Robotic totally endoscopic double-vessel bypass grafting: a further step toward closed-chest surgical treatment of multivessel coronary artery disease.

BACKGROUND: After the introduction of robotic technology into the heart surgery armamentarium the performance of totally endoscopic coronary artery bypass grafting (TECAB) has become a reality. During the first years of development, the majority of TECAB cases were restricted to single-vessel disease, and the development of multivessel procedures is desirable. We report on a preliminary series of totally endoscopic double-vessel coronary artery bypass grafting. METHODS: From 2004 to 2006, 10 patients underwent endoscopic placement of the right internal mammary artery (RIMA) to the left anterior descending artery (LAD) in combination with left internal mammary artery (LIMA) grafting to an obtuse marginal (OM) branch. Indications for the operation were isolated left main disease or left main equivalents. All procedures were performed using the daVinci telemanipulation system, remote-access perfusion, and aortic balloon endo-occlusion. RESULTS: Seven of the 10 interventions were completed endoscopically, and 3 patients were converted to sternotomy. RIMA takedown time was 40 minutes (range, 29-49 minutes); LIMA takedown time was 38 minutes (range, 29-48 minutes). LAD and OM anastomotic times were 23 minutes (range, 14-53 minutes) and 38 minutes (range, 29-48 minutes), respectively. Total TECAB time was 477 minutes (range, 385-545 minutes). Median ventilation time was 15 hours (range, 6-40 hours), median intensive care unit stay was 41 hours (range, 15-141 hours), and patients were discharged after a median of 7 days (range, 5-22 days). No major adverse cardiac or cerebrovascular events occurred during short-term follow-up. CONCLUSION: Totally endoscopic double-vessel coronary artery bypass grafting on the arrested heart is a reproducible procedure. This intervention offers maximal preservation of patient integrity, but the long operative times need to be investigated.

Robotic technology-probably a safe tool for development of completely endoscopic coronary revascularization procedures.

BACKGROUND: : Totally endoscopic coronary artery bypass grafting (TECAB) requires telemanipulation technologies because attempts using conventional thoracoscopic instrumentation have completely failed. These complex operations require individual and team learning curves and necessitate a stepwise approach. The aim of this study is to assess risk adjusted outcome in robotically assisted coronary artery bypass grafting (CABG) after the first 6 years of application. METHODS: : From 2001 to 2007, 177 CABG procedures were performed using the da Vinci system. A low risk patient population [age 59 (31-76) years, EuroSCORE 1 (0-7)] was treated. The following procedures were carried out: endoscopic internal mammary artery takedown in minimally invasive direct coronary artery bypass, Off-pump coronary artery bypass, and CABG (n = 26); robotic suturing of left internal mammary artery to left anterior descending artery anastomoses through sternotomy (n = 32); TECAB on the arrested heart (n = 108); TECAB on the beating heart (n = 11). RESULTS: : There was no hospital mortality, and cumulative risk adjusted mortality plots showed that 2.76 predicted events did not occur. Given 177 event free procedures Clopper Pearson estimations revealed a 95% confidence interval between 0.0% and 2.3% for perioperative mortality. CONCLUSIONS: : Introduction of robotic TECAB grafting appears to meet current CABG safety standards. Initial application in low risk patients and a stepwise approach towards completely endoscopic versions of the operation are worthwhile. Despite a high grade of innovation and despite learning curves, perioperative mortality may be lower than predicted.