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SECTION 7 Technical aspects ofcoronary artery bypass graft surgery348
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10. Kolh P, Wijns W, Danchin N, Di Mario C, Falk V, Folliguet T, etal.
Task Force on Myocardial Revascularization of the European
Society of Cardiology (ESC) and the European Association for
Cardio- oracic Surgery (EACTS); European Association for
Percutaneous Cardiovascular Interventions (EAPCI), Guidelines
on myocardial revascularization. Eur J Cardiothorac Surg.
2010;38(Suppl):S1– 52.
11. Kolh P, Windecker S, Alfonso F, Collet JP, Cremer J, Falk
V, etal. Task Force on Myocardial Revascularization of the
European Society of Cardiology and the European Association
for Cardio- oracic Surgery; European Association of
Percutaneous Cardiovascular Interventions. 2014 ESC/
EACTS Guidelines on myocardial revascularization:the
Task Force on Myocardial Revascularization of the European
Society of Cardiology (ESC) and the European Association for
Cardio- oracic Surgery (EACTS). Eur J Cardiothorac Surg.
2014;46(4):517– 92.
12. Sousa- Uva M, Neumann FJ, Ahlsson A, Alfonso F, Banning
AP, Benedetto U, etal. 2018 ESC/ EACTS Guidelines on
myocardial revascularization. Eur J Cardiothorac Surg.
2019;55(1):4– 90.
13. Di Giammarco G, Canosa C, Foschi M, Rabozzi R, Marinelli
D, Masuyama S, etal. Intraoperative graft verification
in coronary surgery:increased diagnostic accuracy
adding high- resolution epicardial ultrasonography to
transit- time flow measurement. Eur J Cardiothorac Surg.
2014;45(3):e41– 5.
14. Di Giammarco G, Marinelli D, Foschi M, Di Mauro M.
Intraoperative gra verication in coronary surgery. J Cardiovasc
Med. 2017;18(5):295– 304.
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49
Minimally invasive direct
coronary arterybypass
Volkmar Falk and Sebastian Holinski
Definition
ere are dierent minimally invasive approaches in coronary bypass surgery. Avoiding sternotomy and gaining access to the heart
via an alternative route is one strategy. Another is to avoid cardiopulmonary bypass. Combining these two measures denes the classical minimally invasive direct coronary artery bypass (MIDCAB)
procedure. While multiple gras can be placed through a limited
mini- thoracotomy on the beating heart, the classic MIDCAB procedure is usually limited to graing of the le internal thoracic artery (LITA) to the le anterior descending artery (LAD).
Indications andcontraindications
For patients with single- vessel coronary artery disease of the proximal LAD, there is a classIA recommendation for surgery according
to the European Society of Cardiology (ESC)/ European Association
for Cardio- oracic Surgery (EACTS) 2018 Guidelines on myocardial revascularization. ese patients are ideal candidates for
a MIDCAB operation, and the 2018 ESC/ EACTS Guidelines provide a classIIA recommendation for MIDCAB in patients with isolated LAD lesions. For patients with restenosis aer percutaneous
coronary intervention (PCI) of the proximal LAD and/ or chronically occluded LAD with viable myocardium, MIDCAB is an excellent option. MIDCAB is also feasible in selected patients with
multivessel disease, either performing complete surgical or hybrid
revascularization. Hybrid revascularization with PCI before, during,
or aer the MIDCAB procedure may be benecial for selected elderly and frail patients. In addition, patients with long- term steroid
use and those with arthritic or orthopaedic problems needing a
walking aid should be spared sternotomy, and a mini- thoracotomy
should be preferred. Incomplete MIDCAB revascularization with
only LITA to LAD is acceptable in selected patients if other diseased
vessels cannot be treated surgically or with PCI, or if there is no viability in the remaining target regions.
ere are some contraindications for the classic MIDCAB pro-
cedure. It should not be performed if the diameter of the LAD is
smaller than 1mm or if there is very diuse distal disease. Ahighly
calcied or intramural LAD can also be technically challenging.
Morbidly obese patients and those who suer from severe chronic
obstructive pulmonary disease are not good candidates for a le
mini- thoracotomy due to access- related problems and the need
for single- lung ventilation. Other relative contraindications include emergency cases, patients with haemodynamic instability, or
previous coronary artery bypass gra (CABG) surgery. However,
MIDCAB can be an attractive option for reoperation in patients
with an occluded vein gra to the LAD and a preserved LITA.
Preoperative diagnostic tests andimaging
Patients considered for MIDCAB should generally receive the same
diagnostic work- up as standard CABG patients (coronary angiography, electrocardiogram, chest X- ray, echocardiography, pulmonary
function test, and blood sample). Dobutamine stress echocardiography, positron emission tomography/ computed tomography, or
contrast magnetic resonance imaging is helpful to determine viability of the target region. Athoracic electrocardiogram- gated computed tomography scan should be performed to determine best
anatomical access and to locate and determine the quality of the
target vessel, especially in cases with chronic total occlusion of the
LAD and little retrograde lling.
