Asian Cardiovasc Thorac Ann 2006;14:447-451
© 2006 Asia Publishing EXchange Ltd
Totally Endoscopic Coronary Artery Bypass Surgery
Yugal K Mishra, PhD,
Harpreet Wasir, MCh,
Krishan K Sharma, MD1,
Yatin Mehta, MD1,
Naresh Trehan, MD
Department of Cardiovascular Surgery
1 Department of Cardiovascular Anesthesiology, Escorts Heart Institute and Research Center, New Delhi, India
For reprint information contact: Yugal K Mishra, PhD Tel: 91 11 2682 5000 Fax: 91 11 2682 5013 Email: dryugal{at}yahoo.com, Escorts Heart Institute and Research Centre, Okhla Road, New Delhi 110025, India.
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ABSTRACT
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Robotically enhanced surgery is a fast-developing technique that allows totally endoscopic cardiac surgery on both the beating and arrested heart. Between December 2002 and May 2005, 13 patients underwent totally endoscopic coronary bypass using the da Vinci system; 11 operations were on a beating heart and 2 on arrested hearts. The mean time for internal mammary artery mobilization was 42 min. The time for left internal mammary artery-to-left anterior descending artery anastomosis was 20–36 min for totally endoscopic cases. In one patient, the right internal mammary artery was anastomosed to the diagonal artery. No patient required conversion to a median sternotomy. Mean intensive care unit stay was 1.2 days and mean hospital stay was 4.5 days. There was no hospital mortality. All 13 patients had coronary angiography at 3-month intervals, which showed 100% patency in 12 patients while one had 50% anastomotic narrowing for which coronary angioplasty was performed. Using robotic technology, completely endoscopic anastomosis is possible in patients with single-vessel disease. Use of robotics is now extended to achieve complete myocardial revascularization by harvesting both internal mammary arteries in addition to making a small thoracotomy for direct anastomosis.
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INTRODUCTION
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The goal of minimally invasive coronary artery bypass grafting (CABG) is to perform the entire anastomosis endoscopically and avoid cardiopulmonary bypass (CPB). The aim is to reduce postoperative morbidity, length of hospital stay, and overall cost. Advances and experience in beating heart surgery have aided this approach. In patients undergoing surgery on an arrested heart, where direct arteriovenous cannulation is not possible through a limited incision, the femoral approach using Heartport catheters (Heartport Inc., Redwood City, CA, USA) is very helpful for establishing CPB.1–3 With the advent of telemanipulation, truly closed-chest totally endoscopic procedures are now possible.4–7 Our institute initiated a robotic program using the da Vinci telemanipulation system (Intuitive Surgical Inc, Mountain View, CA, USA) in December 2002. Our experience of totally endoscopic coronary artery bypass (TECAB) is reviewed.
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PATIENTS AND METHODS
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Between December 2002 and May 2005, 13 patients underwent totally endoscopic coronary artery bypass (TECAB). Eleven operations were performed on beating hearts while 2 were carried out on arrested hearts using the Heartport system for CPB. Twelve patients had single-vessel left anterior descending (LAD) artery disease, the other had single-vessel disease with additional proximal diagonal artery disease for which anastomosis was performed using the right internal mammary artery on a beating heart. All patients were informed about the procedure preoperatively and each gave written consent. Institutional Review Board permission was also obtained.
The 13 patients (12 males and 1 female) had a mean age of 56.3 ± 7.2 years (range, 34–67 years). The preoperative demographic profile is given in Table 1
. Left ventricular ejection fraction (LVEF) was 58% ± 3.6% and mean New York Heart Association (NYHA) functional class was 2.1 ± 0.6. The prerequisites for patients included for any robotic procedure were those requiring CABG, 18–80 years of age, with informed consent for the procedure. Patients with significant comorbidity including compromised pulmonary function, those requiring additional cardiac procedures, LVEF < 30%, associated ventricular or aortic aneurysm surgery, or significant peripheral vascular disease precluding femoral CPB procedures, were not considered for robotic surgery. Other preoperative exclusion criteria included body mass index > 35.0 kg·m–2, decompensated congestive heart failure (NYHA class III–IV), acute pulmonary edema, uncontrolled hypertension, any coagulopathy, or history of acute myocardial infarction within 30 days. The procedure was converted to conventional CABG on a beating heart if any of the following were found intraoperatively: systolic arterial pressure decrease > 20% of baseline or < 80 mm Hg for more than 15 min or not responding to therapy, dense pleural or pericardial adhesions limiting visibility, intramyocardial LAD or target LAD diameter < 1.5 mm previously not identified by coronary angiography, or inadequate accessibility of the target vessel via routine endoscopic ports.
