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Ann Thorac Surg 1997;64:928-929
© 1997 The Society of Thoracic Surgeons

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Editorial

Minimally Invasive Coronary Artery Bypass Surgery: Really Minimal?

Cardiovascular Surgery Center of South Arkansas, PA, Pine Bluff, Arkansas

The term "minimally invasive coronary bypass surgery" is a misnomer. Whether the preferred technique is a thoracotomy, parasternal incision, or port access, it represents a major and complex surgical procedure lasting several hours with or without the assistance of a heart/lung machine.

Since the introduction of laparoscopic interventions, the public is attracted by quicker and easier ways to undergo surgical procedures. This expectation has created the idea that coronary bypass grafting can be done safely through "keyhole" incisions similar to a laparoscopic cholecystectomy. This, of course, has caught the attention of the news media and patients with coronary artery disease. Also, companies manufacturing surgical equipment see a golden opportunity to cash in on a fast and careless evolving market.

Cardiac surgeons are caught in the middle. For the last 20 years single-vessel disease with a normal ejection fraction has demonstrated a different pathologic process from multiple lesions with ischemic damage to the heart muscle and other associated medical conditions. The use of the internal mammary artery in these cases has proved to give excellent initial as well as late results. Such results show patency rates greater than 97% after 15 years and a mortality approaching zero. These techniques of coronary bypass grafting have been mastered by all cardiac surgeons all over the world and can be reproduced repeatedly.

We are concerned about the widespread publicity offering the so-called minimally invasive surgery or keyhole surgery to potential coronary patients. We fear that patients are misinformed in that they believe these techniques can be used in every case and that the results are as good as those of conventional coronary artery surgery. They expect virtually no pain, no complications, very early discharge, and prompt return to their usual lifestyle. They do not know that a learning curve in the harvesting of the internal mammary artery through small openings, or the techniques of suturing the vessels to a moving heart, can jeopardize their chances of getting the best operation available for single-vessel disease.

Marketing minimally invasive surgery is used by some centers as a gimmick to attract patients even if they do not qualify for this type of operation. Once the patients are in the system, it is easy to persuade them to stay and undergo operation by the usual methods.

Cardiac surgeons are being pressed to undertake a procedure that is not proved to be as reliable or successful as conventional bypass surgery. Pressure comes from patients and cardiology colleagues who do not understand the implications of minimally invasive surgery.

Recently, one of us attended a course designed to teach these new procedures. Nine bypass grafts were performed live on closed-circuit television using a thoracotomy incision with the division or resection of costochondral junctions and without the use of a heart/lung machine. In a follow-up letter sent to the participants, three of the nine bypass grafts were angiographically proved to have closed down in less than 24 hours. These results are totally unacceptable, especially when the procedures were performed by the leading authorities in the field. One has to wonder what kind of result can be expected of surgeons in the learning stages of these operations.

Because we understand the need to simplify and lower the cost of coronary bypass grafting, we have developed a protocol for single-vessel coronary bypass. We would like to share it and hopefully persuade our colleague surgeons not to abandon the well-established surgical principles for the sake of novelty and fame at the expense of the patient's well-being.

Recognizing that single-vessel coronary artery disease occurs usually in younger and healthier individuals, cardiac surgeons can take several steps to reduce the invasiveness of coronary bypass grafting without sacrificing the exactness and quality of the procedure:

1. There are no large central lines used. Two size 16 peripheral lines are sufficient for access.
   
2. The length of the skin incision is shortened about 2 cm on both ends. The sternum is opened in the usual way.
   
3. The sternum is gently elevated enough to provide easy access to the internal mammary artery without over-stretching the ribs.
   
4. The sternal spreader is opened enough to provide access to the heart without over-stretching the ribs.
   
5. The internal mammary artery and if possible the site of implantation at the anterior descending artery are made ready before going on bypass.
   
6. When the operation is over, subcuticular closure of the skin is done.
   
7. A single tube for drainage is used.
   
8. Patients are extubated in the operating room. This requires changes in the anesthesia protocol, including the use of short-acting narcotic and muscle relaxants.
   
9. Patients are awake and up in a chair within 6 to 8 hours after the operation.
   
10. Patients are transferred to a step-down unit within 12 to 24 hours after the operation.
    
11. Patients are discharged 3 days after the operation.
    

We have operated on 12 patients with single left anterior descending lesions in this fashion. Our average operating time is 1 hours. Our average bypass time is 19 minutes. No respirators are used postoperatively, and postopera-tive discomfort is usually controlled with acetaminophen plus codeine. All patients have returned for their follow-up visits feeling well with no complaints. We have no doubts that the bypass grafts are open and functioning well.

We firmly believe that single-vessel bypass grafting can be done in the above-described manner with the assurance of excellent results and with relatively little invasiveness. Thus, patients can undergo a procedure proved to be effective that can be done safely and accurately and will cause minimal discomfort.

Footnotes

Address reprint requests to Dr Ancalmo, Cardiovascular Surgery Center of South Arkansas, PA, 1609 W 40th Ave, Pine Bluff, AR 71603.

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