Operativetechnique
Patients can be placed in a supine position under general anaesthesia. Importantly, the le hemithorax is slightly elevated and the
shoulder dropped in order to provide maximum access. Placement
of a double- lumen endotracheal tube or endobronchial blocker
balloon for single right lung ventilation is required. Anaesthetic
management is generally the same as for o- pump CABG procedures. e chest and groins should be disinfected and prepped into
the sterile eld to prepare for emergent conversion to sternotomy
or femoro- femoral cardiopulmonary bypass installation in case of
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Fig.49.1 Dissected left internal thoracic artery using the Thoralift
retractor and electrocautery.
®
Fig.49.2 Completed left internal thoracic artery to left anterior
descending coronary artery anastomosis with myocardial wall stabilizer
still in place.
haemodynamic instability. A5– 8cm anterolateral, infra- mammary
skin incision is performed to access the fourth or h intercostal
space. e pectoralis muscle should not be cut but rather bluntly
divided in the direction of its bres to achieve a good cosmetic result. e intercostal muscles are widely opened to reduce the risk
of rib fracture. Arib retractor is introduced and the pericardium
may be opened at this point to visualize the LAD. It is recommended
to proceed with the procedure only when the LAD is visible, large
enough, not too calcied, and accessible. e internal thoracic artery takedown can be performed either under direct vision or endoscopically. For direct vision harvest, specially designed asymmetric
rib spreaders are used. Either a skeletonized or pedicled dissection
technique is feasible by the MIDCAB approach; the skeletonized
technique may be slightly more technically demanding, but generally provides a longer conduit. Endoscopic dissection is possible
manually or with robotic assistance. e dissection of the LITA is
completed up to the subclavian vein and down past the h intercostal space (Fig. 49.1). Additional gras in case of multivessel
they are more expensive and may require slightly more space inside
the thorax. e LAD is dissected and opened aer proximal snare
occlusion. Insertion of an intraluminal shunt is not mandatory but
may be useful occasionally to maintain distal perfusion. Acarbon
dioxide mister- blower helps to provide a bloodless eld. e anastomosis is performed with an 8- 0 Prolene® suture in a running fashion
(Fig. 49.2). Blood ow measurement in the gra is checked with a
ow probe. Half- dose protamine is given to incompletely reverse
the eect of heparin. Careful inspection of the harvest sites for potential bleeding sources is important before taking out the retractor
because later access can be cumbersome. Haemostasis is performed
and a chest tube(s) is/ are placed into the le pleural space. e insertion of an intercostal pain catheter is recommended. e chest is
closed in a standard fashion. Lifelong aspirin intake of 100 mg per
day aer the operation is recommended. Temporary clopidogrel administration is optional depending on quality of target vessels and
presence of stents.
revascularization (e.g. radial artery, right internal thoracic artery)
may also be harvested, preferably in minimally invasive or endoscopic fashion. Usually Y- gras with the LITA are created before the
Perioperativeresults
distal anastomoses are performed.
Intravenous heparin is given to achieve an activated clotting time
of 300 seconds throughout the operation. In order to provide a clean
surgical eld, a so tissue retractor may be used. Distal anastomoses
are performed as in o- pump CABG procedures. Acoronary artery
stabilizer is placed either through the thoracotomy or through a separate port. Pure pressure stabilization may be sucient for the LITA
to LAD anastomosis; one advantage of this approach is reduced cost
achieved by utilizing a reusable metal stabilizer. Vacuum- assisted
stabilizers may also be used, and these may provide superior stabilization with lesser degree of haemodynamic compromise, although
e MIDCAB operation can be safely performed with low morbidity and mortality (Fig. 49.3). In one of the largest reported singlecentre experiences, Holzhey etal. evaluated a series of more than
1300 patients with mean age of 63years and mean ejection fraction of 61%. Multivessel disease was present in 36% of the patients.
Mean operation time was 106 ± 14 minutes with one distal anastomosis performed in 95.5%. Ahybrid procedure was performed in
5.9%. Conversion to sternotomy was necessary in 1.1% and cardiopulmonary bypass was used in 0.7%. Low- cardiac output requiring
mechanical support (intra- aortic balloon pump/ extracorporeal
49 Minimally invasive direct coronary arterybypass 351
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included. Perioperative as well as mid- and long- term results up to
10years were taken into account. ere was no dierence with regard to stroke, myocardial infarction, and mortality between both
therapies. However, there was an increased incidence of MACCE
aer PCI as early as 6months aer the procedure that persisted
over the years and was mainly caused by repeat target vessel
revascularization (TVR). In the presence of chronic total occlusions, MIDCAB produced better short- and long- term results as
compared with PCI.
