or in the cath lab, and there won’t be many open sternums being done.”