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Ann Thorac Surg 2006;82:790-794
© 2006 The Society of Thoracic Surgeons
a Center for Advanced Surgery and Technology, Trinity Mother Frances Health System, Tyler, Texas, USA
b University of Texas at Tyler, College of Nursing and Health Science, Tyler, Texas
Accepted for publication March 28, 2006.
* Address correspondence to Dr Turner, Trinity Mother Frances Health System, Center for Advanced Surgery and Technology, 1100 E Lake Suite 210, Tyler, TX 75701 (Email: wftjrtyler{at}aol.com).
Presented at the Fifty-second Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 10–12, 2005.
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Abstract |
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METHODS: Robotically-assisted coronary artery bypass grafting through a small thoracotomy on a beating heart without the use of cardiopulmonary bypass was performed on 70 patients from February 16, 2004 through September 20, 2005. Postoperative morbidity, mortality, and length of stay were recorded.
RESULTS: Operative mortality was 0%. The average operative time per case for the entire series was 4 hours, 3 minutes. The average operative time per case for the first 10 cases was 5 hours, 56 minutes, which decreased to 3 hours, 52 minutes for the last 10 cases of the series. The incidents of postoperative complications were as follows: reoperations for bleeding (2 patients; 2.8%); transfusions (7 patients; 10%); atrial fibrillations (6 patients; 8.5%); infections (2 patients; 2.8%); neurologic (0%); renal failure (0%); and ventilation greater than 1 day (0%). The average postoperative length of stay was 5.7 days.
CONCLUSIONS: Early results suggest robotic-assisted coronary artery bypass grafting is a safe and effective means of myocardial revascularization and its continued clinical use is justified. Operative time has decreased with experience. Robotic-assisted coronary artery bypass grafting performed through a small thoracotomy on a beating heart without the use of cardiopulmonary bypass may pave the way to a completely endoscopic, closed chest procedure for coronary artery bypass grafting.
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Introduction |
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To achieve this goal, robotic microsurgical systems have been developed to enhance the surgeon's ability, dexterity, and precision. Although robotic-assisted totally endoscopic coronary artery bypass grafting using facilitated anastomotic devices is still in development, practical, less invasive surgical strategies using the intuitive da Vinci Robot Micro-Surgical System (Intuitive Surgical, Inc., Mountain View, CA) have been applied to perform coronary artery bypass grafting through a small thoracotomy on a beating heart without the use of cardiopulmonary bypass. This report reviews the clinical experience of the first 70 robotic-assisted coronary artery bypass grafting procedures performed using the da Vinci Robot by a single surgeon at Mother Frances Hospital in Tyler, Texas.
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Material and Methods |
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Contraindications to robotic-assisted surgery included patients with a body mass index greater than 35, patients with very large hearts (cor bovinum), decompensated congestive heart failure, inaccessible calcified coronary arteries, and small coronary arteries (less than 1.5 mm).
The surgical procedure was performed under general anesthesia, maintained by continuance infusion of narcotics and benzodiazepines and intermittent administration of pancuronium to provide muscle relaxation. All patients had double lumen endotracheal tubes or bronchial blockers for single lung ventilation. All patients had standard invasive monitoring with a radial arterial line, pulmonary artery catheter with continuous mixed venous oxygen saturations, and transesophageal echocardiography.
Endoscopic vessel harvesting was used to harvest the greater saphenous vein and the radial artery.
The left internal mammary artery was harvested endoscopically using the da Vinci Robot Micro-Surgical System (Intuitive Surgical, Inc., Mountain View, CA). The robotic system consists of three principle components: (1) a surgical console, (2) a computer controlled system, and (3) robotic manipulations. The surgeon sits at the console and grasps specially designed instrument handles. The surgeon's motions are relayed to a computer processor, which digitizes the surgeon's hand motions. The digitized information from the computer control system is relayed in real time to robotic manipulators, which are attached to the operating room table. These manipulators hold the endoscopic instrument tips which are inserted through small ports.
After skin prepping and draping, the left lung is deflated and the camera port is introduced into the fifth intercostal space inferior to the nipples in males. In females the breast tissue is retracted with iodinated drape and the camera port is placed 2 cm below the submammary crease in the line of the nipple. After connecting the carbon dioxide insufflation, the 3-dimensional camera optic is attached and the left cavity is explored. Carbon dioxide insufflation at pressures between 3 and 10 mm of mercury was used to harvest the internal mammary artery. In addition to the camera port, two other ports for instrumentation located in the third and seventh intercostal spaces in the same line as the camera port are then introduced.
The full length of the left internal mammary artery is then harvested by means of careful low energy cautery of the side branches in a skeletonized fashion. After heparinization at a dose of 2 mg per kilogram, the distal end of the mammary is divided, clipped, and placed on the pericardium.