Outcomes of the dierent stent types compared to MIDCAB
were also studied. Comparison of bare- metal stents versus
MIDCAB for stenosis of the LAD in a randomized trial showed,
again, more MACCE due to more TVR (29% vs 8%; P=0.003) and
less freedom from angina in PCI patients (79% vs 62%; P=0.03) at
6- month follow- up. e signicantly greater need for TVR persisted in the PCI group and was still present 10years aer the procedure. ere was no signicant dierence in the rate of death
or myocardial infarction at any time during follow- up. is is in
accordance with the results for drug- eluting stents (DES) versus
MIDCAB in a meta- analysis of Raja and colleagues. In more than
900 patients with follow- up times from 6months to 7years, patients treated with DES were shown to have a greater need for TVR
Fig.49.3 Angiogram showing left internal thoracic artery to left anterior
descending coronary artery bypass after MIDCAB operation.
with no signicant dierences in death and myocardial infarction.
However, at 10 years postoperatively, Benedetto and colleagues
found that PCI with DES was associated not only with a 2.0- fold
increased risk of repeat revascularization (P= 0.008), but also a
membrane oxygenation) was necessary in 0.8%. Incidences of postoperative complications were as follows:stroke, 0.4%; acute kidney
injury requiring dialysis, 0.6%; myocardial infarction, 0.6%; wound
infection, 0.9%; respiratory failure requiring prolonged ventilation,
1.8%; and reoperation for bleeding, 3.4%. Routine angiogram before discharge revealed a patency rate of 95.6%. Early postoperative
2.2- fold increased risk of late death (P=0.01). e greater survival of MIDCAB patients was present across all age classes and
independent of diabetes status or type of DES, in this study with
larger sample size. It was assumed that a lack of statistical power
was the reason why other studies did not detect a survival benet
of MIDCAB compared to PCI.
mortality was 0.8% and compared favourably with an EuroSCORE
of 3.6% as well as with the 1.2% mortality for o- pump single bypass graing as reported in the registry of the German Society of
Conclusion
oracic and Cardiovascular Surgery. e results of Holzhey etal.
were also in line with those of a comprehensive review of MIDCAB
studies done by Kettering et al. Compared with conventional
CABG, MIDCAB may reduce the initial postoperative morbidity
rate and hospital costs, especially in high- risk patients, as shown by
Magovern and colleagues.
MIDCAB can be performed with excellent perioperative as well as
long- term results. It provides minimal surgical trauma compared
with standard CABG and superior revascularization results than
PCI. erefore, MIDCAB should be considered a rst- line treatment at least in patients with isolated disease of the LAD.
Mid- term and long- term results of the MIDCAB procedure have
been studied by multiple groups. e group of Al- Ruzzeh reported
excellent health perception and quality of life in patients 1year aer
the operation. A5- year follow- up in a large series of patients revealed
a survival rate of 91.9% and a rate of freedom from major adverse
cardiac and cerebrovascular events (MACCE) and angina of 98.5%.
Other groups made similar observations., Afollow- up available for
more than 700 patients showed a 10- year survival rate of 76.6% as
well as a 10- year rate of freedom from MACCE and angina of 70.9%.
Vicol etal. found a slightly higher rate of mid- term adverse events
such as recurrence of angina and need for coronary reintervention in
MIDCAB patients compared to LITA– LAD o- pump CABG.
MIDCAB results should also be compared to PCI, another established therapeutic option for single- vessel disease of the LAD.
Deppe and colleagues performed a meta- analysis of 12 studies
comparing MIDCAB versus PCI. More than 2800 patients were
REFERENCES
1. Neumann FJ, Sousa- Uva M, Ahlsson A, Alfonso F, Banning AP,
Benedetto U, etal. 2018 ESC/ EACTS guidelines on myocardial
revascularization. Eur Heart J. 2019;40(2):87– 165.
2. Holzhey DM, Jacobs S, Mochalski M, Walther T, iele H, Mohr
FW, etal. Seven- year follow up aer minimally invasive direct
coronary artery bypass experience with more than 1300 patients.
Ann orac Surg. 2007;83(1):108– 14.
3. Beckmann A, Funkat AK, Lewandowski J, Frie M, Ernst M,
Hekmat K, etal. Cardiac surgery in Germany during 2014. orac
Cardiovasc Surg. 2015;63(4):258– 69.
4. Kettering K, Dapunt O, Baer FM. Minimally invasive direct
coronary artery bypass graing:a systematic review. J Cardiovasc
Surg. 2004;45(3):255– 64.
SECTION 7 Technical aspects ofcoronary artery bypass graft surgery352
https://t.me/medicina_free
5. Magovern JA, Benckart DH, Landreneau RJ, Sakert T, Magovern
GJ Jr. Morbidity, costs, and six- month outcome of minimally
invasive direct coronary artery bypass graing. Ann orac Surg.
1998;66(4):1224– 9.
6. Al- Ruzzeh S, Mazrani W, Wray J, Modine T, Nakamura K,
George S, etal. e clinical outcome and quality of life following
minimally invasive direct coronary artery bypass surgery. J Card
Surg. 2004;19(1):12– 6.
7. Ziminarino M, Gallina S, Di Fulvio M, Di Mauro M, Di
Giammarco G, De Caterina R, etal. Intraoperative ischemia and
long- term events aer minimally invasive coronary surgery. Ann
orac Surg. 2004;78(1):135– 41.
