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216 J. Zacharias
5. Dang QH, Le NT, Nguyen CH, et al. Totally
endoscopic cardiac surgery for atrial septal defect
repair on beating heart without robotic assistance in 25
patients. Innovations (Phila). 2017;12(6):446–52.
https://doi.org/10.1097/IMI.0000000000000436.
6. Walther T, Binner C, Rastan A, Dähnert I, Doll N,
Falk V, Mohr FW, Kostelka M. Surgical atrial septal
defect closure after interventional occluder placement:
incidence and outcome. J Thorac Cardiovasc Surg.
2007;134(3):731–7. https://doi.org/10.1016/j.jtcvs.
2007.04.041. Epub 2007 Jul 20 PMID: 17723825.
Further Recommended Viewing
7. Abdelbar A, Laswaski G, Zacharias J. An endoscopic
solution to a residual postinfarct ventricular septal
defect. December 2019https://doi.org/10.25373/ctsnet.
11310929.
8. ECSClub Youtube channel: https://www.youtube.
com/watch?v=jDS84IfbN6M.
Multi-vessel Endoscopic Coronary
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Artery Bypass Grafting
Alaaddin Yilmaz, Jade Claessens,
and Abdullah Kaya
Abstract
Coronary artery bypass grafting (CABG) is the
most commonly performed cardi ac surgery
since its introduction in 1968. In the years that
followed, research focused on reducing the
surgical trauma caused by the median sternotomy. To make the surgery less invasive,
smaller incisions in the chest were used,
eventually leading to totally endoscopic surgery. In this case, the entire procedure is
performed through endoscopic ports. The most
common way to perform totally endoscopic
CABG is robotically assisted surgery which is
more expensive and time-consuming that other
types of minimally invasive cardiac surgery.
An alternative technique is using endoscopic
instruments to perform CABG which is called
endo-CABG. This technique is proven to be a
safe and effective procedure for multi-vessel
coronary artery disease without patient selec-
Supplementary Information The online version
contains supplementary material available at
https://doi.org/10.1007/978-3-031-21104-1_15. The
videos can be accessed individually by clicking the
DOI link in the accompanying figure caption or by
scanning this link with the SN More Media App.
A. Yilmaz (&) J. Claessens A. Kaya
Jessa Hospital, Stadsomvaart 11, Hasselt, Belgium
e-mail: alaaddin.Yilmaz@jessazh.be
J. Claessens A. Kaya
UHasselt - Hasselt University, Martelarenlaan 42,
3500 Hasselt, Belgium
tion. During endo-CABG, the mammary arteries are chosen as conduits for grafting to avoid
the need for proximal anastomoses. In this
way, no manipulation of the ascending aorta is
needed (no touch). The mammary arteries are
harvested using three endoscopic ports in a
triangular configuration. Additionally, a utility
port of 3–4 cm is made to perform the
anastomosis. When the patient has three vessel
disease, a Y-graft construction is created
intrathoracically by performing an end to side
anastomosis of the free right internal mammary artery to the in situ left internal mammary
artery. An overview of multi-vessel coronary
bypass grafting using endoscopic instruments
is explained in this chapter, including a
step-by-step explanation.
Keywords
Endoscopic on pump CABGBilateral
mammary artery harvesting
CABG
Since the introduction in the 1960s, coronary
artery bypass grafting (CABG) is the most commonly performed cardiac surgery [1]. In 1964,
Vasilli I. Kolesov performed the first sutured
internal mammary artery coronary anastomosis
through a median sternotomy [2]. After this surgery, the symptoms of coronary artery disease,
chest pain and shortness of breath, were relieved
Total arterial endo grafting
No touch
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
J. Zacharias (ed.), Endoscopic Cardiac Surgery,
https://doi.org/10.1007/978-3-031-21104-1_15
217
218 A. Yilmaz et al.
in these patients [3]. However, according to the
European Association for Cardio-Thoracic Surgeons (EACTS) database, several procedu ral
risks such as atrial fibrillation, cerebrovascular
accidents (CVA) and myocardial infarction after
CABG can occur [1]. Due to morbidity and
mortality of the median sternotomy, the focus on
research in the field of cardiac surgery was to
reduce the surgical trauma by using smaller
incisions in the chest and, in this way, making the
surgery less invasive. Starting from 1994, some
centres performed minimally invasive CABG
through a left mini-thoracotomy using videoassisted left internal mammary artery (LIMA)
harvesting, also called minimally invasive direct
coronary artery bypass (MIDCAB) [4, 5].
