The crux of the problem as it relates to MIS is that knot tying with traditional suture materials using laparoscopic or robot-assisted tools can lead to increased operation times. Operating time can be especially critical for cardiac procedures involving cardiopulmonary bypass (CPB). Increased CPB times lead to higher risks of multiple organ dysfunction syndrome (MODS), and procedures involving CPB are linked to adverse cerebral outcomes, including strokes, transient ischaemic attacks and seizures. Patient mortality rates increase with the time during which the heart is arrested, especially in the case of older patients. This leads to the double bind between the ‘need for speed’, which the direct access and visibility of traditional ‘open heart’ procedures allow, and the requirement that the MIS patient be comparatively ‘young and healthy’ to survive the increased CPB times required for MIS. Furthermore, older patients and otherwise ‘unhealthy’ patients make up a majority of the candidates requiring surgical procedures. To address this need, various laparoscopic instruments have been developed to automate the knot-tying process or deploy pre-tied sliding knots. Devices include the Autosuture™ Endo Stitch (Covidien, Mansfield, MA, USA), the Suture Assist (Ethicon Endo-Surgery, Cincinnati, OH, USA), and a Suture Cartridge as well as others. Suture-free alternatives such as staples, clips and glues have proven effective in certain procedures but can have limited applicability. For example, the nitinol U-clip™ (Medtronic ® ) has been used effectively to secure annuloplasty bands in minimally invasive mitral valve repair, but cannot be used for leaflet repair.
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