8. Fraund S, Herrmann G, Witzke A, Hedderich J, Lutter G, Brandt
M, etal. Midterm follow- up aer minimally invasive direct
coronary artery bypass graing versus percutaneous coronary
intervention techniques. Ann orac Surg. 2005;79(4):1225– 31.
9. Holzhey DM, Cornely JP, Rastan AJ, Davierwala P, Mohr FW.
Review of a 13- year single- center experience with minimally
invasive direct coronary artery bypass as the primary surgical
treatment of coronary artery disease. Heart Surg Forum.
2012;15(2):E61– 8.
10. Vicol C, Nollert G, Mair H, Samuel V, Lim C, Tiikidis M,
etal. Midterm results of beating heart surgery in 1- vessel
disease:minimally invasive direct coronary artery bypass versus
o- pump coronary artery bypass with full sternotomy. Heart Surg
Forum. 2003;6(5):341– 4.
11. Deppe AC, Liakopoulos OJ, Kuhn EW, Slottosch I, Scherner M,
Choi YH, etal. Minimally invasive direct coronary bypass versus
percutaneous coronary intervention for single- vessel disease:a
meta- analysis of 2885 patients. Eur J Cardiothorac Surg.
2015;47(3):397– 406.
12. Holzey DM, Jacobs S, Walther T, Mohr FW, Falk V. Is
chronic total occlusion a risk factor for long- term outcome
aer minimally invasive bypass graing of the le anterior
descending? Ann orac Surg. 2010;89(5):1496– 501.
13. Diegeler A, iele H, Falk V, Hambrecht R, Spyrantis N, Sick P,
etal. Comparison of stenting with minimally invasive bypass
surgery for stenosis of the le anterior descending coronary
artery. N Eng J Med. 2002;347(8):561– 6.
14. Blazek S, Holzhey D, Jungert C, Borger MA, Fuernau G, Desch
S, etal. Comparison of bare- metal stenting with minimally
invasive bypass surgery for stenosis of the le anterior descending
coronary artery:10- year follow- up of a randomized trial. JACC
Cardiovasc Interv. 2013;6(1):20– 6.
15. Raja SG, Uzzaman M, Garg S, Santhirakumaran G, Lee M, Soni
MK, Khan H. Comparison of minimally invasive direct coronary
artery bypass and drug- eluting stents for management of isolated
le anterior descending artery disease:a systematic review
and meta- analysis of 7710 patients. Ann Cardiothorac Surg.
2018;5(5):567– 76.
16. Benedetto U, Raja SG, Soliman RF, Albanese A, Jothidasan A,
Ilsley CD, etal. Minimally invasive direct coronary artery bypass
improves late survival compared with drug- eluting stents in
isolated proximal le anterior descending artery disease:a 10year follow- up, single- center, propensity score analysis. J orac
Cardiovasc Surg. 2014;148(4):1316– 22.
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50
Robotic coronary artery surgical
revascularization
Bob Kiaii, Vincenzo Giambruno, Michael W.A. Chu,
Mary Ann C. Wertan, and Francis P. Sutter
Evolution ofminimally invasive robot- assisted
coronary bypasssurgery
With a general trend in surgery towards endoscopic approaches,
cardiac surgeons, over the last 15years, have recognized the importance of achieving video dexterity and are adopting video- assisted
techniques in increasing numbers. e early work by Drs Nataf in
Paris, Mayeld in Atlanta, and Wolf in Cincinnati, laid the groundwork for an endoscopic minimally invasive revolution. e development of video- assisted techniques and the use of new equipment in
cardiac procedures represented a paradigm shi and quantum leap
in our eorts to provide a less traumatic coronary revascularization
procedure. In parallel to these developments, new robotic technology was emerging and demonstrating ecacy in endoscopic surgery in other disciplines.
ere are presently two levels of robotic coronary surgery being
practised:
1. Telerobotic conduit harvesting and manual anastomosis— known
as endoscopic atraumatic coronary artery bypass (endoACAB)
or robotic minimally invasive direct coronary artery bypass
(MIDCAB):the internal thoracic artery (ITA) is harvested from
the master console, using the da Vinci® Surgical System (Intuitive
Surgical, Sunnyvale, CA, USA) and anastomosis performed
manually through a mini- thoracotomy.
2. Totally endoscopic coronary artery bypass (TECAB), with either
arrested or beating heart:the ITA is harvested from the master
console and anastomosis performed robotically from the master
console via port- access on the arrested or beating heart.–
Indications forroboticrevascularization
• Complex le anterior descending artery (LAD) disease:ostial,
bifurcation, calcied, long lesions, and chronic occlusions.
• Multivessel disease utilizing bilateral ITA or hybrid technique
(generally le ITA (LITA)- to- LAD graing plus percutaneous
coronary intervention to non- LAD vessels).
• Distal le main disease when le main and circumex could be
stented aer LITA has been placed to LAD.
• High risk for open sternotomy approach.