The surgical trauma was reduced even more by
the use of totally endoscopic surgery [6]. In totally
endoscopic CABG (TECAB), the entire procedure is performed without any surgical incision,
only using access through endoscopic ports.
Robotically assisted TECAB is the most common
way to perform a TECAB nowadays, but it is
more expensive and time-consuming than other
types of minimally invasive cardiac surgery [7].
Some centres use endoscopic instruments to
perform CABG. This alternative technique has the
advantage of being lessexpensive but is technically
more challenging with a steep learning curve.
Generally, TECAB is proven to have an acceptably
low operative risk. The pooled event rate for
operative mortality in 16 studies was 0.80% [8].
Recently, Yilmaz et al. introduced a newly developed endoscopic CABG (endo-CABG) method,
using endoscopic instruments [9]. The results
showed that endo-CABG is a safe and effective
procedure for treating single- and multi-vessel
coronaryartery disease without patientselection. In
this chapter, the multi-vessel endo-CABG technique will be explained step-by-step.
1 Anesthesiological Preparation
The patient is placed in a supine position on the
operating table. All patients receive external
defibrillating pads, as well as diathermy and
electrocardiogram pads. Like a conventional
CABG procedure, the patient is lined up with a
peripheral intravenous line, a radial artery line,
and after induction of general anesthesia, a single
lumen intratracheal tube, a urinary catheter and
an internal jugular vein line is introduced. Also,
near-infrared oxygenation monitoring pads
(NIRO) are placed at the frontal area of the
head of the patient, and a transesophageal
echocardiography (TEE) probe is inserted
(Fig. 1).
2 Position of the Endoscopic ports
Arrangement of the access ports is crucial for
endoscopic surgery. The 2nd, 3rd and 4th intercostal spaces are used to introduce the 5 mm
endoscopic ports. The first port is introduced
approximately 2 cm below the anterior axillary
line in the 3rd intercostal space and is used for
the 0-degree endoscope (5 mm, Karl Storz, Tuttlingen, Germany). During the introduction of
this initial port, the ventilation is stopped for a
short moment, the port is introduced, and CO2 is
insufflated through the side-port of this endoscopic port and ventilation is restarted. To create
an adequate working space and avoid selective
lung ventilation, a CO
pneumothorax (6–8 mmHg) is applied. The other
ports are introduced approximately 2 cm above
the anterior axillary line in the 2nd and 4th
intercostal spaces and are the working ports.
These three ports form a triangular configuration
(Fig. 2).
-induced controlled
2
Multi-vessel Endoscopic Coronary Artery Bypass Grafting 219
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Fig. 1 Supine position of the patient on the operating table before and after sterile drapes
Fig. 2 Position of the endoscopic ports
220 A. Yilmaz et al.
3 Endoscopic Mammary Artery
Harvesting
The 3 endoscopic ports and CO2insufflation
provide enough working space in the pleural
cavity. When the right internal mammary artery
(RIMA) is needed as a graft, the three endoscopic
ports are placed on the right thoracic side, as
described above. Long-shafted instruments are
used like an endo grasping forceps and a 34-cm
long-shafted diathermia (Fig. 3). Initially, the
right phrenic nerve is identified and preserved.
The pericardium is opened diathermically in a
vertical fashion to get full exposure of the
ascending aorta. Consecutively, the fascia on the
RIMA is opened in full length and admission of
gentle traction and short diathermia use facilitates harvesting the RIMA with its pedicle
(Fig. 4). Side branches of the RIMA are clipped
with a small endoscopic clip-applicator (Fig. 5).
Harvesting the RIMA or LIMA endoscopically is
preferred pedicled to prevent damage or severe
spasm to the mammary artery. Next, the anterior
mediastinum is opened to the left pleural space.
On the left thoracic side three endoscopic ports
are introduced, as described above. Again, the
left phrenic nerve is identified and preserved.
Any major fat pads on the left-sided pericardium
are removed, and the pericardium is opened in
full length 2–3 cm above the phrenic nerve.
The LIMA is harvested as described above for
the RIMA. After completing the dissection,
heparin is given to the patient (300 IU/kg), and
the LIMA is clipped and transected after its distal
bifurcation. It is important to fixate the LIMA
and/or the RIMA to the pericardium with a clip
to prevent torsion of it.
4 Groin Vessel Cannulation
While harvesting the mammary arteries, the
groin vessels can be prepared for cannulation.
