In March 2019, I flew to London, Ontario, Canada to pursue my interest in minimally invasive cardiac surgery (MICS) where I did a year of fellowship at London Health Science Centre, one of the main MICS referral centres in the eastern part of Canada.

During the fellowship, I had a great opportunity to work with two inspiring surgeons who are now my mentors – Dr Michael Chu, who has a special interest in complex aortic surgery, and Dr Bob Kiaii, who takes pride in robotic coronary artery bypass programme.

A passion for MICS

As compared to conventional cardiac surgery carried out through sternotomy, MICS has multiple established benefits such as reduced need for blood transfusion, reduced length of hospitalisation stay and cost, faster recovery and better patient satisfactory from improved cosmetic result.

In fact, I have often heard others describe MICS as a procedure where pain is transferred from the patients to the surgeon! This is probably because the surgeon has to perform the heart operation through a small incision on the side of chest in between the ribs as opposed to a conventional, open heart surgery. In MICS, there is no luxury of having an unrestricted visual on the surgical field and tactile feedback. A successful MICS hinges on careful pre-operative planning and mastery of using long instruments, aided by using endoscope for visual improvement.

Learning from the masters

A typical day at work starts at 6am with ward rounds, followed by clinic sessions or operations, and ending at 7pm after reviewing post-operative patients in intensive care. There were also several call duties a month where I had to attend to issues in ward/ICU and emergency surgery – all not very different from what we do at NHCS.

The exciting moments were those weekly operations on transcatheter valve implantation (TAVI) and keyhole mitral/ aortic valve surgery which I performed together with my mentors. Not only did I gain experience in keyhole valve surgery and robotic coronary bypass surgery, I had the exposure to rare complex aortic surgeries.

In Canada, a typical patient is generally larger in size than our Asian counterparts, and it is not uncommon to have a patient who is over 100 kg.

It was an eye-opener to see how my mentors performed a mitral valve surgery on a thick-chested patient via a mere 4-cm incision in a very respectable time frame. Interestingly, it is precisely this group of patients who would benefit most from MICS albeit very challenging for the surgeon – as MICS offers smooth and fast recovery and reduced risk of complications (such as poor wound or bone healing if it was done via sternotomy). Now, we know why MICS is often described to be having ‘pain transferred from patient to surgeon’!


It is not all work and no play as Dr Chua also took the chance to explore Canada on his off days.
Patience through it all

For me, the most challenging part of MICS is not the technical part of the surgery. It is extremely crucial to maintain an extraordinary sense of calmness and patience when performing surgery, and to be swift in making appropriate strategy changes for patient’s safety, for instance, convert to open chest surgery.

My mentors had inspired and instilled in me these valuable virtues – (1) to perform MICS with careful planning and great patience, (2) not to give up easily in the face of challenges yet know when not to proceed when it is unsafe to do so, and lastly, the technical knowledge and skills will come naturally as one’s experience accumulates.

Benefits for NHCS patients

In NHCS, together with my fellow surgeon, Dr Naik Madhava Janardhan, Senior Consultant from the Department of Cardiothoracic Surgery, we have been offering keyhole coronary artery bypass for suitable patients. On an average, we perform about 30 such surgeries annually. While valve surgery is still mainly performed via open chest in NHCS, I have performed a few keyhole valve surgeries on suitable patients since my return from the HMDP.

MICS is already a standard approach for straight forward cases in many parts of the world. In NHCS, with the well-equipped MICS equipment, trained anesthetists, scrub nurses, perfusionists and experienced cardiologists, I am confident that more of our patients could benefit from MICS in future.