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Ann Thorac Surg 2000;70:1060-1062
© 2000 The Society of Thoracic Surgeons

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Supplement: cardiothoracic techniques & technologies

Robotic-enhanced arterial revascularization for multivessel coronary artery disease

^a Cardiovascular Institute, University of Dresden, Dresden, Germany

Address reprint requests to Dr Schüler, Cardiovascular Institute, University of Dresden, Fetscherstrasse 76, D-01307 Dresden, Germany
e-mail: monika.weber.hkz_dd{at}t-online.de

Presented at the Sixth Annual Cardiothoracic Techniques and Technologies Meeting 2000, Ft Lauderdale, FL, Jan 27–29, 2000.

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. A tendency to reduce operative trauma is determining the evolution of cardiac surgical techniques lately. The introduction of robotic-enhanced endoscopic systems enables surgeons to perform arterial revascularization for multivessel disease without sternotomy.

Methods. From May 1999, 17 (4 women, 13 men; median age 63 ± 7.4 years) patients with multivessel coronary artery disease were treated surgically using arterial revascularization by means of bilateral internal mammary arteries. Both arteries were harvested endoscopically using the da Vinci system (Intuitive Surgical, Mountain View, CA). These vessels were anastomosed using the "Dresden technique."

Results. Survival was 100%. Mean duration of the operation was 255 ± 40.4 minutes. Bilateral internal mammary artery harvesting took 88.5 ± 15.9 minutes; cross-clamp time was 36 ± 8.7 minutes. An average of 2.06 anastomoses were performed per operation. Postoperatively, patients remained in the intensive care unit for 21 ± 13 hours. One patient (5.8%) needed reexploration due to bleeding.

Conclusions. The robotic surgical system introduces a new treatment of coronary artery disease to surgical practice, and enables arterial revascularization with distinctly reduced surgical trauma.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
After achieving a level of very low patient mortality and morbidity, the next goal for cardiac surgical techniques was the reduction of surgical trauma. Many approaches were undertaken in this subject, aiming at the avoidance of extracorporeal circulation or reduction of access to the target area. Two important events accelerated this evolution: operation through a minithoracotomy on a beating heart and the introduction of the Port-Access (Heartport Inc, Redwood City, CA) system. Based on these two facts, many different techniques to treat coronary artery disease (CAD) have been developed in the past few years [1–6].

At the Cardiovascular Institute in Dresden, a special minimally invasive technique for coronary artery revascularization was developed. It is performed with application of extracorporeal circulation on an arrested heart through a 6- to 8-cm minithoracotomy in the second intercostal space (ICS) of the left chest. This technique allows a complete revascularization of the coronary arteries, avoiding sternotomy [3, 4]. Before installation of the da Vinci surgical system (Intuitive Surgical, Mountain View, CA) it was, however, impossible to use bilateral internal mammary arteries (BIMA) as bypass grafts in full length.

It is this unique surgical robot that enables a safe harvesting of BIMA totally endoscopically through three 1-cm chest incisions. Because sternotomy is avoided, the length of the harvested vessel allows the surgeon to reach every targeted area of the heart, leaving the mammary arteries in situ, originating from their respective subclavian arteries.

The unique anatomic attributes of long arterial grafts and their functional capabilities make them an attractive choice for advanced coronary revascularization in minimally invasive coronary artery operation.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Since the introduction of the da Vinci surgical system (Intuitive Surgical) [7] at our institution in May 1999, altogether 85 patients (61 men, 24 women; median age 63 ± 9.1 years) were treated successfully using the system. This report presents the first 17 consecutive patients with multivessel CAD. In all patients, both IMAs were dissected totally endoscopically using the da Vinci system.

Technique of endoscopic robotic left internal mammary artery harvesting
Following skin desinfection and sterile draping the camera port is introduced in the fifth ICS in the anterior axillary line. After connecting the CO₂ insufflation the three-dimensional optic is attached and the left chest cavity is explored. CO₂ insufflation (warmed and humidified) at pressures between 3 and 10 mm Hg is used. The robot is then placed from the right, so that the camera actuator of the robot can be connected to the camera port.

