CABG is performed to relieve angina unsatisfactorily controlled by maximum tolerated anti-ischemic medication, prevent or relieve left ventricular dysfunction, and/or reduce the risk of death. CABG does not prevent myocardial infarction (heart attack). This surgery is usually performed with the heart stopped, necessitating the usage of cardiopulmonary bypass. However, two alternative techniques are also available, allowing CABG to be performed on a beating heart either without using the cardiopulmonary bypass, a procedure referred to as "off-pump" surgery, or performing beating surgery using partial assistance of the cardiopulmonary bypass, a procedure referred to as "on-pump beating" surgery. The latter procedure offers the advantages of the on-pump stopped and off-pump while minimizing their respective side-effects.
CABG is often indicated when coronary arteries have a 50 to 99 percent obstruction. The obstruction being bypassed is typically due to arteriosclerosis, atherosclerosis, or both. Arteriosclerosis is characterized by thickening, loss of elasticity, and calcification of the arterial wall, most often resulting in a generalized narrowing in the affected coronary artery. Atherosclerosis is characterized by yellowish plaques of cholesterol, lipids, and cellular debris deposited into the inner layer of the wall of a large or medium-sized coronary artery, most often resulting in a partial obstruction in the affected artery. Either condition can limit blood flow if it causes a cross-sectional narrowing of at least 50 percent.
Three coronary artery bypass grafts, a LIMA to LAD and two saphenous vein grafts – one to the right coronary artery system and one to the obtuse marginal system.
There are many variations in terminology, in which one or more of "artery", "bypass" or "graft" is left out. The most frequently used acronym for this type of surgery is CABG (pronounced 'cabbage'), pluralized as CABGs (pronounced 'cabbages'). Initially the term aortocoronarybypass (ACB) was more popularly used to describe this procedure.CAGS (coronary artery graft surgery, pronounced phonetically) should not be confused with coronary angiography (CAG).
Number of arteries bypassed
Illustration depicting single, double, triple, and quadruple bypass
The terms single bypass, double bypass, triple bypass, quadruple bypass and quintuple bypass refer to the number of coronary arteries bypassed in the procedure. In other words, a double bypass means two coronary arteries are bypassed (e.g., the left anterior descending (LAD) coronary artery and right coronary artery (RCA)); a triple bypass means three vessels are bypassed (e.g., LAD, RCA and left circumflex artery (LCX)); a quadruple bypass means four vessels are bypassed (e.g., LAD, RCA, LCX and first diagonal artery of the LAD) while quintuple means five. Left main coronary artery obstruction requires two bypasses, one to the LAD and one to the LCX.
A coronary artery may be unsuitable for bypass grafting if it is small (< 1 mm or < 1.5 mm), heavily calcified, or located within the heart muscle rather than on the surface. A single obstruction of the left main coronary artery is associated with a higher risk for a cardiac death and usually receives a double bypass.
The surgeon reviews the coronary angiogram prior to surgery and identifies the number of obstructions, the percent obstruction of each, and the suitability of the arteries beyond the obstruction(s) as targets. The presumed number of bypass grafts needed as well as the location for graft attachment is determined in a preliminary fashion prior to surgery, but the final decision as to number and location is made during surgery by direct examination of the heart.
The 2004 ACC/AHA CABG guidelines state CABG is the preferred treatment for:
Disease of all three coronary arteries (LAD, LCX and RCA).
Diffuse disease not amenable to treatment with a PCI.
The 2005 ACC/AHA guidelines further state that CABG is the preferred treatment with other high-risk patients such as those with severe ventricular dysfunction (i.e. low ejection fraction), or diabetes mellitus.
Bypass surgery can provide relief of angina when the location of partial obstructions precludes improving blood flow with stents.
There is no survival benefit with bypass surgery vs. medical therapy in stable angina patients.
Age per se is not a factor in determining risk vs benefit of CABG.
Prognosis following CABG depends on a variety of factors, and successful grafts typically last 8–15 years. In general, CABG improves the chances of survival of patients who are at high risk (generally triple or higher bypass), though statistically after about five years the difference in survival rate between those who have had surgery and those treated by drug therapy diminishes. Age at the time of CABG is critical to the prognosis, younger patients with no complicating diseases doing better, while older patients can usually be expected to suffer further blockage of the coronary arteries.
