Step-by-step technique of robotic-assisted minimally invasive direct coronary artery bypass

Abstract

Coronary artery bypass grafting (CABG) is the treatment of choice for coronary artery disease. The traditional method of performing CABG via a full sternotomy has its drawbacks, including increased postoperative morbidity, a higher incidence of complications, and extended hospitalizations. Although minimally invasive and robotic-assisted technology offer promising alternatives, they have not gained wide acceptance, largely because of the limited amount of literature supporting hybrid and robotic-assisted CABG. Since 2005, Lankenau Heart Institute's cardiothoracic surgical team has been developing and refining for selected patients a method for coronary revascularization that involves robotic harvesting of the left internal mammary artery (LIMA) and beating heart surgery through a limited minithoracotomy. This technique precisely places the robotic endoscopic port over the target site of the left anterior descending (LAD) artery. The LIMA is harvested using the enhanced visualization and precision of the robotic platform. The robotic instruments are then removed, and the endoscopic port site is slightly enlarged to become the minithoracotomy, allowing for LIMA-to-LAD anastomosis. The other two robotic ports are used for drains, eliminating the need for additional incisions. The method has been used in over 2,850 patients. The method has been used in over 2,850 patients. This article describes in detail our standardized technique for robotic-assisted minimally invasive direct coronary artery bypass (R-MIDCAB).

Keywords: Robotic coronary artery bypass grafting (robotic CABG); cardiac surgery; minimally invasive direct coronary artery bypass (MIDCAB); precision incision; thoracotomy.

Figure 1

Three landmarks coordinate system for the precision incision. LIMA, left internal mammary artery.

Figure 2

Coordinate 1 marking on the long thoracic axis.

Figure 3

Precision incision adjustment according to coordinate 3.

Figure 4

Longitudinal alignment of the three robotic ports.

Figure 5

Intraoperative pericardial incisions. (A) Posterior phrenic pericardiotomy to drain any blood that may accumulate during the anastomosis; (B) anterior pericardial incision to identify the LAD target. LAD, left anterior descending.

Figure 6

Left internal mammary robotic harvesting (clipping collaterals).

Figure 7

Minithoracotomy precision incision and upper chest drain placement.

Figure 8

OCTOPUS^® NUVO tissue stabilizer with suction tubing and pole (Medtronic, Inc., Minneapolis, MN, USA), are shown as two detachable components that are seen separately on the surgical field (A), and subsequently connected within the minithoracotomy site (B).

Figure 9

SaddleLoop positioning for the LAD anastomosis. LAD, left anterior descending.

Figure 10

Postoperative R-MIDCAB incision in a LIMA to LAD and diagonal (sequential) double bypass. R-MIDCAB, robotic-assisted minimally invasive direct coronary artery bypass; LIMA, left internal mammary artery; LAD, left anterior descending.