The two other ports for the instrumentation, localized in the third (right arm) and sixth (left arm) ICS in the medioclavicular line, are then introduced. With the operating unit completed, the left internal mammary artery (LIMA) is marked as a pedicle in full length and dissected starting laterally to the LIMA, creating a flap, then moving on to medially preparing the LIMA and detaching the vessel from the chest by means of careful cautery of side branches and tissue.

Technique of endoscopic robotic bilateral internal mammary artery harvesting
The first steps are similar to the technique of LIMA takedown described above. After exploration of the left chest cavity the LIMA is exposed in full length—from the first rib down to its bifurcation. All tissue covering the vessel is removed to determine the exact location of the LIMA. The vessel is, however, not prepared as a pedicle, yet, as damage might be caused to it during right mammary artery (RIMA) preparation.

Thereafter, the mediastinal fat is detached from the sternum. This allows the surgeon to lower the position of the heart and increase the space between the sternum and the anterior wall of the heart covered by pericardium. The right pleural cavity is then opened. The patient remains on single right-lung ventilation. The existing positive pressure created by CO₂ insufflation usually results in a slight compression of the right lung. In most cases, this compression does not require additional means concerning ventilation parameters.

Having lowered the position of the heart and achieved a reduced expansion volume of the right lung—the right pleural cavity completely open—the full length of the RIMA is usually easy to follow. The dissection is started medially to the RIMA in a manner well known from the techniques in conventional open chest coronary artery operation, creating a pedicle all along the harvested artery. Median RIMA preparation time was 46 ± 14.5 minutes. Then, LIMA dissection is completed, the patient is heparinized and both mammary arteries are clipped detached. The average time for BIMA dissection was 88.5 ± 15.9 minutes.

Robotic-enhanced Dresden technique coronary artery bypass
During the operation, the patient is placed in supine position with a 30° elevation of the left chest with the arm appositioned onto the body dorsally to the posterior axillary line. After completion of endoscopic BIMA preparation the robotic system is removed. In all cases, a 6- to 8-cm parasternal minithoracotomy in the second ICS of the left chest was chosen for surgical access. The second and third rib is then temporarily detached from the sternum. After introducing a small tissue retractor the harvested BIMA are then retrieved from the chest and spatulated for anastomosis. The pericardial fat is then removed and the pericardium is opened longitudinally and stay sutures are placed. Venous drainage is secured by a percutaneously introduced venous cannula entering the right femoral vein. The ascending aorta is cannulated directly through the second ICS incision; so is the cardioplegic line. Extracorporeal circulation is commenced. After achieving an aimed cardiac index of approximately 2.5 L/m² the ascending aorta is cross-clamped with a conventional cross-clamp and cold crystalloid cardioplegic solution is introduced into the aortic root.

During cardioplegic arrest, aortic root venting is applied. The arrested heart can be rotated using a gause sling that is slung through the space below and around the heart. This way, every targeted area of the heart can be exposed and the target vessel grafted. End-to-side anastomoses are performed between the harvested BIMA and the coronary arteries in a standard fashion. Before removing the aortic clamp, antegrade air removal is performed through the ascending aorta. The cross-clamp is removed and when hemodynamic stability is reached the patient is weaned from extracorporeal circulation. The cannulas are removed from the aorta and from the femoral vein. Two steep stitches secure the venous point of entry. Both ribs are reattached to the sternum. Each pleural cavity is drained separately by a soft thoracic catheter. The right pleural cavity is drained, exiting through the incision in the sixth ICS (left robotic arm) and the left pleural drain is placed in the incision of the camera port.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
All patients left the operating room without inotropic support in sinus rhythm and without signs of acute myocardial ischemia. Survival was 100%.

The application of the da Vinci surgical system resulted in a minimization of surgical trauma caused to the chest wall. Two excellent grafts were obtained for myocardial revascularization and sternotomy was avoided. The initially long duration of graft preparation could be significantly decreased as a learning curve demonstrates (Fig 1).

