Robot-assisted mitral valve surgery may be supported by patient-specific planning aid in port placement

Robotic-assisted mitral valve surgery is gaining renewed popularity in the global surgical community. Appropriate patient-specific planning is pivotal for the safety and effectiveness of this procedure. One main step in this perspective is represented by the choice of placement of four ports in the right chest, for the introduction of robotic arms. Individual anatomical features (e.g., chest morphology and position of the mitral valve inside the chest) may determine inadequate surgical exposure, conversion to open procedure, or refusal for the technique. Currently, and contrary to robotic-assisted procedures in other surgical specialties, there is no dedicated approach or tool for patient-specific planning aimed at formally addressing these issues preoperatively. Herein, we present a dedicated, comprehensive method entailing: a homemade algorithm for rib segmentation (deep learning approach) and identification of intercostal spaces / candidate port entry sites; semiautomatic definition of a target working volume (mitral valve); definition of dedicated Performance Measure J* based on each potential triad of thoracic ports entry sites. We propose the dedicated J* parameter to better indicate the optimal patient-specific entry port solution than other parameters (h_e, ic, CCI and E). Prospective clinical studies should be based on the J* parameter. We hypothesize that this approach, dedicated to the requirements of robotic-assisted mitral valve surgery, may enhance the safety and the diffusion of this surgical strategy.