Patientselection
e patient selection process involves a history and physical exam
heavily weighted on uncovering factors aecting external and internal thoracic structures. Anatomy hindering preoperative port
placement, limiting robotic arm movement (working space),
or reducing the already limited eld of view inside the thorax,
will cause a signicantly increased chance of surgical error and
expose the patient to unnecessary risk (Box 50.1). e assessment
of the intrathoracic working space and general chest conditions
(i.e. adiposity) should be based upon preoperative computed
tomography.
Box 50.1 Patientselection
Absolutecontraindications
• Extensive pleural symphysis.
• Previous left lung surgery.
Relativecontraindications
• Severe obesity.
• Significant cardiac enlargement (insufficient space in thoracic cavity).
• Thick chest wall.
• Previous history of coronary artery bypass surgery.
• Diffuse distal coronary disease.
• Intramyocardial coronary arteries.
• Severe pulmonary disease (intolerance to single- lung ventilation).
SECTION 7 Technical aspects ofcoronary artery bypass graft surgery354
Distal endProximal end
Endoscope port (5th ICS)
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• Outline the draped chest with a felt marker.
• Based on the patient’s chest X-ray and computerized Tomography,
precisely mark the suprasternal notch, the xiphoid, the midline of
the sternum, the probable route of the LITA and the LAD, the diaphragm, and how far the apex of the heart extends laterally in the
le chest.
• Continue to precisely mark where each port is to enter the thor-
acic cavity (Fig. 50.1) using the triangle model conguration
(Fig. 50.2 and Fig. 50.3):
■ Proximal to distal end of LITA is one side of triangle (surgical
area).
■ Endoscope positioned at h intercostal space (ICS) in axillary
line (one vertex of triangle).
■ Lines from endoscope port extend to both proximal and distal
ends of the LITA (triangle formed).
Fig.50.1 Image of a patient with the necessary landmarks for port
placement marked using the triangle model configuration.
■ ‘Camera cone’ created (Fig. 50.2).
■ Instrument ports are placed outside the camera cone (Fig. 50.3).
■ Place ports a few centimetres o the line of the dened triangle.
Operativetechnique
Anaesthesiaconsiderations
• Double- lumen endotracheal tube or bronchial blocker.
• Carbon dioxide insuations of the thoracic cavity (intrathoracic
pressures of 5– 14mmHg).
• Maintaining normothermia with warming and forced air
blankets.
Importance ofsurgicalteam
A dedicated surgical team is a must and will facilitate the nuances
of robotic approaches, instrument exchanges, and troubleshooting
robotic arm restrictions or limitations.
Preparation, positioning, anddraping
Proper positioning minimizes interference from internal and external body structures with the robotic equipment and ensures the
necessary landmarks for port placement in order to maximize robotic arm manoeuvrability (Fig. 50.1).
Standardized guidelines forportplacement
Proper and meticulous port placement is fundamental to the success of the operation, allowing the least amount of impedance to
the robotic arms, and avoiding internal and/ or external robotic arm
collisions.
■ Allow 7– 10cm between ports to ensure robotic arms have full
range of motion without collision.
■ Create a circle from the camera port (7– 10cm) and avoid placing ports inside this circle.
• Common port locations:
■ Port sites will vary based on body habitus. A larger thorax
would require more obtuse angles in order to visualize the entire
anatomy whereas as a small thorax would require more acute
angles.
■ Endoscope port:h ICS anterior axillary line (AAL) or slightly
medial to this point depending on body habitus.
■ Right and le instrument ports:third and seventh ICS respectively. 2– 3cm medial to the AAL or midway between AAL and
mid- clavicular line (MCL).
■ Some robotic coronary surgeons favour a more linear placement
of the ports in the second, fourth, and sixth intercostal spaces,
aligning them from the AAL (second ICS port) to midway between the AAL and MCL (sixth ICS), with the camera port slightly
medial to the AAL in the fourth ICS. In this approach, there is
only a very shallow triangle, if any, dened by the three ports.
Takedown ofLITA
• Request single- lung ventilation.
• Insert the endoscope port. Ensure that no adhesions will pre-
clude the possibility of performing the procedure endoscopically.
Fig.50.2 Creation of the ‘camera cone’ using the triangle model configuration. 5th ICS, fifth intercostal space.
LITA
Camera cone
No port zone
50 Robotic coronary artery surgical revascularization 355
Distal endProximal end
Endoscope port (5th ICS)
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Camera cone
}
Fig.50.3 Instrument ports are placed outside the camera cone. 5th ICS, fifth intercostal space.
LITA
Place ports off line
Robot arm ports
No port zone
Insuate the thoracic cavity with carbon dioxide through the insuation port on the endoscope cannula.
• Insert the 30º endoscope angled up. Locate the distal and prox-
imal ends of the LITA and ensure the endoscope does not collide
with external body parts such as the hip or shoulder.
• Observe insertion of other instrument ports with direct view
from the endoscope.
• Some robotic coronary surgeons habitually insert a Veress
needle into the second or third ICS and insuate carbon dioxide
to create a safe le pneumothorax prior to inserting the camera
port in the fourth or h ICS. An additional technique to promote safety may be to utilize the OptiView® camera- guided
trocar to insert the camera port. ese two measures may minimize the risk of inadvertent pulmonary or cardiac injury during
port placement.
