Robotically enhanced minimally invasive direct coronary artery bypass surgery: a winning strategy?

AIM: Minimally invasive direct coronary artery bypass (MIDCAB) through a small anterolateral thoracotomy on the beating heart can be considered as the better approach for treating isolated lesions on the left anterior descending (LAD) artery. This original MIDCAB procedure, however, involves a larger and often painful thoracotomy due to rib spreading. We describe our experience with robotically enhanced harvesting of one or both internal mammary arteries (IMAs), and with anastomosis performed under direct vision on a beating heart through a very small thoracotomy without rib retraction. METHODS: Between February 2001 and January 2006, 146 consecutive patients underwent robotically enhanced MIDCAB surgery. Perioperative and early follow-up data were analyzed. RESULTS: In all, 144 left and 13 right IMAs were harvested. The mean extubation time was 11.3 h, the mean intensive care (ICU) stay was 30.3 h, the mean hospital stay 8 days. There were no in-hospital deaths, postoperative myocardial infarctions or renal failures. Systematic control angiograms performed in the first 64 patients showed a 96.3% patency rate of the investigated anastomoses. CONCLUSION: Robotically assisted takedown of the IMA and direct off-pump anastomosis through a small anterolateral thoracotomy with no rib retraction appears to be safe, with minimal morbidity, little blood loss, and a reasonable ventilation time, ICU and hospital stay. It is recommended as the preferred method of revascularization for a growing number of indications and certainly an acceptable alternative to percutaneous transluminal coronary angioplasty.

Technical aspects of harvesting the radial artery with the harmonic scalpel.

BACKGROUND: Harvesting the radial artery (RA) with ultrasonic dissection with the Harmonic Scalpel reduces spasm induced by surgical handling. Topical exposure to phentolamine methanesulphonate (Regitine) exerts an additional effect of vasodilatation. METHODS: Between January and December 2002, the RA was harvested as a pediculated vessel with the Harmonic Scalpel in 145 consecutive patients undergoing myocardial revascularization. A fasciotomy of the pedicle was performed after harvest ing. A composite graft with the reverse free RA on the in situ left internal thoracic artery (ITA) was prepared before the construction of distal coronary anastomoses. The RA was then placed in a syringe filled with Regitine (0.07 microg/mL) for 10 minutes. \par RESULTS: The mean number of grafts/patient was 3.0. The mean number of RA anastomoses was 2.0/patient. Left ITA free flow was 105 +/- 34 mL/min. Regitine increased the RA free flow from 60 +/- 35 mL/min to 82 +/- 30 mL/min (P <.05). Fourteen patients underwent postoperative coronary angiography. All RA anastomoses were patent. CONCLUSION: The compound effect of RA harvesting with the Harmonic Scalpel and topical treatment with the alpha- blocking agent Regitine increases the RA free flow and significantly decreases intraoperative spasticity.

A novel thermoregulatory system maintains perioperative normothermia in children undergoing elective surgery.

BACKGROUND: Body heat loss during anaesthesia may result in increased morbidity, particularly in high-risk populations such as children. To avoid hypothermia, a novel thermoregulatory system (Allon) was devised. We tested the safety and efficacy of this system in maintaining normothermia in children undergoing routine surgical procedures. METHODS: The system consists of a computerized body, which receives continuous afferent data, i.e. core (rectal) temperature. These data are then compared with a preset temperature (37 degrees C) and a microprocessor heating/cooling unit warms/cools the temperature of circulating water in a garment that is specially designed to allow maximal coverage of body surface area, without impingement on the surgical field. Water temperature to the garment was limited to a maximum of 39.5 degrees C. Continuous perioperative monitoring of skin and rectal temperature, heart rate and blood pressure was performed. Postoperative shivering and adverse effects were also assessed. RESULTS: The Allon system was used in 38 patients aged 3 months to 14 years undergoing surgery under general anaesthesia lasting more than 30 min. Fifty to 80% body surface area was covered by the garment. Mean operative and postoperative core temperatures were 36.9 +/- 0.5 degrees C and 36.7 +/- 0.5 degrees C, respectively. Intraoperative skin temperatures were maintained at 34.4 +/- 2.7 degrees C. The average core- to-periphery intraoperative gradient was 2.9 +/- 4.9 degrees C. Postoperative shivering was absent in 36 cases and mild in two cases. No device-related adverse effects were observed. CONCLUSIONS: Perioperative thermoregulation using the Allon system is safe and effective in maintaining body temperature within a narrow range in children undergoing brief surgical procedures.

Novel thermoregulation system for enhancing cardiac function and hemodynamics during coronary artery bypass graft surgery.

