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Ann Thorac Surg 2006;81:800-806
© 2006 The Society of Thoracic Surgeons
a Department of Cardiovascular Surgery, Odessa, Texas
b Department of Cardiology, Odessa, Texas
c Alliance Hospital, Odessa, Texas
d Cardiac Surgical Associates, Odessa, Texas
Accepted for publication August 22, 2005.
* Address correspondence to Dr Sudhir Srivastava, 710 East 6th St, Odessa, TX 79761 (Email: sudhirpsrivastava{at}mac.com).
Presented at the Forty-first Annual Meeting of The Society of Thoracic Surgeons, Tampa, FL, Jan 24–26, 2005.
| Dr S. Srivastava discloses a financial relationship with Intuitive Surgical Inc and Medtronic Inc.
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Abstract |
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METHODS: Since July 2002, 150 patients underwent CABG through small lateral thoracotomy using robotic assistance for harvesting of BITA. After single lung ventilation, three 1- to 2-cm incisions were made in the third, fifth, and seventh intercostal spaces 2 to 3 cm medial to the anterior axillary line. After insertion of camera and instrument arms, both ITAs were harvested in a completely skeletonized fashion. A small anterolateral thoracotomy was done, enlarging the camera port incision. Distal anastomoses were performed on a beating heart using nitinol surgical clips. Intercostal cryoanalgesia and local anesthetic infusion were used for pain management.
RESULTS: Planned arterial revascularization was completed in 148 patients. Mean number of arterial grafts per patient was 2.6 ± 0.8. All coronary arteries could be reached with BITA as in situ or composite grafts. There was no mortality, stroke, myocardial infarction, or wound infection. Seven patients had new onset atrial fibrillation. Four patients required exploration of postoperative bleeding. Mean postoperative length of stay was 3.6 ± 2.9 days.
CONCLUSIONS: The da Vinci robotic system was found to be safe and feasible for BITA harvesting in multivessel CABG through small lateral thoracotomy. Further follow-up for graft patency is necessary. Postoperative pain may be reduced with aggressive management strategies. The approach offers fast recovery. This sternum-sparing approach may be an evolutionary step toward closed-chest coronary artery bypass graft surgery.
Myocardial revascularization with aortocoronary bypass graft surgery (CABG) has been performed in the United States for more than 40 years now, first introduced using the saphenous vein and within a year, using the internal thoracic artery (ITA) [1]. The ITA bypass has been shown to yield superior clinical results in studies ranging up to 20 years [1, 2] and has now become the standard of care based on reports of superior graft patency, reduced major adverse cardiac events, and enhanced survival when compared with patients receiving only venous conduits [3, 4]. The use of ITA has several advantages including a low incidence of atherosclerosis [1], functional arterial endothelium, ideal coronary-to-conduit size match, and capacity for flow regulation in response to varying myocardial demand [5].
Observational studies comparing single and double ITA grafts have demonstrated a benefit in terms of both survival and freedom from major adverse cardiac events. Clinical and angiographic outcomes of bilateral internal thoracic artery (BITA) has shown to be superior to single ITA grafting with supplemental vein grafts, when pedicled, sequential, or free aortocoronary internal mammary artery was used [4–7]. Bilateral ITA grafting has also been identified as an independent predictor of lower rates of angina recurrence, late myocardial infarction, and the composite endpoint of any cardiac event [3, 6].
In recent years, the use of skeletonized ITA grafts has received attention as a means of enhancing the versatility of this conduit. The dissected artery is longer, allowing the use of both ITAs as grafts potentially to all target coronary vessels [8].
The use of robotically enhanced manipulation provided by the da Vinci Robotic System (Intuitive Surgical, Sunnyvale, California), with the three-dimensional view and wristed instruments, has made the harvesting of BITA through port incisions and CABG through thoracotomy possible, thereby decreasing surgical trauma [9]. The author has previously described complete coronary revascularization through a left anterolateral thoracotomy (ThoraCAB) [10]. The present report deals with the use of BITA through a thoracotomy approach.
