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Ann Thorac Surg 2000;70:1105-1108
© 2000 The Society of Thoracic Surgeons
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.
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Abstract |
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Methods. Between May 1999 and December 1999 this new wrist-enhanced instrumentation was used in 61 patients. Six patients suffering from single-vessel coronary artery disease and one female patient with double-vessel disease underwent totally endoscopic coronary artery bypass. Thirty-seven patients with single-vessel disease underwent a minimally invasive direct coronary artery bypass procedure. Seventeen patients with double-vessel disease were treated using the robotic-enhanced Dresden technique.
Results. Perioperative survival was 100%. In all patients the internal mammary arteries were safely harvested endoscopically and had excellent quality. In both totally endoscopic coronary artery bypass groups all patients were operated on through three stab incisions.
Conclusions. Our preliminary experience with this new surgical technique using robotic-enhanced minimally invasive methods for coronary artery disease promotes optimism regarding further development of these procedures and application in patients with coronary artery disease.
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Introduction |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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The gradual enlargement of the application of the computer-enhanced system, starting from the endoscopical harvesting of the left internal mammary artery (LIMA) proceeding toward the minimally invasive surgical treatment of double-vessel CAD using the left and right LIMA, is presented.
Technique of endoscopic left internal mammary artery harvesting
Following skin disinfection and sterile draping, the camera port is introduced in the fifth intercostal space (ICS) in the frontal axillary line. After connecting the CO2 insufflation the three-dimensional optic is attached and the left chest cavity is explored. CO2 insufflation pressures between 3 and 10 mm Hg are 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 and sixth ICS on the mediocalvicular line, are then introduced. With the operating unit completed, the LIMA is marked as a pedicle in full length and dissected. Median time of LIMA preparation was 48 ± 16.9 min.
Robotic-enhanced surgical techniques for single-vessel coronary artery disease using the left internal mammary artery
Minimally invasive direct coronary artery bypass grafting technique
Thirty-seven patients suffering from single-vessel CAD (24 men, 13 women, median age 63 ± 10.6 years) were operated on using MIDCABG. Coronary angiography revealed single proximal lesions of the left anterior descending coronary artery (LAD). Eight patients had additional lesions of the diagonal branches (Tables 1, 2).
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Totally endoscopic coronary artery bypass technique I
Six patients (6 men, median age 56 ± 3.5 years) with single-vessel CAD were successfully operated on using the totally endoscopic coronary artery bypass I (TECAB-I) technique. The patients showed single lesions of the LAD. In all patients the operation was successfully performed through three point-stab chest incisions. Exclusion criteria for this technique were primarily based on factors against the use of the Heartport system, such as aortic sclerosis, peripheral arterial vascular occlusion disease, decreased left ventricular ejection fraction (LVEF < 40%), decreased lung functioning (forced expiratory volume in 1 second less than 1.0), adipositas per magna (body mass index > 25), and intramyocardial LAD course or diffuse coronary artery sclerosis. The first steps with this technique are similar to the MIDCABG technique. After completion of the LIMA takedown (median 50 ± 16.9 min) the patient is heparinized and the installation of the Heartport system follows. After the introduction of the endoocclusion catheter through the left femoral artery and correct positioning in the ascending aorta the aorta is occluded and cardioplegia is administered.
After the introduction of a vessel clamp into the chest cavity of the patient the LIMA is then occluded. The LIMA is then prepared for anastomosis at its distal end and checked for flow by a temporary release of the vessel clamp. With the pericardium opened, LAD course is identified and incised for anastomosis. Following LIMA detachment anastomosis using a 7-0 Prolene (Ethicon, Norderstedt, Germany) running suture is begun using the da Vinci surgical system on the arrested heart. After completion of anastomosis the vessel clamp is removed from the LIMA and blood flow is checked by antegrade perfusion of blood. Then the endocclusion catheter is deflated and removed.
Robotic-enhanced techniques for the treatment of multivessel coronary artery disease
Technique of endoscopic bilateral internal mammary artery harvesting
The first steps are similar to both preceded techniques. With the operating unit completed the endoscopic preparation of bilateral internal mammary artery (BIMA) follows, whereas the LIMA is first marked laterally. Then the mediastinal fat is removed from the sternum and the right pleural cavity is opened. After preparation of the right internal mammary artery— with a pedicle being created using the whole artery (47 ± 16.5 min)—LIMA dissection is continued. The patient is heparinized and both mammary arteries are clipped and detached.
