HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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 Stephan Schüler Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kappert, U. Articles by Schüler, S. Search for Related Content PubMed PubMed Citation Articles by Kappert, U. Articles by Schüler, S.

Ann Thorac Surg 2000;70:1699-1701
© 2000 The Society of Thoracic Surgeons

---

Case report

Closed chest bilateral mammary artery grafting in double-vessel 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

	Abstract

Top Abstract Introduction Comment References

 
A clinical case of a closed chest double-vessel total endoscopic coronary artery bypass procedure was performed using a wrist-enhanced, three-dimensional-based robotic system. A patient suffering from lesions of the left coronary artery system was effectively treated surgically without median sternotomy or minithoracotomy. This encourages optimism for introducing closed chest endoscopic bypass operations into the surgical routine for patients suffering from double-vessel coronary artery disease.

	Introduction

Top Abstract Introduction Comment References

 
The introduction of robotic instrumentation has led to new minimally invasive surgical options in patients with coronary artery disease [1–5]. Classic endoscopic instrumentation carries certain disadvantages, especially lack of wrist enhancement and three-dimensional visualization. The development of the da Vinci surgical system (Intuitive Surgical, Mountain View, CA), consisting of a master-slave construction, led to the development of an advanced endoscopic tele-manipulatory system with full clinical use in 1998. We began to use this system in May 1999. Since then it has been applied in 66 patients. A closed chest coronary artery bypass grafting in a patient with double-vessel coronary artery disease using both internal thoracic arteries is presented.

A 60-year-old woman suffering from recurrent angina pectoris underwent coronary angiography, which revealed a significant stenosis of the left anterior descending coronary artery (LAD) and of the first marginal branch of the circumflex artery. Left ventricular ejection fraction was 65%. Physical examination determined the patient to be in New York Heart Association (NYHA) class II and Canadian Cardiovascular Society stage II. Transesophageal echocardiography (TEE) and Doppler ultrasound of the ascending aorta and femoral vessels were performed, excluding the risk factors for the Heartport system (Heartport Inc, Redwood City, CA).

For the surgical procedure the patient was placed in a supine position with the left arm resting slightly beneath the posterior axillary line. After induction of general anesthesia a double-lumen tube was used for single-lung ventilation during the operation. Three 1 cm incisions were placed in the left chest in the 3rd intercostal space (ICS) on the medioclavicular line, in the 5th ICS on the anterior axillary line, and in the 6th ICS on the medioclavicular line (Fig 1). During the port placement no difficulties were observed.

View larger version (140K): [in this window] [in a new window]   Fig 1. Operative setup using the surgical robotic da Vinci system.

Dissection of the RIMA was carried out by creating a pedicle ending distally at the 7th rib using a 0-degree endoscope. After changing to a 30-degree optic looking up a LIMA pedicle of the same length was harvested. Heparin (3 mg/kg) was administered, and the IMAs were skeletonized and spatulated for anastomosis. Before each IMA was transected, vessel clamps were introduced through the right hand port and placed on the arteries about 3 cm proximal to the distal end. Blood flow through the IMAs was controlled by temporary release of these vessel clamps.

The extracorporal circulation (ECC) was installed using the femoral artery for arterial return and percutaneous cannulation for venous return from the femoral vein. The Heartport endoclamp was inflated and cardioplegic solution was applied. The patient’s temperature was lowered to 30°C. Transesophageal echocardiographic monitoring ensured the right positioning of the endo-occlusion balloon. The heart was vented throughout the procedure. Pericardial fat was removed and the pericardium was carefully opened, avoiding touching the epicardial tissue with cautery. The LAD and first marginal branch were identified and the site of anastomosis was prepared using blunt and sharp dissection. Arteriotomy was performed using a sharp blade and microscissors. The prepared LIMA was then approximated to the site of anastomosis. Using a 7-0, 7 cm double-armed custommade Prolene (Ethicon, Somerville, NJ) suture the LIMA was anastomosed end-to-side to the first marginal branch. After the anastomosis was completed, the vessel clamp on the LIMA was released for 1 minute and the anastomosis was explored for leakage. After 30 minutes of endoaortic clamping, additional cardioplegia was administered.

The RIMA was then attached to the LAD in the same fashion, using a running 7-0 Prolene suture. Again, the anastomosis was inspected for bleeding in the above-mentioned manner. The endoclamp balloon was deflated at this point and the coronary circulation was reestablished. The patient was rewarmed and after return of the sinus rhythm, the patient was weaned from ECC. Inotropic support was not necessary. Protamine was administered and the actuators and camera were removed. A chest tube was inserted in both pleural cavities using two of the three stab incisions. Before transferring the patient to the intensive care unit (ICU) a single-lumen endotracheal tube was inserted to replace the double-lumen endotracheal tube.