Veins that are used either have their valves removed or are turned around so that the valves in them do not occlude blood flow in the graft. External support may be placed on the vein prior to grafting into the coronary circulation of the patient. LITA grafts are longer-lasting than vein grafts, both because the artery is more robust than a vein and because, being already connected to the arterial tree, the LITA need only be grafted at one end. The LITA is usually grafted to the left anterior descending coronary artery (LAD) because of its superior long-term patency when compared to saphenous vein grafts.
Both PCI and CABG are more effective than medical management at relieving symptoms, (e.g. angina, dyspnea, fatigue).
CABG is superior to PCI for some patients with multivessel CAD
The Surgery or Stent (SoS) trial was a randomized controlled trial that compared CABG to PCI with bare-metal stents. The SoS trial demonstrated CABG is superior to PCI in multivessel coronary disease.
The SYNTAX trial was a randomized controlled trial of 1800 patients with multivessel coronary disease, comparing CABG versus PCI using drug-eluting stents (DES). The study found that rates of major adverse cardiac or cerebrovascular events at 12 months were significantly higher in the DES group (17.8% versus 12.4% for CABG; P=0.002). This was primarily driven by higher need for repeat revascularization procedures in the PCI group with no difference in repeat infarctions or survival. Higher rates of strokes were seen in the CABG group.
The FREEDOM (Future Revascularization Evaluation in Patients With Diabetes Mellitus—Optimal Management of Multivessel Disease) trial will compare CABG and DES in patients with diabetes. The registries of the nonrandomized patients screened for these trials may provide as much robust data regarding revascularization outcomes as the randomized analysis.
A study comparing the outcomes of all patients in New York state treated with CABG or percutaneous coronary intervention (PCI) demonstrated CABG was superior to PCI with DES in multivessel (more than one diseased artery) coronary artery disease (CAD). Patients treated with CABG had lower rates of death and of death or myocardial infarction than treatment with a coronary stent. Patients undergoing CABG also had lower rates of repeat revascularization. The New York State registry included all patients undergoing revascularization for coronary artery disease, but was not a randomized trial, and so may have reflected other factors besides the method of coronary revascularization.
A meta-analysis with over 6000 patients showed that coronary artery bypass was associated with lower risk for major adverse cardiac events compared to drug-eluting stenting. However, patients had a higher risk of stroke events.
Postperfusion syndrome (pumphead), a transient neurocognitive impairment associated with cardiopulmonary bypass. Some research shows the incidence is initially decreased by off-pump coronary artery bypass, but with no difference beyond three months after surgery. A neurocognitive decline over time has been demonstrated in people with coronary artery disease regardless of treatment (OPCAB, conventional CABG or medical management). However, a 2009 research study suggests that longer term (over 5 years) cognitive decline is not caused by CABG but is rather a consequence of vascular disease. Loss of mental function is a complication of bypass surgery in elderly people, and might influence procedure cost benefit considerations. Several factors may contribute to immediate cognitive decline. The heart-lung blood circulation system and the surgery itself release a variety of debris, including bits of blood cells, tubing, and plaques. For example, when surgeons clamp and connect the aorta to tubing, resulting emboli block blood flow and cause mini strokes. Other heart surgery factors related to mental damage may be events of hypoxia, high or low body temperature, abnormal blood pressure, irregular heart rhythms, and fever after surgery.
Pericardial tamponade: Blood collection around the heart that compresses the heart and causes poor body and brain perfusion. Chest tubes are placed around the heart and lung to prevent this. If the chest tubes become clogged in the early post operative period when bleeding is ongoing this can lead to pericardial tamponade, pneumothorax or hemothorax.
Lower extremity edema, extravasation, inflammation, and eccymoses from vein harvest; entrapment of up to 9 pounds (4.1 kg) of fluid in the extremity is common. This is managed with a thigh length compression stocking, elevation of the limb, and early and frequent slow walking; as well as avoidance of standing in place, sitting, and bending the leg at the knee more than a few degrees.
Anemia - secondary to blood loss, plus the anemia of inflammation, inflammation being inevitable with opening the chest plus harvesting of leg vein(s) for grafting. A fall in the hemoglobin from normal preoperative levels (e.g. 15) to postoperative levels of 6 to 10 are inevitable. There is no benefit from transfusions until the hemoglobin falls below 7.5. Institutions should establish protocols to ensure transfusions are not given unless the hemoglobin falls below 7.5 without some additional compelling reason(s).
