Husam Balkhy, MD: On a relentless quest to make heart surgery less invasive for all patients

Husam Balkhy, MD, has long been captivated by the human heart.

"It’s the most intelligent organ — it’s the organ of life," said Balkhy, a renowned heart surgeon and an expert in robotic cardiac surgery at the University of Chicago Medicine.

He saw his first heart operation fresh out of high school in Saudi Arabia, while volunteering in the hospital over the summer. It was an aortic valve replacement.

“They brought the heart to a standstill, then lowered the valve into the heart to repair it, and then reanimated it at the end of the operation,” Balkhy said, recalling the awe he felt at the time. “I just couldn’t get over it. I told myself that I needed to be doing that.”

Several decades later, Balkhy is now the director of robotic and minimally invasive cardiac surgery at UChicago Medicine and one of the most experienced and renowned robotic heart surgeons in the world, with more than 2,000 robotic heart surgeries under his belt.

But when he was a young medical student in Saudi Arabia and then later as a resident in Boston, minimally invasive and robotic heart surgery was still in its infancy. It was during his residency that Balkhy started to feel dissatisfied — not with the procedures he performed on patients' hearts, but the techniques he had to use to access them.

Challenges of Open-Heart Surgery

Evolution has graced humans with a large, sturdy rib cage, which surrounds and protects critically important heart and lung tissue from damage. Traditional open-heart surgical approaches require surgeons to cut directly through the breastbone and open up the rib cage to access the heart.

This means that, in addition to recovering from heart surgery, patients also have to recover from cracked ribs and a broken breastbone.

“That’s how I was trained and how I worked for many years, but I was unhappy making these big cuts in people," Balkhy said. "I thought all the time about ways that I could fix a problem without invading the body in such a big way.”

Balkhy was also struck by the emotional struggles faced by many patients after an open-heart surgery.

“One of the unspoken problems with major open surgeries like these is that patients have a hard time recovering — not just physically, but psychologically," he said. "Patients sometimes feel that their body has been seriously violated, and they’re left with these massive scars that they have to see every day in the mirror. It can leave patients feeling like they’re not the same person they were before.”

It was the early 1990s when Balkhy, as a junior general surgery resident, saw laparoscopic techniques emerge as a minimally invasive option for abdominal operations. In cardiac surgery, however, there were few alternatives available for surgeons outside of the usual open-heart surgery techniques.

After a couple of years in practice, Balkhy began to explore new, less invasive surgical options, using tools such as small cameras and extra-long surgical instruments to conduct surgeries through small incisions between the ribs. While these techniques led to reduced recovery time and less scarring, they didn't give him the dexterity needed to expand the approach to a broader range of surgeries.

Robots: A Minimally Invasive Option

As he continued to test new methods, Balkhy eventually began to hear about another option: robotic surgery.

“I was still learning the ropes of heart surgery and perfecting my art when the first robotic heart surgery was performed in Paris in 1998," he said. "But as I was building on these less invasive approaches, it quickly became apparent to me that the robot was going to be the best option to achieve my minimally invasive goals.”

Robotic arms could go where his hands and long tools could not, making those delicate procedures possible again. There was just one problem: How could he convince his hospital to invest in such a big and expensive resource, especially when the existing approaches were working?

Balkhy decided to show them exactly what he was dealing with. He pitched the idea of robot-assisted surgery to hospital leadership, then invited the CEO to join him in the operating room to observe an open-heart surgery.

“Look at how we operate,” Balkhy remembered saying. “Look at this big opening I had to make in this patient’s chest to see the heart.”

Hospital leadership quickly changed their tune.

“After looking tentatively over the anesthesia curtain at the big cut we had just made in the patient’s chest, the CEO asked me, ‘Where do you think a robot would fit in this room?’ and I pointed and said, ‘Right over there, in the corner,’” Balkhy recounted with a grin. “Then the CEO said he felt like he might faint and had to leave the room.”

Thanks to the vivid demonstration, Balkhy got his surgical robot less than six months later.

“We're going to do it, if that's what will benefit you the most.”

With the new system in place, Balkhy was able to break new ground, conducting coronary artery bypass surgeries, mitral valve repairs and arrhythmia corrections using dexterous robotic arms and cameras inserted into the chest through incisions between the ribs less than a centimeter across.

The use of robots allowed him to work on developing new applications for the technology in surgical settings, but he knew he could do so much more with this technique.

A New Home At UChicago Medicine

Many hospitals will perform these minimally invasive robotic surgeries on certain types of patients or for specific kinds of procedures. At most institutions, the criteria for who is eligible typically boils down to concerns about patient recovery rates and risk factors.

“Most programs don’t internalize the use of robotics as a philosophy,” said Balkhy. “So, they don’t operate on certain kinds of patients — those who are obese, elderly, medically frail or have already had heart surgery — because they’re considered too risky. Many programs feel that robotics can be used only in situations where the outcome is guaranteed to be pristine, because they are less comfortable with the technique.

“But these less-than-perfect patients are the ones who would often benefit the most from these minimally invasive approaches.”

UChicago Medicine recognized Balkhy’s dedicated and relentless approach to robotic heart surgery and invited him to establish a robotic cardiac surgery program at the academic medical center. He immediately saw that UChicago Medicine's commitment to rigorous biological research would allow him to develop new surgical approaches for his work and the dedication to advancing medicine through innovative patient care would support his goals of expanding robotic approaches in the surgical field.

In 2013, Balkhy moved his team to the Center for Care and Discovery, UChicago Medicine’s $700 million, newly opened state-of-the-art hospital with a name that fit his vision.

“I was so impressed with UChicago Medicine’s commitment to innovation and to supporting a program like mine,” Balkhy said. “The leaders saw my work as something that they could help grow. This was before all of the other big programs started espousing robotics. UChicago Medicine really saw the potential here.”

Balkhy has been able to work with his highly skilled team to continue to develop new surgical approaches using the robot, and nearly all of his heart surgeries are executed using a robotic approach. In addition to the dual console robot dedicated to his program in the operating room, Balkhy also has access to a robot in the lab, where he can test new procedures, techniques and devices, as well as train a junior partner to perform the kinds of surgeries he does.

“Many hospitals that perform robotic heart surgeries use them for only one kind of surgery, and you have to fit a very narrow profile to be eligible for it,” Balkhy said. “I think these robots can facilitate all kinds of surgeries — most procedures could probably be done less invasively and, in most cases, robotically.

"Sometimes the traditional open-heart approach is the best option for a patient, but in our program, we do everything we can with the robot. No other program in the world uses the robot for as many procedures as we do.”

In August 2020, Balkhy and his team performed their 1,000th robotic heart surgery since he started the program at UChicago Medicine seven years ago, and the department has nearly half a dozen da Vinci surgical robots onsite to support these procedures. He has realized many of his goals in bringing the benefits of less invasive surgery to his patients, who are usually in the hospital for only a couple of days and are back to normal activity within a week or two after robotic surgery — compared to three to four months after traditional surgery.

“In our program, if you’re high risk but you need a coronary bypass, I’ll operate with the robot because I know that it’s the best thing for you,” said Balkhy. “It doesn’t matter if it’s hard, if it takes all day, if it takes extra resources to find the right angle or figure out the right route. We’re going to do it, if that’s what will benefit you the most.”