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Material and Methods |
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Patient Selection
The study included patients diagnosed with coronary artery disease requiring CABG, reoperations with stenosed grafts or new disease, and staged hybrid revascularization with percutaneous intervention and excluded patients with history of left lung surgery, empyema, unstable hemodynamics, acute cerebrovascular accident, severe chronic obstructive pulmonary disease with inability to tolerate one-lung anesthesia, and extremely dilated heart.
Anesthesia for the Endoscopic Procedure
All patients have a radial arterial catheter and Swan-Ganz catheter placed for hemodynamic monitoring. After induction of anesthesia, a double-lumen endotracheal tube is inserted for single-lung ventilation. All patients have a transesophageal echocardiographic probe inserted to assess the cardiac function, before the start of the procedure. Intravenous nitroglycerin drip is continued throughout the procedure.
Patient Position
The patient is placed in supine position with an inflatable pressure bag under the left scapula to facilitate opening of the intercostal spaces as well as down displacement of the left shoulder to accommodate the right instrument arm movements. The left arm is allowed to hang on the side supported by a sponge and sheets. Skin preparation from the chin to the toes of both lower extremities is done using antiseptic solutions.
Operative Technique
Three 1- to 2-cm incisions are made in the third, fifth, and seventh intercostal spaces 2 to 3 cm medial to the anterior axillary line (Fig 1). In patients with shorter chests, the incisions are made in the second, fourth, and sixth intercostal space. After deflating the left lung, a camera port is inserted through the middle incision and carbon dioxide insufflation is initiated and maintained at an average of 10 mm Hg. In patients with fatty mediastinum, the carbon dioxide insufflation pressure may be increased to 12 to 15 mm Hg as long as patients are able to maintain satisfactory hemodynamic status. A 30-degree angle-up camera is inserted, and the thoracic cavity is examined as well as the location and course of the left internal thoracic artery (LITA). The left and the right instrument ports are inserted under direct vision of the camera. The surgical cart with the three mechanical arms is brought in and attached to the camera and the instrument arm ports.
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The LITA is left attached to the chest wall with the connecting areolar tissue to prevent it from hanging over the pericardium (Fig 2). Pericardiotomy is done anteriorly extending to the distal part of the ascending aorta. Care is taken to leave 2 inches of pericardium covering the apex of the left ventricle. Systemic heparin, 2 mg/kg, is administered, and hemostat clips are applied at the distal end of the RITA and LITA. Activated clotting time is monitored every 30 minutes, and additional heparin doses are given to maintain activated clotting time over 300 seconds. The transected arteries between the clips are secured to the pericardial fat using hemostat clips to prevent migration or distortion. The left anterior descending artery (LAD) is inspected for suitability of grafting RITA to LAD. In the event RITA will not reach LAD, and still having the endoscopic view, it will be transected for later use as a free graft.
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Postoperative Management
Intravenous nitroglycerin is continued in the intensive care unit for as long as 24 hours. Ketoralac, 30 mg, is given intravenously every 6 hours for 48 hours to patients without evidence renal insufficiency. In patients aged more than 70 years, ketoralac, 15 mg, is given every 6 hours for 48 hours. Precedex is titrated as a continuous drip in doses of 0.2 to 0.7 ug.kg an hour for pain control. Aspirin, 81 mg, and clopidogrel, 75 mg, are given either orally or through the nasogastric tube once the patient arrives in the intensive care unit. Clopidogrel, 75 mg per day, is continued for 3 months and aspirin, 81 mg per day, indefinitely.
Follow-Up for Pain Score
All patients completed a numeric pain scale survey from 0 to 10, with 0 meaning no pain and 10 meaning extreme pain. Reports of the pain score were obtained for the first postoperative day, 1 week, 1 month, and 3 months after the procedure (Fig 6).
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Results |
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Comment |
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Proper port placement plays an important role in robotic ITA harvesting. It is important to telemanipulate the robotic arms and cover the areas of dissection to ensure a full range of accessibility by the instruments to the desired locations. Any adjustments in the position of the ports or the intercostal space through the ports are placed as well as the position of the robotic arms should be done before beginning the dissection. In female patients, the breast is positioned anteriorly and superiorly allowing for easier port placement and subsequent incision. Some additional features such as magnification, three-dimensional vision, a moving camera system, motion scaling, tremor elimination, and ergonomically aligned manipulators at the master console allow swift reduction of time for adaptation [7].