Endoscopic removal of the pericardial fat bed, localization of the anterior descending artery, and determination of anatomic suitability for the minimal access beating heart surgical approach is then performed.
For isolated, single vessel disease, involving the anterior descending artery (19 patients) an anterior thoracotomy incision is extended approximately 2.5 cm on either side of the camera port in the fifth intercostal space. For patients requiring multivessel bypass grafting (51 patients), the camera port incision is extended approximately 4.5 cm on either side to facilitate lateral and inferior wall grafting. The subcutaneous tissue is divided in the same line as the pectoralis major muscle. The fifth intercostal space is entered and the intercostal muscles are undermined in the space. A low profile mini-thoracotomy retractor is placed and is spread open enough to see the distal targets.
Exposure of the anterior descending and diagonal vessels is improved with traction applied to the divided edges of the pericardium.
For lateral and inferior wall vessel grafting, the positioning of the heart is facilitated by the application of an apical suction device.
Rotation of the apex enhances exposure to the circumflex coronary artery system.
A commercially available stabilizing device is used for coronary stabilization.
In the majority of the patients the left internal mammary artery anastomosis was in situ to the left anterior descending coronary artery (LAD) or sequentially to the diagonal and LAD along with composite vein or radial artery grafts from the left internal mammary artery to lateral and inferior wall targets.
Aorto-saphenous vein grafting was facilitated by the placement of pericardial sutures to bring the ascending aorta in view for the performance of proximal anastomoses. Proximal aortic anastomoses were done first when indicated, followed by distal anastomoses when using saphenous vein or radial artery.
All composite grafting was made in a "T" fashion based on the left internal mammary artery pedicle and performed prior to coronary artery bypass grafting.
Standard anastomotic techniques of running 7-0 or 8-0 Prolene sutures (Ethicon, Somerville, NJ) were used for the performance of all distal anastomoses.
In an effort to minimize postoperative incisional pain, intercostal nerve freezing was routinely performed in the posterior third through sixth intercostal spaces using a cryoprobe (Frigtonics, Shelton, CT).
In addition all patients had infiltration of the wound with local analgesic. At the end of the procedure, hemostasis was secured and the thoracotomy incision was closed after inserting a 24-French Blake drain (Ethicon, Somerville, NJ). Figure 1 illustrates the postoperative incision typical for patients with isolated LAD disease requiring left internal mammary artery LAD grafting (19 patients).
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Results |
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All patients in this series had complete revascularization of their coronary disease. Specifically all coronary stenoses 
50% were grafted. All 70 patients had a left anterior thoracotomy approach. The average total operating time was 283.5 minutes which included robotic preparation time as well as harvesting the internal mammary artery. The average operative time per case for the first 10 cases was 5 hours and 56 minutes and decreased to 3 hours and 52 minutes for the last 10 cases of the series. The average number of grafts was 2.19 ± .94 per patient. Robotic assisted coronary bypass was utilized for single (19 patients), double (25 patients), triple (4 patients), and quadruple (6 patients) bypass. The distribution of the conduits and target vessels are presented in Table 3. Three patients (4.3 %) were converted to sternotomy due to inadequate IMA flow (one patient), an intramyocardial vessel (one patient), and bleeding at coronary artery anastomosis (one patient). The duration of postoperative ventilation from the time of arrival to the CVICU to the time of extubation was 4.62 ± 1.49 hours (range 6.08 hours; minimum 1.92 hours; maximum 8 hours). The incidents of postoperative complications were as follows: re-op for bleeding 2 (2.8%); transfused patients 7 (10%); atrial fibrillation 6 (8.5%); infections 2 (2.8%); neurologic 0%; renal failure 0%; ventilation greater than one day 0%. The average postoperative length of stay was 5.7 days.
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As of September 20, 2005, 32 patients were eligible for their 1-year follow-up. All 32 patients had normal stress tests at 1 year postoperatively. There was no late mortality or recurrence of angina at the 1-year follow-up.
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Comment |
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The ultimate goal of minimally invasive coronary artery revascularization is to perform totally endoscopic coronary artery bypass without cardiopulmonary bypass on the beating heart (Fig 2). The first step on the journey to total endoscopic surgery was the elimination of the heart–lung machine for routine coronary artery bypass grafting procedures. This paradigm shift, away from conventional coronary artery bypass grafting with the heart–lung machine, was stimulated by reports of decreased risks-adjusted morbidity and mortality and improved outcomes associated with off-pump coronary artery bypass grafting from large multi-institutional studies of the Veterans Administration [1] and The Society of Thoracic Surgeons database [2]. Improved outcomes have been confirmed by hundreds of peer-reviewed studies and were the subject of a recently reported meta-analysis [3].