Delayed healing or refracture of sternum - the sternum is bifurcated logitudinally (a median sternotomy) and retracted to access the heart. Failure to follow "sternal precautions" following surgery could result in delayed healing or refracture of the sternum which was sutured at the closure of the chest wound:
Hold a pillow against the chest whenever getting out of or into a chair or bed; or coughing, sneezing, blowing nose, or laughing, in order to oppose the intrathoracic outward force created by these activities on the healing sternum.
Avoid using the pectoral muscles, such as by pushing on the chair arms to assist one's self out of a chair, or by using the arms to assist in sitting down. Proper standing technique is to rock three times in the chair and then stand to provide momentum for moving the center of gravity from the sitting to the standing position. Proper sitting technique is to slowly lower the bottom toward the chair seat using gluteus and quadriceps muscles ("legs only") without grabbing the chair arms. Second, patients should avoid lifting objects utilizing the pectoral muscles: carrying light objects with arms extended down at sides, and lifting light objects with the elbows pressed to the chest and using the biceps, are acceptable. Also, avoid using the arms overhead.
Avoid sitting in the car front seat (no driving) for at least four weeks: the explosion of the deployment of an airbag could refracture the sternal union.
Illustration of a typical coronary artery bypass surgery. A vein from the leg is removed and grafted to the coronary artery to bypass a blockage.
Coronary artery bypass surgery during mobilization (freeing) of the right coronary artery from its surrounding tissue, adipose tissue (yellow). The tube visible at the bottom is the aortic cannula (returns blood from the HLM). The tube above it (obscured by the surgeon on the right) is the venous cannula (receives blood from the body). The patient's heart is stopped and the aorta is cross-clamped. The patient's head (not seen) is at the bottom.
The patient is brought to the operating room and moved onto the operating table.
In the case of "off-pump" surgery, the surgeon places devices to stabilize the heart.
In the case of "on-pump" surgery, the surgeon sutures cannulae into the heart and instructs the perfusionist to start cardiopulmonary bypass (CPB) normally instructing the perfusionist to "Go on pump". Once CPB is established, there are two technical approaches: either the surgeon places the aortic cross-clamp across the aorta and instructs the perfusionist to deliver cardioplegia with a cooled potassium mixture to stop the heart and slow its metabolism or performing bypasses on beating state (on-pump beating).
One end of each vein graft is sewn on to the coronary arteries beyond the obstruction and the other end is attached to the aorta or one of its branches. For the internal thoracic artery, the artery is severed and the proximal intact artery is sewn to the LAD beyond the obstruction. Aside the latter classical approach, there are emerging techniques for construction of composite grafts as to avoiding connecting grafts on the ascending aorta (Un-Aortic) in view of decreasing neurologic complications.
The heart is restarted by removing the aortic cross clamp; or in "off-pump" surgery, the stabilizing devices are removed. In cases where the aorta is partially occluded by a C-shaped clamp, the heart is restarted and suturing of the grafts to the aorta is done in this partially occluded section of the aorta while the heart is beating.
Once the grafts are completed distally and proximally, the patient is rewarmed to a normal temperature and the heart and other pressures are normal to support coming off the bypass machine, weaning off the bypass machine begins.
The perfusionist makes sure they have enough volume to come off bypass, confirms that anesthesia is ventilating the patient, confirms that vacuum assist is off (if used), and vocalizes each step in the weaning process to the surgeon and anesthesia. In perfusion, this is known as the 4 V's. Volume, Ventilate, Vacuum, Vocalize. Communication is key during weaning. The surgeon, perfusionist and anesthesia all communicate specialized information at each step in the weaning process. Confirming if it is safe to come down lower on flow until the heart is fully operating on its own. Once the perfusionist clamps both the Venous and Arterial lines the patient is fully off bypass and the perfusionist vocalizes for everyone in the operating room to hear that "we are off pump". This lets all OR staff in the room know that the patient is no longer on the bypass machine. Which is an important stage of the "on pump" coronary bypass surgery. Volume can be given to the patient through the arterial line of the bypass machine while the aortic cannula is still in.
