Asian Cardiovasc Thorac Ann 2003;11:359-361
© 2003 Asia Publishing EXchange Ltd
Endoscopic-Assisted Atraumatic Coronary Artery Bypass
Thomas A Vassiliades, Jr., MD
Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
For reprint information contact: Thomas A Vassiliades, Jr., MD Tel: 1 404 778 4064 Fax: 1 404 778 4346 email: vassiliades{at}pol.net Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA.
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ABSTRACT
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Minimally invasive operations designed to graft the left anterior descending coronary artery with the left internal mammary artery are either traumatic to the chest wall or technically difficult and expensive. This report describes a novel procedure that is less traumatic and simpler.
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INTRODUCTION
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To date, minimally invasive procedures for grafting the left anterior descending coronary artery (LAD) with the left internal mammary artery (LIMA) are either traumatic to the chest wall, as the minimally invasive direct coronary artery bypass procedure,1 or technically difficult and expensive, as the totally endoscopic coronary artery bypass approach performed with or without cardiopulmonary bypass.2 This report describes a less traumatic and simpler method of grafting the LIMA to the LAD.
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TECHNIQUE
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The patient is placed in a supine position with the thorax raised approximately 20 degrees off the operating table by means of a folded blanket placed underneath. The left arm is raised over the head with the elbow bent across the patient’s face. The AESOP system (Computer Motion, Goleta, CA, USA), which consists of a robotic arm holding an endoscope, is attached to the right bed rail. The LIMA is harvested thoracoscopically with the patient on single-lung ventilation and carbon dioxide insufflation. The technique for harvesting the internal mammary artery (IMA) has been described in detail previously.3 Complete mobilization is performed from the subclavian artery origin to the bifurcation near the 6th rib. After harvesting the IMA, the pericardium is opened and the target vessel or vessels are identified clearly. The purpose here is to avoid misidentification of the target arteries, which can occur through small incisions. With the endoscope, the surgeon can view the entire anterolateral wall of the heart and confirm the course patterns of the coronaries seen on the catheterization films. It is extremely helpful to have the catheterization films available for comparison at this stage. Additionally, the presence of intramyocardial portions of the coronaries can be discovered before any incision is made. The position of the ribs is identified from the surface through transillumination of the chest wall using the scope so that the incision site can be placed in the middle of the interspace. A long spinal needle is then passed through the chest wall, and the ideal incision site is determined endoscopically. The incision site is centered directly over the target vessel at the precise location of the anticipated anastomosis. In our experience, the fourth intercostal space just medial to the nipple is the most common place for grafting the LAD.
The next step is to perform an atraumatic chest wall incision. This consists of dividing the intercostal muscle but not necessarily the pectoralis major. The latter muscle can be separated in the direction of the fibers as in any muscle-sparing incision. A standard rib-spreading retractor is not used; rather, a small cloth soft-tissue retractor (Heartport Inc., Redwood City, CA, USA) provides adequate space in all but the smallest of patients. If the target spot on the coronary artery has been centered within the incision, then it is not necessary to spread the ribs. A 4- to 5-cm incision is usually sufficient. The incision needs only be large enough to accept the surgeon’s forceps and needle driver. The array of accompanying equipment (Computer Motion, Goleta, CA, USA) is brought in through the 3 ports previously used for the IMA harvest. A long 3-mm clamp for opening and closing the IMA flow is introduced through the most superior (cautery) port. A 6-mm-diameter stabilizer arm is brought in through the scope port skin incision and attached to the bed rail using a universal clamping device (Figures 1
and 2). The stabilizer arm has a side tube running parallel to it that will accept a carbon dioxide mister. The low-profile stabilizer plate is introduced through the skin incision and attached to the end of the stabilizer arm. The coronary artery is occluded by means of soft silastic tapes (Quest Medical, Allen, TX, USA), which are attached to the stabilizer foot. No equipment is passed through the thoracotomy as it would obstruct the surgeon’s view. Anastomosis is facilitated by means of an IMA holder attached to the stabilizer plate, which places the IMA in close proximity to the LAD arteriotomy. The anastomosis is constructed by hand in a routine manner using conventional instruments without the need for an assistant. The ability to clamp and unclamp the IMA allows bleeding and flow to be checked easily throughout the procedure.
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Figure 1. Intraoperative view of the left thoracotomy through which anastomosis is performed. The stabilizer and the IMA clamp are brought in through ports previously used for IMA harvest. ICS = intercostal space, IMA = internal mammary artery.
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Figure 2. View from the head of the operating table. The left anterior descending artery is positioned and stabilized directly under the left thoracotomy, and the harvested left internal mammary artery is placed near it in preparation for grafting.
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After removal of all instruments, a 20F chest tube is inserted in the most inferior port site and two-lung ventilation is reestablished. Intercostal nerve block is performed and the patient is extubated in the operating room. Postoperative care involves observation for 2 to 4 hours in an intensive care setting followed by routine ward care with telemetry. Discharge is planned in 48 hours.
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DISCUSSION
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The endoscopic-assisted atraumatic coronary artery bypass procedure combines existing techniques and technologies from previously described operations. The endoscopic portion of the procedure includes IMA harvest, pericardiotomy, target vessel identification (usually the LAD), and the planning of the skin incision. The technically more demanding aspects of the procedure — vessel dissection, occlusion, stabilization, and grafting — are performed with conventional instruments under direct vision. By limiting the endoscopic aspect to the more straightforward tasks and relying on conventional techniques for the challenging aspects, the operation becomes less complicated and more adaptable to the novice.
Although this is not a total port approach, the trauma to the chest wall is no greater than in a totally endoscopic operation. Postoperative trauma and pain can be attributed mostly to violation and disruption of the bony thorax, not the size of the skin incision. If performed correctly, all the direct-vision tasks can be carried out through the natural interspace width of most patients, usually 12 to 15 mm. No rib spreading is necessary.
In summary, the advantages of this new approach are a result of the blending of the best parts of existing minimally invasive bypass operations, as summarized in Table 1. The procedure essentially consists of 3 steps: thoracoscopic LIMA harvest; a 4-cm muscle-sparing thoracotomy without rib spreading; and direct-vision beating-heart anastomosis with conventional instruments. Combining these techniques offers the benefit of less surgical trauma and complexity.
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REFERENCES
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- Calafiore AM, Giammarco GD, Teodori G, Bosco G, D’Annunzio E, Barsotti A, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg
1996;61:1658–63.[Abstract/Free Full Text]
- Falk V, Diegeler A, Walther T, Banusch J, Brucerius J, Raumans J, et al. Total endoscopic computer enhanced coronary artery bypass grafting. Eur J Cardio-thorac Surg 2000;17:38–45.
- Vassiliades TA Jr. Technical aids to performing thoracoscopic robotically-assisted internal mammary artery harvesting. Heart Surg Forum
2002;5:119–24.[Medline]
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ABSTRACT
INTRODUCTION