We prefer the left groin vessels because of the
position of the heart–lung machine. A 2– 3cm
oblique skin incision below the inguinal ligament
is made in the left groin. De common femoral
artery and vein are exposed using forceps and
diathermia. It is important to dissect the vessels
lengthwise to avoid excessive lymph node/vessel
damage and postoperative lymphedema. With
digital palpation, we detect any calcification of
the left common femoral artery. A purse-string
with a prolene 5–0 is placed on each vessel. After
heparin administration, the Seldinger method is
used to cannulate. The artery is punctured with a
needle, and a guidewire is advanced in the thoracic aorta and confirmed on TEE. After pre
dilatation, a 17–21 Fr arterial cannula (Biomedicus, Medtronic Inc., Minneapolis, MN,
USA), depending on the patient’s size and thus
on the magnitude of ECC flow needed, is inserted. The common femoral vein is thereafter
punctured with a needle, and the guidewire is
advanced in the superior caval vein and confirmed on TEE, and a 21–25 Fr multi-stage
drainage venous cannula (Bio-medicus, Medtronic Inc., Minneapo lis, MN, USA) is introduced (Fig. 6). Cardiopulmonary bypass (CPB)
with retrograde perfusion is achieved using a
minimally invasive ECC system [the miniInspire JESSA MiECC (Sorin S.p.A., Mirandola, Italy)] [10]. In case of severe calcification
of the common femoral arteries or the iliac
arteries, we prefer to cannulate the right subclavian artery.
5 Mini-Thoracotomy
The selec tion of the exact intercostal space for
the mini-thoracotomy is based on the location of
the target coronary vessel. This is achieved by
simple transthoracic needle insertion throu gh the
selected space under endoscopic vision (Fig. 7 ).
The 2nd and 3rd intercostal spaces close to the
midline are mainly selected. A final 5 mm
endoscopic port is inserted subxyphoidal under
endoscopic vision and is necessary in a later
phase of the operation. A 3–4 cm skin incision is
made through the selected intercostal space, the
pectoral muscle is divided in line of the muscle
fibres and a soft tissue retractor (Shanghai
International Holding Corporation GmbH,
Multi-vessel Endoscopic Coronary Artery Bypass Grafting 221
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Fig. 3 Long-shafted instruments from top till down: endo grasping forceps, 0-degree endoscopic lens, long-shafted
diathermia, endo scissors, a small endoscopic clip-applicator and their positions through the ports
Hamburg, Germany) is placed to enable a sufficient view of the heart (Fig. 8). In case of a large
6 Cardioplegia Catheter
intercostal space (thickness digit 2 of the operator), no rib spreader is necessary. In all other
cases, a low profile rib spreader (Mini-access
retractor, Delacroix-Chevalier, Paris, France) is
used (Fig. 9). Subsequently, the transected end
of the mammary artery is brought extracorporeal
through the mini-thoracotomy and injected
intraluminal with papaverine fluid. Care is specially taken not to twist the pedicle, and this can
be realised by marking the correct side of the
pedicle with a prolene 6–0 (Fig. 10).
Patients undergoing single vessel LIMA to the
left anterior descending (LAD) artery bypass are
placed on MiECC CPB to decompress the heart
but do not receive cardioplegia. All multi-vessel
endo-CABG’s are done under cardioplegic arrest
of the heart. The three ports on the right thoracic
wall and the mini-thoracotomy is used to place a
pledged ticron 2–0 purse-string suture for antegrade cardioplegia. The location of this suture is
near the fat rim of the ascending aorta. An
222 A. Yilmaz et al.
Fig. 4 Opening the fascia on the RIMA in full length
Fig. 5 Clipping a side branche of the RIMA with a small endoscopic clip-applicator
Multi-vessel Endoscopic Coronary Artery Bypass Grafting 223
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Fig. 6 Cannulated left groin vessels with on top the arterial cannula
endoscopic grasping forceps and an endoscopic
needle holder is used to perform this (Fig. 11).
To select the correct intercostal space for the
transthoracic cardioplegia catheter (14G Argon
Secalon-TTM, Singapore, Pte. Ltd., Singapore)
is, again, by simple transthoracic needle insertion
under endoscopic vision. The cardioplegia
catheter is positioned transthoracic but not yet
inserted in the aorta. After removing the port in
the 2nd intercostal space, the transthoracic aortic
clamp is introduced. By gentle manipulation of
the aorta with a blunt endoscopic suction device,
the transthoracic aortic clamp is placed fully over
the distal ascending aorta, and the cardioplegia
catheter is inserted in the aorta in the middle of
the purse-string (Fig. 12). Cardioplegia is
infused, and the heart is arrested. We prefer a
single shot of cold (8˚Celsius) mixed blood cardioplegia (blood:crystalloid 3:1, Fresenius Kabi,
Schelle, Belgium). Afterwards, this cardioplegia
catheter is used for venting the aortic root,
achieving a totally empty heart.