• Dock the robot and adapt the robotic arms to the appropriate
endoscopic ports.
• Insert the instruments via ports and attach to the instrument
arms.
• Initial inspection of the LITA.
• e ITA can be harvested (Box 50.2) as a pedicle (Box 50.3) or
using a skeletonizing technique (Box 50.4).
Haemostasismanagement
It is important to maintain meticulous haemostasis, otherwise the
tissue becomes bloodstained, making further dissection of tissue
more dicult.
To maintain haemostasis when bleeding occurs, evaluate the
severity of the bleed in relation to the increased magnication
of the image projected by the endoscope. When small venous or
arterial branches are responsible, apply gentle pressure to the area
for 2– 3 minutes with the tip of the robotic instruments. is is
oen all that is required. If bleeding continues and the site of concern is in clear view, apply a clip to the vessel and cauterize the
distal end.
If bleeding is felt to be of a high severity or the patient shows
signs of haemodynamic instability, remove robotic instrumen-
Box 50.2 Key points fora successful robotic- assisted takedown
oftheITA
• Progress in a slow and controlled manner maintaining haemostasis.
• Identify ITA and vein and work from the known to the unknown.
• Keep ITA and robotic instruments in view at all times.
• Use ‘no- touch’ technique to mobilize ITA to reduce trauma.
tation immediately and consider conversion to sternotomy.
Robotic coronary artery bypass graing (CABG) should have an
extremely low mortality rate; willingness to convert to sternotomy
to maintain patient safety is an essential mindset.
Pericardiotomy
• Many surgeons rst create a pericardiotomy posterior to the
le phrenic nerve for drainage before approaching the anterior
pericardium.
• Dissect and retract the anterior pericardial fat laterally. is fat
may be abundant and is more easily managed endoscopically than
through a very small mini- thoracotomy.
• Pericardium is opened lateral to the pulmonary artery, usually
3– 4cm anterior to the phrenic nerve.
• e LAD is identied based on its anatomy.
• Identify all branches of the LAD and the diagonal system, thus
avoiding graing to the wrong vessel.
• Mark target site, applying clips into adjacent epicardium.
LITA toLADanastomosis
Mini- anterior thoracotomy approach or atraumatic coronary
arterybypass
(See Boyd etal. and Kiaii etal. for details.)
• e ITA pedicle is transected and to avoid torsion, using a clip, it
is attached to the edge of the pericardium in the normal anatomical orientation.
• Insert a long needle under the direct visualization of the endo-
scope to identify the optimal ICS to perform thoracotomy for best
exposure of LAD.
Box 50.3 Pedicle LITA dissection:technique
• Incise the parietal pleura at the most visible point. This is 1cm medial
to the artery at the second rib. Use a low monopolar electrocautery
setting at power 40, effect 1, and swift/classic mode.
• Begin the dissection by scoring the fascia with the spatula 1cm medial
and then lateral to the LITA. Continue with a lateral to medial dissection technique. Move proximal to the top of the first rib and then distal
to the sixth ICS.
• Be careful not to put undue tension on the pedicle during mobilization.
• Small branches off the LITA are cauterized a safe distance from the vas-
cular pedicle. Larger branches require clips to be applied.
• Once an adequate length has been harvested, the vessel is skeleton-
ized distally.
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Box 50.4 Skeletonization forthe LITA:technique
• Begin by only scoring the fascia lateral to the LITA overlying the lateral
thoracic vein and dividing overlying fat and muscle, the entire length
of LITA. Mobilize this endothoracic flap medially, exposing the entire
LITA and the veins on either side.
• Begin circumferential dissection distally and move proximally cauter-
izing the small branches and clipping large branches. Bipolar cautery
is helpful.
• Dissect the medial portion of the LITA prior to lateral dissection.
Control and divide medial branches before progressing to lateral
dissection.
• Avoid dissecting into a ‘hole’. Rather, make progress along a broad
front to optimize exposure.
• In addition to clips on larger arterial branches, apply liberal clips to
venous branches.
• Leave the LITA partially attached to the chest wall by small strands of
connective tissue. This allows the LITA to remain suspended, and protects it from untoward harm caused by the movement of the robotic
instruments.
• When dissection is complete, heparin is given and the distal LITA
clipped.
experiences by several groups utilizing the rst- generation surgical
robotic systems, demonstrated that robotic- assisted CABG is safe
and reproducible with a 3- month patency rate of 96.3%. With
further developments in robotic systems and robotic procedures,
robotic- assisted coronary procedures can be categorized as either
(1)robotic MIDCAB or (2)TECAB on- pump or o- pump.
