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Eur J Cardiothorac Surg 2001;20:765-769
© 2001 Elsevier Science NL
a Department of Cardiac Surgery, Cardiovascular Institute, University of Dresden, Fetscherstrasse 76, D-01307 Dresden, Germany
b Department of Anaesthesiology, Cardiovascular Institute, University of Dresden, Fetscherstrasse 76, D-01307 Dresden, Germany
Received 13 December 2000; received in revised form 31 May 2001; accepted 12 June 2001.
Corresponding author. Tel.: +49-351-450-1713; fax:+49-351-450-1707
e-mail: monika.weber.hkz_dd{at}t-online.de
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Abstract |
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 Top Abstract 1. Introduction2. Methods3. Results4. Discussion and conclusionReferences |
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Key Words: Robotic enhanced surgery • Totally endoscopic coronary artery bypass • Off-pump coronary artery surgery • Endoscopic surgery • Minimally invasive cardiac surgery
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1. Introduction |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion and conclusionReferences |
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With well-established minimally invasive cardiac surgical techniques getting enhanced by robotic procedures, a broader array of patients suffering from coronary artery disease (CAD) becomes eligible for minimally invasive operations avoiding sternotomy.
New technical innovations, such as the introduction of endoscopic stabilizers into MICS, enables TECAB procedures of CAD via four 1-cm chest incisions on the beating heart and the avoidance of extracorporeal circulation (ECC).
The present paper includes an initial series of totally endoscopic off pump coronary artery bypass grafting in 29 patients (four female, 25 male, median age 64±9.8 years) suffering from CAD operated upon at the Dresden Cardiovascular Institute.
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2. Methods |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion and conclusionReferences |
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Out of this whole patient group 37 patients (five female, 32 male, median age 62±9 years) underwent a TECAB procedure since the installation of the system in May 1999. An initial series of eight TECAB patients was operated upon using an endovascular bypass system (Heartport, Redwood City, CA), whereas the latter patients received a beating-heart TECAB treatment.
The beating-heart TECAB procedure consists of two steps. The harvesting of the left or right internal mammary artery (LIMA/RIMA) and suturing of the coronary anastomoses. Both steps were performed using the three-dimensional-based computer-enhanced surgical system in the 29 patients (four females, 25 males, median age 64±9.8 years) out of the beating-heart TECAB group. Altogether, 26 patients suffering from single-vessel coronary artery disease were revascularized applying LIMA to left anterior descending (LAD) grafting and three patients with two diseased coronary artery vessels received bilateral internal mammary artery grafting on a beating heart, respectively.
Preoperatively, 3.4% of the patients were in Canadian Cardiovascular Society (CCS) stage I, 41.4% in stage II, 54.7% in stage III and 3.4% in stage IV; 6.9% of the patients in New York Heart Association (NYHA) class I, 58.6% in class II, 34.5% in class III and 0% in NYHA class IV.
The patients had a complete follow-up including physical examination, 12-lead ECG and chest X-ray on the first and seventh postoperative day. All patients were scheduled for a stress ECG and clinical examination 4 weeks after surgery and for a clinical examination after 3 months. No routine postoperative angiography was performed. A 1-year follow-up including coronary angiogram is still planned.
Exclusion criteria were decreased LVEF (<40%), decreased lung function (FEV1<1.0), obesity (body mass index (BMI)>35) and intramyocardial LAD course or diffuse coronary artery sclerosis.
Perioperative data on age, sex, BMI, LVEF, left ventricular end diastolic pressure, duration of surgery, duration of endoscopic IMA dissection, duration of bypass, vessels affected by coronary sclerosis and actually performed anastomoses, ventilation time, intensive care unit stay and hospitalization were analyzed (Tables 1 and 2).
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The three 1-cm skin incisions are placed in the left chest in the third intercostal space (ICS) at the medioclavicular line for the right port, in the fifth ICS at the anterior axillary line for the central optical port and in the sixth ICS at the medioclavicular line for the left port, forming a triangle whose angle may vary depending on the habitus of the patient (Fig. 1) .
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A slight upward movement of the camera port under CO2 insufflation improved IMA dissection due to increase of the precordial space, which is essential for IMA takedown and left anterior descending artery (LAD) grafting. Using 30-W cautery, endoscopic LIMA takedown is begun, creating a pedicle.
Endoscopic internal mammary artery (IMA) takedown is always performed using the three-armed da Vinci robotic unit via three 1-cm chest incisions, choosing a single left-sided approach with the patient being placed on single right lung ventilation.
After IMA takedown via the three 1-cm chest incisions, the preparation of the IMAs for anastomosis is performed inside the chest of the patient in the case of TECAB or done under direct sight with the pedicle being pulled through the chest incision in the case of REDTCAB (robotic enhanced ‘Dresden Technique’ coronary artery bypass) [7,8] or MIDCAB (minimally invasive direct coronary artery bypass). The initial marking of the LIMA course in case of a planned bilateral IMA takedown is mandatory, as pedicle injury to the left IMA through the instrumentation can be avoided.
After IMA harvesting a vessel clamp is introduced via the skin incision at the level of the third ICS and is placed on the proximal IMA. Heparin is administered in order to achieve an ACT (anti-coagulation time) above 300 s.
The pericardial fat is then resected and the pericardium is opened in a rectangular fashion exposing the LAD. The LIMA pedicle is then dissected for anastomosis.