The entire procedure was performed through three 1 cm stab incisions using the wrist-enhanced robotic system (da Vinci). Both LIMA and RIMA were harvested in 102 minutes (LIMA 48 minutes, RIMA 54 minutes), and the aorta was occluded for 98 minutes. The anastomoses were performed in 48 minutes. The surgical procedure was completed within 480 minutes. The patient stayed in the ICU for 42 hours. Postoperative blood loss was 350 mL. No perioperative complications occurred. The patient was discharged from the hospital on the 7th postoperative day.

	Comment

Top Abstract Introduction Comment References

 
A closed chest surgical treatment of coronary artery double-vessel disease using total arterial revascularization was performed. The da Vinci robotic surgical system allows a fully endoscopic technique without any other chest incision. We began applying this new wrist-enhanced surgical tool at our clinic in May 1999. Since then a gradual learning curve associated with the system can be noticed. Three-dimensional visualization and wrist-enhanced instrumentation outrun by far the options that classic endoscopy holds for the cardiac surgeon as 6 degrees of motion freedom guarantees easy handling of tissue inside the patient’s body. Motion scaling and optimized hand-eye alignment contribute to achieve safety and efficiency in bypass operations. This procedure contributes to the differentiated minimally invasive surgical concept for treatment of single-vessel and double-vessel coronary artery disease developed in our clinic. In our opinion, the described case reflects a major step toward totally endoscopic surgical treatment of patients with coronary artery multivessel disease.

	References

Top Abstract Introduction Comment References

 

1. Carpentier A., Loulmet D., Aupecle B., Berribi A., Relland J. Computer assisted cardiac surgery. Lancet 1999;353:379-380.[Medline]
2. Falk V., Gummert J., Walther T., Hayesi M., Berry G.J., Mohr F.W. Quality of computer enhanced endoscopic coronary artery bypass graft anastomosis—comparison to conventional technique. Eur J Cardiothorac Surg 1999;15:260-265.[Abstract/Free Full Text]
3. Loulmet D., Carpentier A., d’Attellis N., et al. Endoscopic coronary artery bypass grafting with the aid of robotic assisted instruments. J Thorac Cardiovasc Surg 1999;118:4-10.[Abstract/Free Full Text]
4. Shennib H., Bastawisy A., McLoughlin J., Moll F. Robotic enhanced telemanipulation enhances coronary artery bypass. J Thorac Cardiovasc Surg 1999;117:310-313.[Abstract/Free Full Text]
5. Shennib H., Bastawisy A., Mack M.J., Moll F.H. Computer assisted telemanipulation. Ann Thorac Surg 1998;66:1060-1063.[Abstract/Free Full Text]

This article has been cited by other articles:

				J. Bonatti, T. Schachner, N. Bonaros, and G. Laufer A new exposure technique for the circumflex coronary artery system in robotic totally endoscopic coronary artery bypass grafting Interact CardioVasc Thorac Surg, June 1, 2006; 5(3): 279 - 281. [Abstract] [Full Text] [PDF]

				A. W Susilo and A. P Schulz Totally Robotic Technique in Multivessel Coronary Disease -- Is it Possible? Asian Cardiovasc Thorac Ann, March 1, 2002; 10(1): 92 - 94. [Abstract] [Full Text] [PDF]

				U. Kappert, R. Cichon, J. Schneider, V. Gulielmos, T. Ahmadzade, J. Nicolai, S.-M. Tugtekin, and S. Schueler Technique of closed chest coronary artery surgery on the beating heart Eur J Cardiothorac Surg, October 1, 2001; 20(4): 765 - 769. [Abstract] [Full Text] [PDF]

				U. Kappert, J. Schneider, R. Cichon, V. Gulielmos, S.-M. Tugtekin, J. Nicolai, K. Matschke, and S. Schueler Development of Robotic Enhanced Endoscopic Surgery for the Treatment of Coronary Artery Disease Circulation, September 18, 2001; 104(2009): I-102 - I-107. [Abstract] [Full Text] [PDF]

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 Stephan Schüler Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kappert, U. Articles by Schüler, S. Search for Related Content PubMed PubMed Citation Articles by Kappert, U. Articles by Schüler, S.