The da Vinci telemanipulation system consists of a master console (Figure 1) used by the operating surgeon to control the microinstruments mounted on the surgical cart (slave unit) which has 3 arms (Figure 2). The surgical assistant manages the change of instruments, the position of the arms, and the camera on the slave unit. The left and right arms are articulated like the human wrist and carry the microinstruments, the middle arm carries a stereo endoscope for 3-dimensional vision at the console end. An additional video cart carries the light source, a continuous carbon dioxide insufflator, and a conventional 2-dimensional monitor for viewing by the surgical team. The video image from the camera is transferred to the master console, magnified 10-fold, and projected as a 3-dimensional image for optimal visualization.
After routine induction of anesthesia, double-lumen intubation was carried out for single right lung ventilation. Both radial and femoral arteries were cannulated. Bilateral radial cannulation was carried out for invasive monitoring of the endoaortic occlusion catheter in patients who underwent TECAB on an arrested heart. All patients had thermodilution catheter monitoring via the pulmonary artery, and transesophageal echocardiography for assessment of cardiac function and for positioning and monitoring the endoaortic catheter of the Heartport system. The approach to both the left internal mammary artery (LIMA) and the right internal mammary artery (RIMA) was from the left pleural cavity. The patient was placed in the supine position with the left chest elevated by 30 degrees. Landmarks such as the suprasternal notch, xiphoid, and 2nd to 6th ribs were marked. After ensuring single right lung ventilation, the camera cannula with the CO2 insufflator was inserted into the 4th or 5th intercostal space, close to the anterior axillary line, and the chest was insufflated with CO2 at 37°C. After insertion of the endoscope, 2 ports were placed to accommodate the 2 robot arms, usually in the 2nd and 6th intercostal spaces. The LIMA was harvested and skeletonized from where it just became visible near the subclavian vein up to its bifurcation using a 30°-angled endoscope facing upwards (Figure 3). Unipolar cautery was used at low intensity for the LIMA branches. The RIMA was approached via the same ports after creating a retrosternal mediastinal plane and opening the right pleura. The pericardium was opened using the same endoscope with a 30°-down position for visualization of the LAD and its target site for anastomosis. For TECAB on an arrested heart, the Heartport system was used to initiate CPB and infuse antegrade cardioplegia into the aortic root. In the case of beating heart surgery, when the internal mammary artery (IMA) was harvested, an endostabilizer was inserted via a 4th port in the xiphoid area, under endoscopic vision. The patient was heparinized and the IMA was prepared for anastomosis. Throughout the procedure, the CO2 pressure was kept between 10 and 14 mm Hg, depending on the working space; at the same time, systolic pressure was monitored to detect hemodynamic instability. When the LAD was opened, the anastomosis was performed (Figure 4) using a continuous endoscopic suture or Endoclips (US Surgical Corp., Norwalk, CT, USA). On completion of the anastomosis, the endoaortic occlusion catheter was deflated and the patient was weaned from CPB. Heparin was reversed using protamine, and a single chest tube was placed via the xiphoid port and guided into the left pleural cavity.
