Robotic totally endoscopic coronary artery bypass: program development and learning curve issues

Patient complexity does not affect surgical learning curve and clinical outcomes during early experience in robotic assisted coronary surgery

Adoption of robot-assisted coronary artery bypass grafting (RA-MIDCAB) remains limited due to concerns about learning curves, outcomes, and patient-specific anatomic challenges. This study evaluates our initial single-center experience with RA-MIDCAB. Between December 2022 and June 2024, 52 patients underwent RA-MIDCAB. Inclusion criteria comprised isolated left anterior descending artery (LAD) stenosis or LAD revascularization as part of a hybrid valvular/coronary strategy. Primary endpoints were 30-day mortality, conversion to sternotomy, and graft injury. Operative times and biometric indices (body indices such as body mass index [BMI], Haller Index, and Cardiothoracic Ratio) were analyzed for correlation with learning curve progression and surgical outcomes. Mean age was 68.5 ± 11.5 years, and 82.7% (43/52) were males. Robotic LITA harvesting was successfully completed in 98.1% (51/52) of patients (one patient had a graft injury), with no perioperative mortality. Postoperative complications occurred in 38.5% (20/52), mostly due to atrial fibrillation (19.2%, 10/52) and acute kidney injury (13.5%, 7/52) with no correlation with operative times at logistic regression. According to thoracic indexes, no correlation was found between chest complexity and postoperative complications. Neither EuroSCORE II, BMI nor thoracic indices significantly impacted operative times. Linear regression demonstrated significant reductions in overall surgical and graft-harvesting times across the experience, suggesting improved efficiency. RA-MIDCAB is feasible and safe, even in patients with challenging thoracic anatomy. This early experience demonstrated promising outcomes and significant learning curve improvements, supporting the potential for broader adoption of this technique even in patients unlikely deemed suitable for minimally invasive cardiac revascularization surgery.

The Role of Robotics in Cardiac Surgery: Innovations, Outcomes, and Future Prospects

In recent years, there has been a notable increase in the use of robotic technology in medical surgery, especially in heart surgery. Many advancements in surgery have been made possible by the development of these robotic devices, such as the da Vinci surgical system (Intuitive Surgical, Sunnyvale, California, United States). These advancements include improved ergonomics, three-dimensional (3D) imaging, and increased dexterity. This research evaluates the advancements, results, and potential applications of robots in heart surgery. A systematic review that adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) principles was carried out. The PubMed and Cochrane databases underwent a thorough search that turned up articles from 2015 to 2023. Nine articles that satisfied the requirements for inclusion were evaluated for quality using the Critical Appraisal Skills Programme (CASP) checklists. Standardized templates and conventional content analysis techniques were used for data extraction and analysis, respectively. Nine studies with a range of approaches, including randomized, prospective, observational, and retrospective investigations, were included in the review. This research included a variety of robotic heart treatments, including mitral valve repair, atrial septal defect (ASD) closure, and coronary artery bypass grafting (CABG). Notable results include identical or shorter operating durations, fatality rates that are comparable to those of conventional techniques, fewer postoperative complications, and shorter hospital stays. Surgeons did, however, face an initial learning curve. Variants of the da Vinci surgical system were the most frequently used robotic systems. Robotic heart surgery has shown encouraging outcomes in terms of effectiveness, safety, and patient recovery. The dependability of robotic procedures is demonstrated by shorter operating times, reduced blood loss, a low incidence of conversion to conventional methods, and a reduction in postoperative complications. Shorter hospital stays suggest better patient outcomes and potential financial advantages. Nonetheless, the need for specific training and knowledge among surgeons is emphasized. Sustained investigation and advancement are essential for the refinement and broader use of robotic heart surgery. Robotic-assisted cardiac surgery has a promising future with a focus on improved patient outcomes, training, and procedural development.

Minimal invasive coronary surgery is not associated with increased mortality or morbidity during the period of learning curve

BACKGROUND

Minimally invasive procedures for coronary revascularization have been performed for over 20 years; however, their technical complexity, steep learning curves and absence of training programs explain the weak acceptance of these techniques. The aim of this study is to describe the step-by-step learning process on how to establish a minimally invasive coronary artery revascularization program. The short-term outcomes of our first 30 patients were compared to our left internal mammary artery (LIMA) to left anterior descending (LAD) artery off pump coronary artery bypass (OPCAB) cohort as a quality control baseline.