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As the sternum is not divided in a small thoracotomy incision, sternal wound infection and dehiscence can not occur, and this permits expanded use of double internal mammary artery operations in patients at risk for sternal complications, including diabetics and patients with chronic lung disease.
Robotic telemanipulation further minimizes the access trauma of the internal mammary artery harvesting by eliminating rib spreading, dislocation, and fractures, thus diminishing postoperative pain levels associated with open harvesting through a lateral thoracotomy.
As compared with direct takedown lateral thoracotomy (ie, the minimally invasive direct coronary artery bypass technique), the length of the conduit is usually longer with endoscopic harvesting technology because better access to the proximal and distal portion of the conduit is facilitated. In addition, robotic telemanipulation allows in situ preparation of the mammary conduits, removal of the pericardial fat pad, localization of the anterior descending artery, and determination of anatomic suitability for minimal access approach while maintaining a comfortable and ergonomic arm position at the surgical console. Robotic-assisted internal mammary artery harvesting and mini-thoracotomy in coronary artery bypass grafting has been previously described by Vassiliades [4] and Subramanian and colleagues [5]. The current report confirms the viability and safety of this approach, although a longer postoperative length of stay was demonstrated when applied to older patients with significant comorbidities.
The limitation of this study is the lack of routine postoperative angiography to access graft patency. Freedom from major adverse cardiac events and postoperative stress tests have been used as surrogate markers for graft patency.
Sixty-four of 66 patients were free from angina, myocardial infarction, and repeat revascularization at their 1-year follow-up.
Although the ultimate goal of endoscopic coronary artery bypass grafting is yet to be realized, this report describes a current, practical interim robotic-assisted approach intended to provide a logical stepping stone to newer more complex revascularizations.
Further refinement in robotic technology, heart positioning devices, and port access will have a revolutionary impact on cardiac surgery resulting in significant augmentation of our surgical abilities while markedly reducing the morbidity of coronary revascularization procedures.
Ultimately these refinements may result in the realization of routine total endoscopic coronary artery bypass grafting.
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Discussion |
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DR TURNER: Thank you, John. I think before we can expand closed chest surgery on a wider basis, we have to have an improvement of enabling technology, specifically our cardiac positioners and stabilizers. The current generation of port-access stabilizers are a rigid shaft, and I found them to be very impractical when trying to do multivessel disease. That is the first step and I think that is going to be the largest step towards the path to closed chest surgery.
DR MICHAEL MACK (Dallas, TX): Bill, regarding the place for robotics, Dr Shumway has characterized xenotransplantation as something that has a great future and always will, and I wonder whether that same concept is operative for robotics. We are now 7 or 8 years into the clinical application of robotics, and you have demonstrated that you can surmount the learning curve and achieve excellent results, and get the times down to something reasonable, but it doesn't seem to be widely adopted in the clinical setting. And as we know, drivers of adoption include reproducibility, user-friendliness, and documentation of benefit, and with the experience in a lot of institutions now with robotics, the role of this seems to be mainly in prostate cancer. In addition, with coronary bypass surgery procedure volume going down and companies reluctant to invest in ancillary technology to do the things that you alluded to, would you share your insight is into where you see the role of robotics in cardiac surgery?
DR TURNER: Thank you, Dr Mack. It is a privilege to share the podium with you, a pioneer in off pump surgery and the preeminent off pump coronary bypass surgeon in North America. I recall in 1996 at a meeting in Minnesota, which subsequently was to become the ISMICS, I believe you were asked a similar question by members in the audience when you gave your experience with the minimally invasive direct coronary artery bypass (MIDCAB).
DR MACK: I hope you give a better answer than I gave then.
DR TURNER: Well, I think the answer is here, because it is 10 years later, and you are still here, and there are people like me that have adopted your philosophies and have done a considerable amount of off-pump surgery. I believe that we can reach this goal. I think it is going to take some improvement in enabling technology, it is going to take some perseverance, but if we are going to remain viable as a specialty we must adapt to a less invasive approach to coronary bypass surgery.
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References |
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This article has been cited by other articles:
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  M. Takata, G. Watanabe, T. Ushijima, and N. Ishikawa A novel internal thoracic artery harvesting technique via subxiphoid approach - for the least invasive coronary artery bypass grafting Interactive CardioVascular and Thoracic Surgery, November 1, 2009; 9(5): 891 - 892. [Abstract] [Full Text] [PDF]
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S. D. Demertzis, M. W. Laschke, F. P.A. Siclari, and M. D. Menger Non-robotic thoracoscopic internal mammary artery preparation in the pig. A training model Interactive CardioVascular and Thoracic Surgery, August 1, 2008; 7(4): 556 - 559. [Abstract] [Full Text] [PDF]
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