Robotic-enhanced Dresden technique for coronary artery bypass grafting
Seventeen patients (12 men, 5 women, median age 61 ± 7.2 years) with coronary artery multivessel disease were operated on using the robotic-enhanced Dresden technique for coronary artery bypass grafting (REDTCAB) technique. The minimally invasive surgical Dresden technique was developed in 1996 at our institution [3, 4]. Before the introduction of the da Vinci system 164 patients with coronary artery single-vessel and multivessel disease had been treated. The application of the da Vinci system now allows the use of both internal mammary arteries without sternotomy enabling closed chest procedures.
After completion of the BIMA takedown the robotic system is removed. A left second ICS incision is made serving as a means to access the central parts of the heart. The 6-cm incision is made as described in literature [3, 4]. Following the percutaneous installation of the venous cannula in the right femoral vein, the arterial cannula is placed in the ascending aorta. The following steps are similar to conventional coronary operations. The chest and wound is closed in the usual fashion. Both ribs are reattached at the sternum and the ICS is reconstructed. 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 and the left pleural drain is placed in the incision of the camera port.
Totally endoscopic coronary artery bypass technique II
A 60-year-old patient with coronary artery double-vessel disease was operated on successfully using the TECAB-II technique. Coronary angiography revealed significant stenoses of the proximal LAD and of the proximal marginal branch of the circumflex artery. Left ventricular ejection fraction was determined to be 65%. Preoperatively collected criteria showed no contradictions for this surgical technique. This technique is analogous to the TECAB-I technique, although, in addition, the right internal mammary artery is used for revascularization.
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Results |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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All intra- and postoperative data are listed in Tables 1 and 2. All patients had their LIMA preparation performed totally endoscopically using the da Vinci system. The dissection of BIMA in connection with the REDTCAB technique was performed in 17 patients.
All patients left the operating room without inotropic support in sinus rhythm and without signs of acute myocardial ischemia. Survival was 100%. Two patients (3.27%) needed to be reexplored due to bleeding. One patient underwent a median sternotomy due to damage caused to the right subclavian vein and was converted to a conventional operation. In 1 patient (1.63%) a ventricular tachycardia was observed that could be converted only after a median sternotomy was performed.
Due to new signs of angina pectoris 1 patient in the MIDCABG group underwent reangiography, revealing stenosis at the anastomotic site. This patient underwent a successful reoperation through the access of the initial operation in the fourth ICS.
In both presented TECAB groups all patients were operated on through three point-stab incisions. It should be noted that the initially long duration of the operation could be significantly shortened during the first 6 months since the introduction of the system at our institution.
In all patients in the REDTCAB group the concept of total arterial revascularization was successfully applied using BIMA grafting. All operations were performed using BIMA grafting and total endoscopical BIMA harvesting with the da Vinci system. Also, the cosmetic outcome of all of the surgical techniques was excellent (Fig 1).
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Performing endoscopic mammary artery dissection in the MIDCABG group, LIMA preparation by a minithoracotomy—causing significant trauma to the fourth ICS and the adjacent ribs—was avoided. Using the robotic modification of this technique the chest wall remains intact. For patients with single-vessel CAD who show risk factors for extracorporeal circulation the robotic-enhanced MIDCABG technique is the method of choice.
For patients without serious risk factors for extracorporeal circulation the TECAB technique is a preferred method for surgical treatment of coronary artery single-vessel and double-vessel disease. The surgical procedures are performed through three point-stab incisions alone; postoperative convalescence is excellent and superior to all other techniques.
Patients with coronary artery multivessel disease were operated on using the modified robotic-enhanced Dresden technique. Endoscopic BIMA dissection using the da Vinci system can be used avoiding median sternotomy, thus reducing the risk of sternal instability and infection or chronic pain. Endoscopic preparation provides longer conduits and allows the use of sequential grafting. Our demonstrated preliminary experiences in the field of robotic-enhanced minimally invasive coronary artery surgical techniques, being an essential alternative to conventional heart operation, are positive and represent only first steps toward future developments. In the near future patients with single-vessel CAD will routinely be treated surgically using three 1-cm skin incisions.
Obviously, the application of these differentiated new robotic-enhanced techniques has enabled a significant development of heart operations. In the future, more patients will be eligible to be operated on using these new procedures. Some of the established surgical procedures have already been displaced by new minimally invasive surgical techniques. In addition, the presented concept for patients with single-vessel CAD undergoing LIMA revascularization may give reason to question the cardiological treatment of single-vessel CAD as first choice, presently holding a high reintervention rate.
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