As in any new technology-based surgical innovation, there was a learning curve that was considered to be acceptable. The performance of this procedure may improve, especially with further technical development of the robotic system. With the inclusion of our previous report of ThoraCAB [10], subsequent nonrobotic and robotically harvested single ITA in ThoraCAB, and the present report, we have performed 800 complete coronary revascularizations through the ThoraCAB approach. The harvest of BITA was made possible only after the advent of robotic manipulation. Some advantages of minimal invasive techniques are obvious, such as reduction of wound infection, reduction of length of hospitalization, preservation of a stable thorax, earlier functional recovery, and excellent cosmetic results. There was a lower incidence for new onset atrial fibrillation in our series of patients. Multivariate analysis was not done to assess reasons for lower incidence of atrial fibrillation. For the purposes of this report, postoperative atrial fibrillation was defined as new onset atrial fibrillation requiring medications or electric cardioversion. The addition of cryoanalgesia and the I-flow On-Q Pump may reduce the incidence of the incisional chest pain. Although there is higher initial procedural cost for robotically enhanced surgery, the economic impact will require a thorough analysis of overall cost reduction secondary to early extubation, lower use of blood products, shorter length of stay, and earlier functional recovery.
Computed tomography angiography, although it has limitation of defining the quality of anastomoses, opacification of the conduit and the coronary artery beyond the anastomosis may show gross patency of the graft. Computed tomography angiography as compared with conventional coronary angiography appears to be more acceptable, particularly to the patients who are asymptomatic after the procedure. The introduction of 64-slice computed tomography scan may provide superior imaging results. In this study, the short-term graft patency appears satisfactory but additional follow-up is needed for long-term patency results.
There is a learning curve, and as experienced in other minimally invasive cardiac surgical procedures, the initial operative times are longer. Although in this group, no patient required conversion to cardiopulmonary bypass or sternotomy, patients can be placed on cardiopulmonary bypass by cannulating the aorta and right atrial appendage, or peripheral cannulation through the femoral artery and vein. Surgeons may choose a step-by-step approach to total revascularization through thoracotomy. One may start out with one or two anterior left-sided vessels and gradually incorporate other arteries as the exposure becomes easier. Surgeons who are currently using cardiopulmonary bypass may consider doing revascularization through thoracotomy on a beating heart with CPB.
In conclusion, robotic assistance has allowed the use of BITA through the ThoraCAB approach. The approach appears safe and feasible with low associated mortality and morbidity while providing earlier functional recovery. There may be reduction in pain with use of cryoanalgesia and the On-Q Pump. There appears to be a lower incidence of atrial fibrillation and use of blood products. The approach may be an evolutionary step to totally endoscopic coronary bypass surgery.
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Discussion |
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Can you give me some estimate whether the reduction in length of stay is likely to overtake the increased costs owing to the use of the robot, or to put it another way, have you amortized the increased cost of using the robot in these cases?
DR SRIVASTAVA: Thank you for the very good question, and I think it is a real practical concern in many hospitals. Yes, I think the initial capital outlay is a concern and probably turns some people away from buying a robot, but we have looked at the economics of all of this, and in fact one of these days we will share that data with you. What we have found is that apart from the initial purchase it can be amortized if one does three or four additional cases at least in the United States based on the reimbursement system.
Secondly, the average cost of the disposables is somewhere between $800 to $1,000. Many of these patients come out extubated in the operating room; they are not on many drugs; there is a very significant lower use of blood and blood products; and of course, the hospital length of stay, I think with more educational programs to our patients and the community, will all help achieve a reduction in the overall cost in this group of patients.
DR FRANK SELLKE (Boston, MA): Why do you think there is an advantage over a sternotomy with regard to pain control? Did you look at some of your OPCABG sternotomy patients and make a comparison between them and the current technique?
DR SRIVASTAVA: No, we did not, because we kind of stopped doing the sternotomies some years ago, and before that we really were not looking at that as a study. It is quite interesting that the surgeons somehow just have accepted the morbidity associated with a sternotomy as standard. So I am not so sure there are many studies out that truly have compared, and it probably would be a good idea to maybe have a matched patient base and look at it that way, maybe in a prospective way. We do not have it.
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