Despite the lack of randomized controlled trials of robotic
MIDCAB and no standardization of surgical techniques or clinical
follow- up, the reported results are acceptable, demonstrating safety
and ecacy similar to conventional approaches. e early reported
results conrmed that the robotic harvesting of the ITA is advantageous and early angiographic follow- up was similar to conventional CABG., Recently, there have been two systemic reviews
of robotic- assisted CABG., Both of these reviews demonstrated
that the perioperative outcomes such as myocardial infarction,
stroke, acute kidney injury, reoperation for bleeding, and postoperative atrial brillation were comparable to conventional CABG. e
pooled perioperative mortality rate was found to be 1.0% in robotic
MIDCAB. Furthermore, the recently published 18- year singlecentre experience with robotic CABG demonstrated a long- term
patency rate of 97.4% of the LITA with reduction in rates of cerebro-
• Insuation can be momentarily stopped to return the medias-
tinum laterally to a more normal anatomical location.
• Mark the intercostal space.
• e robot is undocked and instrument ports removed.
• Mini- anterior thoracotomy performed.
• Identify the pericardiotomy site and the ITA pedicle.
• Detach the ITA and deliver through incision and immediately
place two suspension sutures to prevent the pedicle from twisting.
• Assess ITA length and ow and prepare for anastomosis.
• Select port site (typically the inferior port) for the endoscopic
Octopus® Nuvo Stabilizer (Medtronic, Minneapolis, MN, USA).
• Apply proximal and distal occlusion snares or intravascular shunt
depending on patient’s haemodynamics.
• Perform anastomosis in the usual fashion.
• Check gra ow using an intraoperative ow measuring device.
• Consider ITA patency by angiography same or next day.
TECAB
vascular accident (1%), and postoperative atrial brillation (8.9%),
and length of stay in the intensive care unit and hospital length of
st ay. e reduction in length of stay and the economic advantage
was well demonstrated by Poston and colleagues. In addition, patients post robotic- assisted CABG have the potential of undergoing
ultrafast- track recovery, thus avoiding the intensive care altogether
and further reducing length of stay in the hospital.
e experience with TECAB can be subdivided into arrested
heart (AHTECAB) and beating heart (BHTECAB). ere has been
no randomized control trial of TECAB, but multiple observational
and retrospective reviews have been published from single centres.
Most of the studies included BHTECAB with fewer including
AHTECAB, primarily because surgeons switched to the beating
heart approach aer gaining experience with AHTECAB. ere is
general consensus that TECAB entails a steep learning curve with
progressive decrease in operating times, conversion rates, and
short- term morbidity– One of the major challenges of TECAB
is performing the closed chest anastomosis. is was illustrated
by Bonatti etal. with the diculty associated when performing a
running suture anastomosis without counter traction; however,
• ITA pedicle is not detached from the chest wall until the anasto-
mosis is ready to be performed to avoid torsion of gra. Afourth
endoscopic port is inserted in the subxiphoid area slightly to the
le side of the costal margin and adapted to the fourth robotic arm.
e EndoWrist® (Intuitive Surgical) stabilizer is placed in this port.
Aer stabilization of the target coronary artery, the anastomosis is
performed using standard suturing technique or using anastomotic
connectors.– Unfortunately the EndoWrist stabilizer is not being
produced any longer, preventing the ability to perform TECAB.
possible solutions to these challenges include the utilization of special sutures for interrupted anastomosis such as a Nitinol U- Clip®
(Medtronic) or anastomotic connectors., In addition, Balkhy and
colleagues reported a longer- term patency rate of the anastomotic
connectors and equivalent to the sewn anastomosis in conventional
cases undergoing sternotomy.
us far there have been two systemic reviews of TECAB.,
Both of these reviews emphasize the importance of patient selection and careful progression up the learning curve to avoid conversions to sternotomy. ere were consistently longer operating
Discussion:evidence base forroboticCABG
times with AHTECAB due to the need for peripheral cannulation.
e short- term results were heterogeneous in patients who were
younger and low risk compared to patients undergoing sternotomy
As robotic- assisted cardiac surgery completes its second decade of
existence, the quest to provide the best and least invasive coronary
artery surgical revascularization platform continues. Most institutions have discovered very comparable results. e rst reported
for revascularization. In earlier studies, all- cause mortality was
high (3.8%), but this improved with the development of newergeneration robotic surgical systems and more experience of specic
centres. e pooled mortality rate was found to be 1.7% for TECAB.
50 Robotic coronary artery surgical revascularization 357
https://t.me/medicina_free
In addition, the anastomotic complications ranged from 0.7% to
13%. ese reviews demonstrated that the revascularization of
patients with multivessel disease has been a signicant technical
challenge in TECAB resulting in prolong operating times, long
periods of single- lung ventilation, higher conversion rates, higher
transfusion rates, longer length of stay in the intensive care and in
the hospital, and higher rates of major morbidities and mortality.