BACKGROUND: Myocardial ischemia, arrhythmias, and coagulopathies are associated with postoperative hypothermia. This study assessed the efficacy of a novel thermoregulation system in alleviating these events during coronary artery bypass graft (CABG) surgery. METHODS: Elective CABG surgery patients were randomized into either Allon thermoregulation (AT, n = 40) or routine thermal care (RTC, n = 20) groups in whom the maintenance of normothermia during the nonbypass phases of the operation was compared. The AT used patients' rectal temperature as reference data to monitor the maintenance of the water temperature circulating at 37 degrees C in a garment. Rectal temperature, patient hemodynamics, and cardiac-specific troponin I (cTnI) levels were assessed at the induction of anesthesia, 30 minutes into surgery, at discontinuation of bypass, end of surgery, and 2 hours postoperatively. RESULTS: Body temperature was higher in the AT group compared to the RTC group at all five time points. Cardiac index (CI) (L/min) was higher in the AT group, 2.5 +/- 0.5, 2.6 +/- 0.5*, 3.2 +/- 0.6*, 3.3 +/- 0.5*, 3.1 +/- 0.7 at the respective time points, compared to the RTC group, 2.3 +/- 0.6, 2.1 +/- 0.2, 2.6 +/- 0.7, 2.7 +/- 0.7, 2.7 +/- 0.7 (*p < 0.05). Systemic vascular resistance (SVR) (dyne x s)/cm5) was consistently lower in the AT patients. Enzyme levels were elevated in both groups but were less so in the AT patients. CONCLUSIONS: The AT system can efficiently maintain normothermia. The beneficial effects are expressed by reduced SVR, elevated CI, and lower levels of cTnI, which may show a possible attenuation of myocardial injury.

[Video-assisted thoracic surgery--experience with 586 patients].

Recent advances in optics, video systems and endoscopic operating instruments have led to increasing application of thoracoscopic surgery, as it has become easier to perform and more accurate. We performed 586 video-assisted thoracic surgical procedures for diagnosis and treatment (May 1992-Dec. 1998) 127 were for diagnostic thoracoscopy and 79 for pleurodesis. 380 cases of operative thoracoscopy included pulmonary wedge resection (for interstitial lung disease, benign and malignant pulmonary tumors and pulmonary metastases) bullectomy, management of empyema, pleural tumor biopsy, thoracic sympathectomy, pericardial window formation, thoracic spinal procedures and resection of posterior mediastinal cysts. Recently we have had good experience in evacuating blood and blood clots from the thorax which accumulated after cardiac and thoracic surgery. Patients were placed in the lateral thoracotomy position and were ventilated with a double-lumen endotracheal tube, enabling collapse of the operated lung. The operating approach was through 1-3 thoracic ports. Mean operation time was 55 minutes, chest-tubes remained for 2.2 days (mean) and mean hospitalization was 3.3 days. There were no wound infections or significant postoperative complications. 5 patients had air leaks longer than 7 days; none required further surgical intervention. There was intercostal neuralgia and Horner's syndrome after thoracic sympathectomy (1 each) In cases in-which localizing the parenchymal lesion was difficult, the lung was palpated directly by inserting a finger through a small incision or a mini-thoracotomy. Conversion to thoracotomy was performed when primary malignancy of lung was diagnosed by frozen section. Only 2 patients had thoracotomy for uncontrolled bleeding. Thoracoscopy is a minimally invasive surgical technique with very low morbidity and high diagnostic accuracy. Postoperative recovery is brief and uneventful.

[Videothorascopic sympathectomy (VATS) for palmar hyperhidriosis:summary of a clinical trial and surgical results].

Palmar hyperhidriosis is not a life-threatening disease but leads to loss in the quality of life. Conservative treatment is ineffective and major surgery involves perioperative complications and esthetic impairment. From 1992 to 1998 we treated 156 patients with palmar hyperhidriosis using a single port, drainless videothoracoscopic procedure with almost no complications.

[Acute fungal endocarditis due to Trichosporon beigelli].

We report a 59-year-old woman with acute fungal endocarditis of a prosthetic valve caused by the endogenic organism, Trichosporon beigelli. This slowly developing disease mainly effects drug addicts who use intravenous narcotics. In nonaddicts it is rare, with mortality as high as 50%. There are only sporadic reports of T. beigelli as a complication long after open heart surgery. The ongoing infection is undetected for even years after the primary infection, due to its prolonged latent phase. We present the difficulties of diagnosis, and of treating the disease with a combination of surgery and of long-term chemotherapy.