The patient is moved to an intensive care unit (ICU) or cardiac universal bed (CUB) to recover. Nurses in the ICU monitor blood pressure, urine output, respiratory status, and chest tubes for excessive or no drainage. Excessive drainage suggests continued bleeding which may require re-operation to manage; no drainage suggests an obstructed tube, which can result in cardiac tamponade and/or pneumothorax which can be lethal.
After awakening and stabilizing in the ICU for 18 to 24 hours, the person is transferred to the cardiac surgery ward. If the patient is in a CUB, equipment and nursing is "stepped down" appropriate to the patient's progress without having to move the patient. Vital sign monitoring, remote rhythm monitoring, early ambulation with assistance, breathing exercises, pain control, blood sugar monitoring with intravenous insulin administration by protocol, and anti-platelet agents are all standard of care.
The patient without complications is discharged in four or five days.
Hybrid Coronary Revascualrisation, where the LIMA-to-LAD anastomosis is combined with percutaneous stents in other atherosclerotic sites, has been shown to have significant advantages compared to conventional CABG, including a decrease in the incidence of blood transfusion, and a reduced intubation time. A 2018 meta-analysis has however demonstrated a greater financial cost when compared to conventional CABG.
Choice of source of grafts
Heart bypass patient showing almost invisible residual scarring. Left: days after operation. Middle: chest scar, two years later. Right: leg scar from harvested vein, two years later.
The choice of vessel(s) is highly dependent upon the particular surgeon and institution. Typically, the left internal thoracic artery (LITA) (previously referred to as left internal mammary artery or LIMA) is grafted to the left anterior descending artery and a combination of other arteries and veins is used for other coronary arteries. The great saphenous vein from the leg is used approximately in 80% of all grafts for CABG. The right internal thoracic (mammary) artery (RITA or RIMA) and the radial artery from the forearm are frequently used as well; in the U.S., these vessels are usually harvested either endoscopically, using a technique known as endoscopic vessel harvesting (EVH), or with the open-bridging technique, employing two or three small incisions. The right gastroepiploic artery from the stomach is infrequently used given the difficult mobilization from the abdomen.
Acute - patients without complications are typically seen 3–4 weeks post operatively, at which time driving may be resumed and formal cardiac rehabilitation begun to increase aerobic endurance and muscular strength.
an intensive medical regimen including statins, aspirin, and aerobic exercise is essential to delaying the progression of plaque formation in both the native and grafted vessels.
Illustration depicting coronary artery bypass surgery (double bypass)
Illustration of Single bypass
Illustration of Double bypass
Illustration of Triple bypass
Illustration of Quadruple bypass
CABG is one of the most common procedures performed during U.S. hospital stays; it accounted for 1.4% of all operating room procedures performed in 2011. Between 2001 and 2011, however, its volume decreased by 46%, from 395,000 operating procedures performed in 2001 to 213,700 procedures in 2011.
Between 2000 and 2012, the number of CABG procedures carried out decreased across the majority of OECD countries. However, there remained substantial variation in the rate of procedures, with the U.S. carrying out four times as many CABG operations per 100,000 people as Spain. These differences do not appear to be closely related to the incidence of heart disease, but may be due to variation in financial resources, capacity, treatment protocols and reporting methods.
The first coronary artery bypass surgery was performed in the United States on May 2, 1960, at the Albert Einstein College of Medicine-Bronx Municipal Hospital Center by a team led by Robert H. Goetz and the thoracic surgeon, Michael Rohman with the assistance of Jordan Haller and Ronald Dee. In this technique the vessels are held together with circumferential ligatures over an inserted metal ring. The internal mammary artery was used as the donor vessel and was anastomosed to the right coronary artery. The actual anastomosis with the Rosenbach ring took fifteen seconds and did not require cardiopulmonary bypass. The disadvantage of using the internal mammary artery was that, at autopsy nine months later, the anastomosis was open, but an atheromatous plaque had occluded the origin of the internal mammary that was used for the bypass.