Interestingly, the rate of postoperative atrial brillation was lower in
TECAB and in robotic MIDCAB, which could be secondary to reduction in surgical trauma. Another advantage of TECAB is also an
improvement in patient recovery times and quality of life similar
to the nding in robotic MIDCAB.
e most up- to- date intermediate to long- term results in TECAB
invasive robotic approaches go well beyond these indications. In
addition, creation of a specic guideline for the systematic reporting
of robotic results, including dened end points and composite measures, would facilitate our understanding of the appropriate role for
these procedures.
e robotic- assisted approach to myocardial revascularization has
enabled surgeons to overcome the main limitations aecting standard
revascularization approaches such as the need for sternotomy and
cardiopulmonary bypass, oering at the same time numerous potential benets such as less tissue trauma, lower transfusion rates, reduced systemic inammatory response, reduction in pain, reduced
postoperative complications, shorter hospital stay, and faster return
to normal activities, with a positive impact on the quality of life.,,
were reported by Bonatti and colleagues describing their 5- year results for one- and two- vessel TECAB. ey reported survival of
95.8% and 93.9%, freedom from major adverse cardiac and cerebro-
Conclusion
vascular events of 83.1% and 73.5%, and freedom from angina of
91.1% and 85.1% for one- and two- vessel bypass patients, respectively. ese results are comparable to patients with double- vessel disease who underwent robotic MIDCAB and percutaneous coronary
intervention of the non- LAD vessel. Aer a median follow- up of
8years, the survival was 97% and freedom from angina was 91%.
Robotic- assisted CABG has prompted increased interest in hybrid
coronary revascularization. e collaboration with interventional
cardiologists and addition of percutaneous coronary intervention
to robotic- assisted coronary bypass enables revascularization of the
right coronary artery and has the potential advantage of reducing
the single- lung ventilation and operating time which have been associated with increased morbidity in multivessel robotic CABG.
Our experience and other current experiences suggest that a hybrid revascularization strategy is safe and provides excellent short-
and long- term results with a low rate of postoperative complications,
short hospital stay, fast recover, and very good rate of freedom of angina, freedom from any revascularization, and long- term survival.
Advances in computer telemanipulation systems and minimally invasive surgical techniques and instrumentation, cardiac anaesthesia, and
perfusion technology has enabled minimal access robotic- assisted
coronary artery surgical revascularization to be performed more efciently. Minimal access robotic- assisted approaches preserve the
mechanical stability of the thorax and provide an excellent cosmetic
result. Smaller incisions are translated into reduced wound pain and
complications, infection, and blood loss/ transfusion requirements,
earlier discharge from hospital, faster recovery times, and earlier return to routine activities. Further renement and miniaturization of
the next- generation robotic systems with single port systems and development of parallel technologies such as anastomotic connectors,
image guidance, development of haptic feedback systems, surgical
navigation using real- time three- dimensional scanner images, and
the robot as an information system, will help to improve the technical
diculties encountered in present- day robotic coronary artery surgical revascularization and further improve patient outcomes.
As the eld of robotic surgery continues to develop, the outcomes
of robotic coronary artery bypass will continue to improve with
advancements in robotic technology and increase in experienced
surgeons. Success in robotic coronary surgery, whether robotic
MIDCAB or TECAB, requires rigorous training, patience, and an
acceptable steep learning curve, specically acquiring the ability to
use visual clues without tactile feedback. In addition, thoughtful patient selection and appropriate preoperative testing and imaging,
are key elements for safe robotic coronary artery surgery and avoidance of conversion to sternotomy.
Presently, based on the most recent guidelines from the 2018
European Society of Cardiology/ European Association for Cardiooracic Surgery Guidelines on myocardial revascularization, the
indications for minimally invasive coronary artery bypass (which
would include robotic- assisted surgery) include (1)classIIa recommendation, level of evidence B:where expertise exists, minimally
invasive CABG through limited thoracic access should be considered in patients with isolated LAD lesions or in the context of
hybrid revascularization; and (2)classIIb recommendation, level of
evidence B:hybrid procedures, dened as consecutive or combined
surgical and percutaneous revascularization, may be considered in
specic patient subsets at experienced centres.
Clearly more careful clinical trials will be necessary to further expand these guidelines, since present clinical application of minimally
REFERENCES
1. Franco KL, Verrier ED, eds. Advanced therapy in cardiac surgery.
Hamilton, ON:BC Decker Inc; 2003.
2. Sutter FP, Berry T, Wertan MC. Precision incision:robotic
coronary revascularization via 3.9- cm minithoracotomy.
Innovations. 2012;7(3):223– 8.
3. Bonaros N, Schachner T, Lehr E, Koer M, Wiedemann D, Hong
P, etal. Five hundred cases of robotic totally endoscopic coronary
artery bypass graing:predictors of success and safety. Ann
orac Surg. 2013;95(3):803– 12.
4. Srivastava S, Barrera R, Quismundo S. One hundred sixty- four
consecutive beating heart totally endoscopic coronary artery
bypass cases without intraoperative conversion. Ann orac Surg.
2012;94(5):1463– 8.
5. Balkhy HH, Wann LS, Krienbring D, Arnsdorf SE. Integrating
coronary anastomotic connectors and robotics toward a totally
endoscopic beating heart approach:review of 120 cases. Ann
orac Surg. 2011;92(3):821– 7.
6. Rodriguez E, Nifong LW, Bonatti J, Casula R, Falk V, Folliguet TA,
etal. Pathway for surgeons and programs to establish and maintain
a successful robot- assisted adult cardiac surgery program. Ann
orac Surg. 2016;102(1):340– 4.
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