Asian Cardiovasc Thorac Ann 2002;10:92-94
© 2002 Asia Publishing EXchange Pte Ltd
Totally Robotic Technique in Multivessel Coronary Disease — Is it Possible?
Andi W Susilo, MD,
Arndt P Schulz, MD
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Department of Cardiovascular and Thoracic Surgery Heart Center Coswig Coswig, Sachsen-Anhalt, Germany
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Andi W Susilo, MD Tel: 32 53 70 6817 Fax: 32 53 70 6817 email: Dr.Susilo{at}web.de Lindenstraat 108, Aalst B-9300, Belgium.
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ABSTRACT
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Robotic techniques in coronary surgery have been established for a few years. The preparation of the internal mammary arteries is now a well-described procedure, as is anastomosis to the anterior wall vessels under cardiopulmonary bypass. To achieve totally robotic complete revascularization of the heart, there are still some problems to be solved. Potential solutions are discussed. Current techniques using telemanipulation systems in cardiac surgery are described and explained. Totally endoscopic off-pump complete revascularization of the heart might be achieved by a combination of techniques already developed by different teams around the world.
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INTRODUCTION
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In an astonishingly short period of time, robotic tech-niques in coronary surgery have become established.1,2 Preparation of the internal mammary arteries is now a well-described procedure. Anastomosis to the anterior wall vessels and the right coronary artery, with or without cardiopulmonary bypass (CPB), is also well established.3–13
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ROBOTIC SYSTEMS
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Two systems that enable robotic minimally invasive coronary surgery are the ZEUS robotic surgical system (Computer Motion, Santa Barbara, CA, USA) and the da Vinci telemanipulation system (Intuitive Surgical, Mountain View, CA, USA). The expected advantages of these systems in coronary surgery include: reduced pain and less surgical trauma from the tiny incisions, roughly the diameter of a pencil; applicability in beating-heart approaches, thereby further reducing the surgical trauma; improved technical precision and dexterity with the elimination of hand tremor; better visualization in 2- or 3-dimensional fields; and minimal surgeon fatigue with an ergonomic operating environment. The expected shorter hospital stays and convalescent periods have not yet been statistically proven.
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GENERAL TECHNICAL ASPECTS
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Indications for robotic coronary revascularization procedures including off-pump techniques are not yet clearly defined. When CPB is contraindicated, minimally invasive off-pump procedures might be used. Contra-indications to minimally invasive and robotic assisted procedures include extreme cardiac enlargement such as aneurysm of the left ventricle or cardiomegaly. A relative contraindication is a small intrathoracic space, a fact that is sometimes difficult to assess before the procedure commences.
After preparing and draping the patient, a camera port is constructed in the 5th intercostal space in the anterior axillary line. After connection of warm humidified CO2 for insufflation, the 3D optic is attached. Two additional ports for instrumentation are created in the 3rd and 6th intercostal spaces above the anterior axillary line. Another port may be necessary for introduction of a stabilizer or when performing a right coronary anastomosis. The left chest cavity is explored and the left internal mammary artery (IMA) is identified. The right chest is entered through the mediastinum, and right IMA dissection is performed before left IMA harvesting. Dissection of the right IMA is carried out by creating a pedicle extending distally to approximately the 7th rib, using a 0-degree endoscope and low-energy cautery (15 W). After changing to a 30-degree optic, a left IMA pedicle of the same length is harvested.14
Experimentally, it has been possible to mobilize the right gastroepiploic artery endoscopically and anastomose it within the pericardium.15 This is performed by CO2 insufflation into the abdominal cavity through the usual Veress needle, and insertion of 3 ports. The laparoscope is positioned, followed by 2 endoscopic instruments. Dissection of the gastroepiploic artery is started in the middle portion and extended towards the proximal and distal ends, using endoscopic scissors, forceps, clips, and electrocautery. An additional port is sometimes needed for a Babcock forceps to be positioned in the epigastrium to retract the stomach. The same port can be used for insertion of the endoscopic stabilizer needed for carrying out anastomosis on the beating heart. After heparinization, an endoscopic atraumatic temporary-occlusion vessel clamp is applied to the right gastroepiploic artery and positioned in the pericardium. Via this transabdominal technique, it is also possible to harvest both mammary arteries.
For extracorporeal circulation, the Heartport endoCPB System (Heartport, Redwood City, CA, USA) is installed using the femoral artery for arterial return and percutaneous cannulation for venous return from the femoral vein. The Heartport Endoclamp is inflated and cardioplegic solution is applied. The patient's temperature is lowered to 30°C. Transesophageal echocardiographic monitoring ensures correct positioning of the occlusion balloon. The heart is vented throughout the procedure. The left anterior descending coronary artery and the first marginal branch are identified, and the anastomosis site is prepared using blunt and sharp dissection. After the procedure, the Endoclamp balloon is deflated and the coronary circulation is reestablished.
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TOTALLY ROBOTIC ENDOSCOPIC ANASTOMOSIS
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On the beating heart, it is possible to temporarily occlude the vessel or create a completely bloodless field using a second-generation stabilizer for immobilization of the target vessel and silastic vessel loops or intracoronary shunts. With the Heartport CPB system, it is then possible (via 3 pencil-sized incisions in the left hemithorax) to perform anastomoses to the left anterior descending artery, diagonals, and marginal branches, as well as right coronary artery anastomosis via similar incisions in the right thorax.2,5–7,16 Furthermore, experimental studies have demonstrated the possibility of performing anastomosis on all target vessels through a transabdominal approach.15,17 With the transabdominal approach, we still face two problems: hemodynamic depression and the technical problem of safe closure of the diaphragm.17 We suggest that it might be possible to avoid the abdominal cavity by a very high subxiphoid incision, and so keep within the intrathoracic space. However, endoscopic anastomosis for 3-vessel disease is only possible at present with CPB and a conventional sternotomy or the Dresden technique.3,14
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IMPLICATIONS FOR THE FUTURE
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Rapid advances over the last few years have resulted in no differences between the times for arrested and beating-heart endoscopic coronary anastomoses, which range from 14 to 50 minutes (median, 25 minutes).4 Theoretically, an incision of the pericardium on the left side below the phrenic nerve, and use of an apical suction device for extension (via a subxiphoid port) could allow manipulation of the heart to provide a safe working space for anastomosis to the circumflex artery. Totally robotic endoscopic surgery without CPB for 3-vessel coronary disease is not tech-nically possible so far, but with the combination of various new instruments and techniques, it is an achievable goal.
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REFERENCES
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ABSTRACT
INTRODUCTION