Via a further fourth 1-cm skin incision at the subxyphoidal area the endoscopic stabilizer is introduced. This endoscopic device consists of two branches, like common beating-heart stabilizers. However, the branches can be guided from outside the chest. A joint at the heel of the stabilizing device allows a precise and stable positioning at the anastomotic site. For the attachment of silastic vessel loops, for later coronary occlusion, special cleats are placed on these branches ensuring a firm hold for the loops during coronary artery occlusion. An irrigation tube is attached above the heel-joint of the endostab, allowing saline-flushing for clear visualization of the desired anastomotic area (Fig. 2) .
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After the anastomosis is completed, the vessel clamp is released and the anastomosis is explored for leakage. Protamine is administered and the actuators and camera are removed. The insertion of a soft thoracic catheter through the 1-cm incision in the six ICS in combination with subcutaneous and skin sutures completes the procedure.
Before transferral of the patient to the intensive care unit, a single-lumen endotracheal tube replaces the double-lumen endotracheal tube or the endotracheal blocker is simply removed.
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3. Results |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion and conclusionReferences |
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Conversion to a median sternotomy was necessary in one patient (3.4%) due to damage to the left IMA. In the overall series of 56 patients intended to be treated TECAB, 19 (33.9%) were converted to a MIDCAB procedure. Hence, in five patients LAD identification was not possible endoscopically. Diffuse sclerosis of the LAD (five patients), difficulties with endoscopic stabilization (three patients), pleural adhesions (two patients), intramural course of the LAD (two patients) and two patients with an insufficient occlusion of the LAD were factors for a conversion to a MIDCAB procedure.
In three (10.3%) of the patients an explorative second-look control was performed because of increased postoperative drainage. Bleeding muscle tissue adjacent to the ports was coagulated thoroughly and hemostasis regained.
Perioperative data are listed in Table 1. The pattern of coronary vessels grafted and conduits used are listed in Table 2. Three (10.3%) patients with coronary artery disease affecting more than one vessel were treated with bilateral IMA (BIMA) grafting. In two cases with hypoplastic circumflex system and big LAD and diagonal branch BIMA grafting was applied. In one case with a double-vessel CAD, BIMA grafting proved feasible and was hence performed.
No routine postoperative angiography was performed, and a 1-year follow-up control angiography is planned. As a limitation to the study this should be noted. One patient developed chest pain on postoperative day 1. A consecutive coronary angiography revealed complete patency of the anastomosis (Fig. 3) .
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A 4-week postoperative stress ECG and 12-week postoperative clinical examination of all patients is still going on. So far this short-term follow-up was performed in 55.2% and revealed no signs of myocardial ischemia. However, one patient (3.4%) claimed to suffer from angina 4 weeks postoperatively. Coronary angiography revealed a progredient lesion of the circumflex artery and the patient had an uneventful percutaneous transluminal coronary angioplasty.
Twelve weeks postoperatively, so far 81.2% of the patients were in Canadian Cardiovascular Society (CCS) stage I, 12.5% in stage II and 6.3% in stage III; 68.7% of the patients in New York Heart Association (NYHA) class I and 31.3% in class II.
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4. Discussion and conclusion |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion and conclusionReferences |
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The technical development of an endoscopic stabilizer (Intuitive Surgical, Mountain View, CA, USA) led to a beating-heart closed-chest procedure via four 1-cm chest incisions. With the demonstrated surgical technique at hand, an optional new concept for the minimally invasive surgical treatment of CAD can be developed [9,10].
The conversion rate to a MIDCAB procedure (33.9%) may decline in the future by growing experience with this new endoscopic technique. Further technical improvements concerning LAD occlusion, endoscopic stabilization, and better LAD identification may lead to overcome the present obstacles. One out of three patients with the current technical standard so far applied becomes eligible for a true beating-heart TECAB.
The feasibility of endoscopic BIMA grafting on the beating heart cannot be judged overenthusiastically. It may only be beneficial to a very peculiar patient group and still poses controversial discussion.
Proper port placement setup plays an essential role in this endoscopic bypass procedure. The robotic arm placement setup is paramount to reduce the degree of difficulty, ensuring the success of the procedure (Fig. 1). The previously postulated rule of creating a triangle-like port arrangement in the left chest of the patient is not always reliable to ensure a safe case. Modifications have to take place in accordance with the patient's habitus.
By experience and intuition the surgeon will, however – keeping this golden rule in mind – create an arrangement, which is suitable for ensuring proper instrumentation movement inside and outside the chest by a careful evaluation of the patient intercostal spaces, rib cage, body mass index, breast size and tissue rigidity. The ports have to be moved according to these factors (Fig. 1) to avoid actuator collisions.
Our early experiences using an essential alternative to conventional heart surgery are positive and represent only the first steps towards future developments. Closed-chest OPCAB grafting of SVCAD was performed using the da Vinci system. This new minimally invasive technique is a promising alternative for patients suffering from SVCAD, avoiding median sternotomy and minithoracotomy.
Six days of hospitalization may seem prolonged for a minimally invasive procedure; it is, however, related to the German medical care system. A further reduction of the postoperative hospital stay, down to 3–4 days, seems to be possible.
The TECAB technique on the beating heart is a unique and new method for the surgical treatment of coronary artery disease. The surgical procedure performed without any thoracotomy via a four-point stab incision allowed to fully maintain the integrity of the chest wall. Postoperative convalescence with only little visible scars is excellent (Fig. 5) .
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Footnotes |
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References |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion and conclusionReferences |
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