Soviet cardiac surgeon, Vasilii Kolesov, performed the first successful internal mammary artery–coronary artery anastomosis in 1964. However, Goetz has been cited by others, including Kolesov, as the first successful human coronary artery bypass. Goetz's case has frequently been overlooked. Confusion has persisted for over 40 years and seems to be due to the absence of a full report and to misunderstanding about the type of anastomosis that was created. The anastomosis was intima-to-intima, with the vessels held together with circumferential ligatures over a specially designed metal ring. Kolesov did the first successful coronary bypass using a standard suture technique in 1964, and over the next five years he performed 33 sutured and mechanically stapled anastomoses in Leningrad (now St. Petersburg), USSR.
Soon Dudley Johnson extended the bypass to include left coronary arterial systems.
In 1968, doctors Charles Bailey, Teruo Hirose and George Green used the internal mammary artery instead of the saphenous vein for the grafting.
According to the CDC, the average cost of hospitalization (only) associated with a coronary bypass operation in the United States in 2013 was $38,707, for an aggregate hospitalization cost of $6.4 billion. The International Federation of Healthcare Plans has estimated the average cost of hospitalization and physician fees for a coronary bypass operation in various countries as shown in the Table below.
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F. Mason Sones, Jr. (October 28, 1918 – August 28, 1985) was an American physician whose pioneering work in cardiac catheterization was instrumental in the development of both coronary artery bypass surgery and interventional cardiology.
Hybrid coronary revascularization (HCR) or hybrid coronary bypass is a relatively new type of heart surgery that provides an alternative to traditional coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI or PTCA) by combining the two into one operation. It is this combining aspect that "hybrid" refers to. HCR is one of several types of hybrid cardiac surgery; it is not to be confused with a MIDCAB (minimally invasive direct coronary artery bypass) procedure, which uses the smaller thoracotomy incision but does not involve coronary stenting.
Kotturathu Mammen "K.M." Cherian (born 8 March 1942) is an Indian heart surgeon. He performed India's first coronary artery bypass surgery and is considered a pioneer of pediatric cardiac surgery in the country. He is also a former honorary surgeon to the President of India and a Padma Shri awardee.
Median sternotomy is a type of surgical procedure in which a vertical inline incision is made along the sternum, after which the sternum itself is divided, or "cracked". This procedure provides access to the heart and lungs for surgical procedures such as heart transplant, corrective surgery for congenital heart defects, or coronary artery bypass surgery.
Median sternotomy is often mistakenly referred to as open heart surgery, in which it is a preliminary step. However, open heart additionally involves incision of the pericardium, and many median sternotomy procedures do not require this. Open heart usually involves the use of a cardiopulmonary bypass, also known as a heart-lung machine.
Should this procedure be performed upon an individual more than once, each subsequent sternotomy may be referred to as a "resternotomy".
Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) is a surgical treatment for coronary heart disease that is a less invasive method of coronary artery bypass surgery (CABG). MIDCAB gains surgical access to the heart with a smaller incision than other types of CABG. MIDCAB is sometimes referred to as "keyhole" heart surgery because the operation is analogous to operating through a keyhole.
MIDCAB is a form of off-pump coronary artery bypass surgery (OPCAB), performed "off-pump" - without the use of cardiopulmonary bypass (the heart-lung machine). MIDCAB differs from OPCAB in the type of incision used for the surgery; with traditional CABG and OPCAB a median sternotomy (dividing the breastbone) provides access to the heart; with MIDCAB, the surgeon enters the chest cavity through a mini-thoracotomy (a 2-to-3 inch incision between the ribs).
MIDCAB surgery is no more reserved for anteriorly placed single- or double-vessel diseases, because recently such lesions are usually managed with angioplasty. Hence this surgery has recently been used in multivessel diseases.
In cardiology, stunned myocardium is a state when some section of the myocardium (corresponding to area of a major coronary occlusion) shows a form of contractile abnormality. This is a segmental dysfunction which persists for a variable period of time, about two weeks, even after ischemia has been relieved (by for instance angioplasty or coronary artery bypass surgery). In this situation, while myocardial blood flow (MBF) returns to normal, function is still depressed for a variable period of time.
Myocardial stunning is the reversible reduction of function of heart contraction after reperfusion not accounted for by tissue damage or reduced blood flow.After total ischemia occurs, the myocardium switches immediately from aerobic glycolysis to anaerobic glycolysis resulting in the reduced ability to produce high energy phosphates such as ATP and Creatinine Phosphate. At this point, the lack of the energy and lactate accumulation results in cessation of contraction within 60 seconds of ischemia (i.e. Vessel Occlusion). Subsequent to this is a period of "myocardial stunning," in which reversible ischemic damage is taking place. At approximately 30 minutes after the onset of total ischemia the damage becomes irreversible, thereby ending the phase of myocardial stunning.
