Do manual assisting maneuvers increase speed and technical performance in robotically sutured coronary bypass graft anastomoses?

Robotically assisted totally endoscopic coronary artery bypass surgery

Robotically assisted totally endoscopic coronary artery bypass surgery has emerged as a feasible and efficient alternative to conventional full sternotomy coronary artery bypass graft surgery in selected patients. This minimally invasive approach using the daVinci robotic system allows fine intrathoracic maneuvers and excellent view of the coronary arteries. Both on-pump and off-pump operations can be performed to treat single and multivessel disease. Hybrid approaches have the potential of offering complete revascularization with the "best of both worlds" from surgery (internal mammary artery anastomosis in less invasive fashion) and percutaneous coronary intervention (least invasive approach). In this article we review the indications, techniques, short and long term results, as well as current developments in totally endoscopic robotic coronary artery bypass operations.

Five hundred cases of robotic totally endoscopic coronary artery bypass grafting: predictors of success and safety

BACKGROUND

Robotic technology has enabled totally endoscopic coronary artery bypass (TECAB) grafting. Little information is available on factors associated with successful and safe performance of TECAB. We report a 10-year multicenter experience with 500 cases, elucidating on predictors of success and safety in TECAB procedures.

METHODS

Between 2001 and 2011, 500 patients (364 [73%] men; 136 [27%] women; median age [minimum-maximum] 60 years [31-90 years], median EuroSCORE 2 [0-13]), underwent TECAB. Single, double, triple, and quadruple TECAB was performed in 334, 150, 15, and 1 patient, respectively. Univariate analysis and binary regression models were used to identify predictors of success and safety. Success was defined as freedom from any adverse event and conversion procedure, safety was defined as freedom from major adverse cardiac and cerebral events, major vascular injury, and long-term ventilation.

RESULTS

Success and safety rates were 80% (400 cases) and 95% (474 cases), respectively. Intraoperative conversions to larger thoracic incisions were required in 49 (10%) patients. The median operative time was 305 minutes (112-1,050 minutes), and the mean lengths of stay in the intensive unit (ICU) and in hospital were 23 hours (11-1,048 hours) and 6 days (2-4 days), respectively. Independent predictors of success were single-vessel TECAB (p = 0.004), arrested-heart (AH)-TECAB (p = 0.027), non-learning curve case (p = 0.049), and transthoracic assistance (p = 0.035). The only independent predictor of safety was EuroSCORE (p = 0.002).

CONCLUSIONS

Single-vessel and multivessel TECAB procedures can be safely performed with good reproducible results. Predictors of success include procedure simplicity and non-learning curve cases, whereas predictors of safety are mainly associated with patient selection.

Catheter-based endoscopic bypass grafting: an experimental feasibility study

PURPOSE

Construction of an endoscopic catheter-guided, bonded anastomosis to facilitate total endoscopic coronary artery bypass.

DESCRIPTION

Total endoscopic coronary artery bypass of the left internal thoracic artery to the left anterior descending coronary artery was performed on the beating heart in six pigs using a telemanipulation system. An angioplasty catheter was advanced through the left internal thoracic artery to stabilize the anastomotic site. The anastomosis was created by applying glue externally to the surrounding tissue of the left internal thoracic artery and the left anterior descending coronary artery while it was kept open by an inflated angioplasty catheter.

EVALUATION

Angiography and catheter placement at the graft site was performed in 12 minutes (10 to 28 minutes). The anastomotic constructions were easily accomplished in 3.5 minutes (2 to 4.5 minutes). The adverse events that were encountered were anastomotic leakage requiring additional glue and left anterior descending artery dissection due to the guidewire. All except one animal with an open graft and anastomosis survived the procedure. Patency was 5 of 6.

CONCLUSIONS

Catheter-based endoscopic bypass grafting is feasible. The combination of robotic technology and this simple technique for anastomotic construction may facilitate beating heart total endoscopic coronary artery bypass.

Training Models for Coronary Surgery

This paper reviews currently used training models for coronary artery bypass grafting (CABG). Training models for CABG are extremely helpful not only for training surgical techniques, but also for the evaluation of new technologies and for research on bypass graft pathophysiology. Wet-lab models serve as training platforms for surgical residents and allow the evaluation of new technology (e.g., robotically enhanced CABG). The right coronary artery to left anterior descending artery model on the slaughterhouse pig heart is easily available, cheap, and effective. In vivo animal models for CABG are much more sophisticated and cost intensive. Pigs and dogs are the most commonly used animals for CABG training. Offpump CABG techniques, totally endoscopic CABG, endoscopic gastroepiploic artery harvesting, and axillocoronary bypass grafting have been evaluated in animal models.