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RESULTS
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In 12 patients, TECAB was undertaken on the beating heart: for single-vessel LAD disease in 11 and for single-vessel disease with the RIMA anastomosed to a diagonal branch and the LIMA to the LAD in the other patient. In all patients, the IMA could be harvested robotically in a skeletonized fashion. No patients had to be converted to conventional CABG. Intraoperative and postoperative data are summarized in Tables 2 and 3. There was no incidence of postoperative infection. One patient who had undergone beating heart TECAB was re-explored for bleeding via a 5 cm left anterior thoracotomy incision. The bleeding was from an ITA branch that was easily accessed via this incision. There was no mortality in the TECAB group. During the same period, we used the da Vinici system to endoscopically take down the IMA in 216 patients, followed by minimally invasive direct coronary artery bypass in 145, and via a left anterolateral thoracotomy in 71, using a left anterior thoracotomy incision with a mean length of 6.4 cm.8
Although all patients were ambulated by the 1st postoperative day, and most were fit for discharge by the 2nd postoperative day, according to our protocol, they were discharged on the 4th postoperative day and came for their first follow-up on the 7th postoperative day. Table 4 summarizes the follow-up data. All patients had an angiogram after 3 months; there was 100% anastomotic patency (Figure 5) in 12 patients, and one had 50% anastomotic narrowing for which angioplasty was immediately performed. All 4 patients who have completed 2 years of follow-up are symptom-free during regular physical activity.
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DISCUSSION
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The treatment of single-vessel coronary artery disease is generally nonsurgical. However, when surgery is indicated, a less invasive procedure may be chosen to minimize surgical trauma, improve cosmesis, reduce the risk of infection, and minimize postoperative pain. With minimally invasive and off-pump CABG becoming established techniques, morbidity has been reduced compared to conventional CABG on CPB. The development of femoral access technology for peripheral CPB induction has allowed the chest incision to be further reduced.9,10 Totally endoscopic coronary artery bypass has revolutionized minimally invasive techniques of CABG.4,6 If carried out on the arrested heart, femoral CPB is mandatory. Our experience with femoral access surgery, which we have been routinely performing for atrial septal defect closure and mitral valve surgery, was helpful, as was our experience of beating heart surgery, which we now routinely apply for most CABG operations. Our CPB time of 64 min and crossclamp time of 44 min are comparable with those in other centers performing TECAB, mostly on arrested hearts.4
We believe there should be a low threshold for conversion to an open technique in the initial stages of robotic surgery, to reduce the patient’s risk. Although pleural as well as pericardial adhesiolysis is certainly possible, it should be avoided unless sufficient experience with this technique has been gained. Adequate port placement was possible in all patients, but as each has a different chest topography, proper marking of the port sites is important to avoid a struggle due to instrument collision and failure of complete IMA takedown due to left shoulder or subcostal interference. This is more important in patients who have a medium-sized chest cavity, extremely obese males, or females with large breasts. We believe these are the patients who will benefit most from an endoscopic procedure because the risk of wound infection is almost zero, as seen in our series. The feasibility and safety of closed-chest IMA takedown has been shown by several other groups.5,11,12 Although the use of TECAB can be extended to patients with double-vessel disease, as in one of our patients, the anatomy must be suitable. Dogan and colleagues4 reviewed their experience of double-vessel disease using both isolated IMAs and sequential anastomoses.7 Bilateral IMA grafting is feasible but appears to be challenging and time-consuming, thus it has a very limited indication. Multi-detector computed tomography has also been used to determine the exact position of the target coronary site and size for TECAB anastomosis.4
The ultimate success of the robotic procedure depends on the combined efforts of the surgeon at the console, the assistant surgeon at the slave cart, the anesthesiologist, and the perfusionist who all need to work as a team with communication at every stage. From the change of instruments to hemodynamic monitoring, the CO2 pressures and routine blood gas monitoring all require the utmost vigilance at all times. Hypotension secondary to raised intrathoracic pressure due to CO2 insufflation needs to be controlled meticulously. Most centers perform TECAB on the arrested heart but it is premature to comment on the quality of anastomosis on beating versus arrested hearts. We believe that TECAB on a beating heart is a safe option that circumvents all the deleterious effects of CPB, especially if used as a new procedure. Totally endoscopic coronary artery bypass can also be extended to achieve complete myocardial revascularization by robotic bilateral IMA takedown and direct anastomosis via a small thoracotomy.
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ABSTRACT
INTRODUCTION