Clinical situations of stunned myocardium are:
acute myocardial infarction (AMI)
after percutaneous transluminal coronary angioplasty (PTCA)
after cardiac surgery
'neurogenic' stunned myocardium following an acute cerebrovascular event such as a subarachnoid hemorrhage
Redmond Regional Medical Center, (originally Redmond Park Hospital), is located in Rome, Georgia, United States, and is one of the largest employers in Floyd County with a staff of 1,200 and over 250 affiliated doctors. Redmond is a 230 bed medical, surgical and rehab unit serving Rome, Floyd County, and surrounding counties.
Serving as the heart hospital for northwest Georgia, Redmond offers cardiac services and is the only dedicated chest pain center in Northwest Georgia. Other areas include emergency care, orthopaedics, vascular care, the surgery center, and an inpatient rehabilitation unit. The hospital does coronary artery bypass surgery, heart attack care, knee surgery, total and partial hip joint replacement, and hip fracture surgery.
Improvements include a new ICU wing, a new 34 bed medical/surgical unit made up of exclusively private rooms and an extended parking lot. Emergency Department and patient room renovations are underway.
Robert S. Poston is an American cardiac surgeon at University of Arizona Medical Center most noted for his research in robot-assisted heart surgery and Coronary Artery Bypass Surgery. Dr. Poston's research interest regarding the mechanism of early graft thrombosis was recognized with a five-year RO1 clinical research grant from the National Institutes of Health in 2007. Consistent with his goal of addressing routine clinical problems with a mechanistic based understanding, he has also been awarded grants from Intuitive Surgical to study how robotics accelerates patient recovery time, Maquet to study the impact of endoscopic harvesting techniques on the quality of bypass conduits and Cardiogenesis to study the impact of laser revascularization techniques on bypass graft flow. He has been the first/senior author of 100 papers and abstracts. His research manuscripts are available on pubmed.
Totally Endoscopic Coronary Artery Bypass Surgery (TECAB) is an entirely endoscopic robotic surgery used to treat coronary heart disease, developed in the very late 1990s. It is an advanced form of Minimally Invasive Coronary Artery Bypass Surgery, which allows bypass surgery to be conducted off-pump without opening the ribcage. The technique involves three or four small holes in the chest cavity through which two robotic arms, and one camera are inserted.
Vasilii Ivanovich Kolesov (September 24, 1904, Martyanovskaja village in Vologda Oblast – August 2, 1992, St Petersburg) was one of the pioneers of global cardiac surgery. He was the first to perform successful internal Coronary artery bypass surgery using mammary artery–coronary artery anastomosis in 1964. Also in 1964, he performed the first successful coronary bypass using a standard suture technique. Kolesov was a recipient of the USSR State Prize and Honoured Worker of Science in USSR (1964).
Wenner Dudley Johnson (April 3, 1930 – October 24, 2016) was an American cardiothoracic surgeon who became known as the father of coronary artery bypass surgery. He and a colleague operated on one of the longest-surviving patients in the early days of heart transplants, and he made significant contributions to several other cardiac surgical procedures.
Walter Douglas Boyd, M.D. is a notable Canadian cardiothoracic surgeon.
born in Ottawa, he is a graduate of Carleton University, and the University of Ottawa for his medical degree. In 1999, he Boyd completed the world's first closed-chest, beating-heart coronary artery bypass surgery with the use of the ZEUS Robotic Surgical System, and has conducted pioneering work in cardiothoracic surgery and the use of robotic surgical systems. Dr. Boyd is also recognized for performing the first human extracellular matrix xenograft implant for cardiovascular repair in March 2006.He was the head of the Department of Cardiothoracic Surgery at the Cleveland Clinic in Florida from 2002-2009. In August, 2009 he was named Professor of Surgery, and Director of Robotics and Biosurgery at the University of California, Davis.Current areas of research include pioneering work in cardiac tissue regeneration with extracellular matrix/stem cells, and remote presence surgery including the development of remote telerobotic surgery systems with supervised autonomy.
He has a wife, Lee and two children.
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