7 Mobilising the Heart
holding a peanut gauze and a clamp with a
peanut used through the mini-thoracotomy
(Fig. 13). With gentle movements, the heart can
be mobilised towards the mini-thoracotomy with
these two atraumatic instruments. It is essential to
have already opened the pericardium on the left
side in full length for comfortable manipulation
of the heart. After positioning the heart in the
way that the target vessel is fully exposed via the
mini-thoracotomy, the subxyphoid endoscopic
clamp is fixed in that position with an instrument
holder attached to the operating table (Fig. 14).
Additional epicardial stay sutures with prolene
6–0 laterally to the target vessels are used when
necessary. To visualize and anast omose target
vessels on the anterior wall, the heart has to be
gently pushed cranially. For the lateral wall, the
empty heart has to be pushed up and tilted to the
midline. When the posterior descending artery
needs to be anastomosed, the inferior wall of the
empty heart has to be pushed cranially.
8 Coronary Artery Anastomosis
Technique
All target coronary vessels, including the right
coronary artery, can be visualized and reached by
gentle manipulation of the empty heart by a
subxyphoid introduced endoscopic clamp
Anastomoses with LIMA and/or RIMA are performed through the mini-thoracotomy in a typical fashion using a normal Castroviejo needleholder and forceps. The suturing technique is the
224 A. Yilmaz et al.
Fig. 7 Selection of the exact intercostal space for the mini-thoracotomy is by simple transthoracic needle insertion
through the selected space under endoscopic vision
same as in open surgery, namely a running 8–0
suture (Fig. 15). When necessary, a Y-graft
construction is created intrathoracically by performing an end to side anastomosis of free RIMA
to in situ LIMA through the mini-thoracotomy
utility port (Fig. 16). An intracoronary shunt can
be used to create a blood-free operative field in
case of back bleeding. After completing the
anastomoses, the temporary clamp on the LIMA
and/or RIMA is released, and the grafts are
checked for leakage or possible twist s or distensions. When this is not the case, the heart is
returned to its natural position in the pericardium.
Care is taken that the LIMA or RIMA does not
get caught at the edge of the pericardial opening
while descending the heart intrapericardial by
pulling the pericardium laterally with a forceps.
Subsequently, the aortic clamp is released and
the cardioplegia catheter removed, and its suture
tied down with an automated fastener device
(Cor-knot®, LSI Solutions, NY, USA) (Fig. 17).
The pericardium on the left side is always closed
by separated sutures, leaving only the entrance
space for the LIMA or RIMA.
Multi-vessel Endoscopic Coronary Artery Bypass Grafting 225
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Fig. 8 Left sided mini-thoracotomy skin incision with a soft tissue retractor
9 Weaning from CPB
While the heart is regaining its rhythm, the thoracic port wounds are coagulated for haemostasis. Pericardial drainage is only used when
necessary. Chest tubes are placed in both thoracic
cavities with negative suction (−15 cm water).
When a retractor is used, a local pain catheter
(Pajunk SonoLong Echo NanoLine® 19G x
60 mm, Geisingen, Germany) is inserted in the
same intercostal space and Ropivacaine
(2 mg/ml, Fresenius Kabi, Schelle, Belgium) is
infused postoperatively (Fig. 18). The ventilation
is restarted, and the patient is weaned from cardiopulmonary bypass, and an appropriate dose of
protamine is administered. Surgical wounds are
closed with uninterrupted intradermal sutures and
simple stitches (Fig. 19).
10 Graft Construction
In our centre, there is a strong conviction that
mammary arteries are superior as grafting material compared to all other available conduits,
especially in-situ mammary arteries. We reach a
near 100% totally mammary artery grafting in
our endo-C ABG group. By using the mammary
arteries, proximal anastomoses (with venous
graft or radial artery) are avoided, and the
transthoracic aortic clamping with the cardioplegia line are the only manipulations of the
ascending aorta that is needed.
Obviously, in single-vessel coronary artery
disease, we look for solutions with in situ
mammary arteries, like LIMA to the LAD or
LIMA to the obtuse marginal (OM) branch of the
circumflex artery (Cx). An in situ RIMA to the
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