View larger version (12K): [in this window] [in a new window]   Fig 1. Learning curve demonstrating a decrease in the time of the operation. (REDTCAB = robotic-enhanced Dresden technique coronary artery bypass.)

All preoperative, perioperative, and postoperative data are presented in Table 1. The average number of grafts anastomosed was 2.1 per patient. Left internal mammary artery harvesting was 41 ± 10.9 minutes. Right internal mammary artery harvesting was 46 ± 14.5 minutes. Cross-clamping took 36 ± 8.7 minutes. Total time for the operation was 255 ± 40.4 minutes. All patients were intubated with a double-lumen endotracheal tube and single-lung ventilation was started shortly before introducing the camera port into the left chest cavity. In this manner, the patients were ventilated throughout BIMA harvest.

	Comment

Top Abstract Introduction Material and methods Results Comment References

Having collected experience in many performed cases applying minimally invasive techniques, we took the initial step by starting endoscopic LIMA harvesting using AESOP (automatic endoscopic system for optimal positioning) (Computer Motion, Goleta, CA) 6 months before beginning to work with the da Vinci robotic system. This allowed us to appreciate the role of CO₂ insufflation and we gathered experience about the influence of pleural insufflation on a patient’s hemodynamic status. Subsequently, we learned to study and follow the LIMA from this new perspective and gradually, a training program for endoscopic LIMA dissection was developed.

It was the new features of the da Vinci system that made us welcome this next generation tool. It should be emphasized that a general advantage of this computerized device arises on the one hand from the 6 degrees of motion freedom and on the other hand from an optimized three-dimensional visualization. Some additional features such as a moving camera system, motion scaling, tremor elimination, and ergonomically aligned manipulators at the master console allow us to swiftly reduce the adaptational period for LIMA harvesting with the system.

With REDTCAB the treatment of multivessel CAD without sternotomy is possible, applying the concept of total arterial revascularization using totally endoscopic BIMA dissection. The REDTCAB technique provides a further advantage for diabetic patients, in whom a conventional procedure may cause severe complications related to delayed wound healing of the sternum.

Even though the time of the operation was longer in this group compared with conventionally operated patients with similar coronary pathology, the intensive care unit stay remained unchanged. The postoperative morbidity (postoperative pain and convalescence) in patients who underwent the minimized approach was altogether less than in patients who underwent the conventional procedure.

In our belief, the da Vinci system for operating on multivessel CAD proved to be a safe and efficient procedure, maintaining the highest standards for coronary revascularization.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Reichenspurner H., Gulielmos V., Daniel W.G., Schüler S. Minimally coronary artery bypass surgery (CABS) with the safety of cardiopulmonary bypass and cardioplegic arrest. N Engl J Med 1997;336:67-68.[Free Full Text]
2. Reichenspurner H., Gulielmos V., Wunderlich J., et al. Port access coronary artery bypass grafting with the use of cardiopulmonary bypass and cardioplegic arrest. Ann Thorac Surg 1998;65:413-419.[Abstract/Free Full Text]
3. Gulielmos V., Knaut M., Cichon R., et al. Minimally invasive surgical treatment of coronary artery multivessel disease. Ann Thorac Surg 1998;66:1018-1021.[Abstract/Free Full Text]
4. Gulielmos V., Brandt M., Knaut M., et al. The Dresden approach for complete multivessel revascularization. Ann Thorac Surg 1999;68:1502-1505.[Abstract/Free Full Text]
5. Calafiore A.M., Di Giammarco G., Teodori G. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658-1665.[Abstract/Free Full Text]
6. Cremer J., Strüber M., Wittwer T., et al. Minimally invasive direct coronary artery bypass (MIDCAB) to anterior coronary vessels on the beating heart. Ann Thorac Surg 1997;63:79-83.
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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Romuald Cichon Vassilios Gulielmos Stephan Schüler Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cichon, R. Articles by Schüler, S. Search for Related Content PubMed PubMed Citation Articles by Cichon, R. Articles by Schüler, S.