METHODS

All patients who benefited from an endoscopic atraumatic coronary artery bypass (Endo-ACAB) in our hospital, from July 2018 to May 2020 (n = 30) were identified. Baseline demographics, peri, postoperative and laboratory data were extracted from each patient's medical records. These results were compared to our LIMA-LAD OPCAB cohort (n = 23).

RESULTS

Twenty-eight patients were planned for a single LIMA-LAD Endo-ACAB. The remaining two had a T-graft double Endo-ACAB. Ten patients had a hybrid revascularization with the culprit lesion being treated first. Three patients were converted to sternotomy because of a LIMA lesion during thoracoscopic harvesting. We accounted three major adverse cardiovascular events (MACE). Demographic, peri and postoperative data showed no significant differences between the Endo-ACAB and the OPCAB group.

CONCLUSION

Endo-ACAB is a technically demanding operation, however, it can safely be introduced in centers with no previous experience with no extra cost in terms of morbidity or mortality. Thoracoscopic LIMA harvesting is the most demanding surgical skill to acquire.

Inexpensive and Easy to Set Up Robotic Cardiac Simulator Offers "Unlimited" Endoscopic Coronary Artery Bypass Grafting Experience: Proof of Concept

OBJECTIVE

Robotic totally endoscopic coronary artery bypass (TECAB) grafting is the least invasive form of coronary bypass surgery. However, despite its advantages, this approach has not gained widespread adoption. One possible reason is the advanced and complex robotic skills required to execute a totally endoscopic sutured coronary anastomosis. We prepared a novel, inexpensive, easy to set up robotic TECAB simulator.

METHODS

A pig heart was placed in a cardboard box, and 3 holes were made on the side to mimic the exposure and surgical ergonomics of TECAB port placement. Four robotic ports were placed and docked to the da Vinci Si robot (Intuitive Surgical, Sunnyvale, CA, USA). Monofilament 7:0 suture (7 cm long) was used to perform the anastomosis to the left anterior descending artery using remnant conduit. Seven cardiac surgeons of various training levels participated and were asked to fill out a 10-point questionnaire.

RESULTS

The cost of the simulator totaled $20 per session, with 20 min to assemble. Each session allowed each trainee to practice 3 to 4 coronary anastomoses. Three cardiac surgeons completed the survey and strongly agreed that the model was easy to set up, the anastomotic exercise was realistic, and that this practice helped them gain confidence.

CONCLUSIONS

Our TECAB simulator is inexpensive, easy to set up, and allows trainees to practice endoscopic coronary suturing. We believe this to be a valuable training tool to learn how to do TECAB for established surgeons and that such a simulator may be of great value to cardiothoracic training programs and their trainees. Further studies are warranted.

Minimal-Access Coronary Revascularization: Past, Present, and Future

Minimal-access cardiac surgery appears to be the future. It is increasingly desired by cardiologists and demanded by patients who perceive superiority. Minimal-access coronary artery revascularisation has been increasingly adopted throughout the world. Here, we review the history of minimal-access coronary revascularization and see that it is almost as old as the history of cardiac surgery. Modern minimal-access coronary revascularization takes a variety of forms-namely minimal-access direct coronary artery bypass grafting (MIDCAB), hybrid coronary revascularisation (HCR), and totally endoscopic coronary artery bypass grafting (TECAB). It is noteworthy that there is significant variation in the nomenclature and approaches for minimal-access coronary surgery, and this truly presents a challenge for comparing the different methods. However, these approaches are increasing in frequency, and proponents demonstrate clear advantages for their patients. The challenge that remains, as for all areas of surgery, is demonstrating the superiority of these techniques over tried and tested open techniques, which is very difficult. There is a paucity of randomised controlled trials to help answer this question, and the future of minimal-access coronary revascularisation, to some extent, is dependent on such trials. Thankfully, some are underway, and the results are eagerly anticipated.

Comparison of the internal thoracic artery flow dissected by video endoscopy or conventional technique

Purpose:

To compare the blood flow in the internal thoracic artery when dissected endoscopically in a conventional manner, in addition to develop a reliable experimental training model for the surgical team.

Methods:

Paired experimental study. Ten pigs were operated and had both internal thoracic arteries dissected, the right with a conventional technique and the left by video endoscopy. The main outcomes to be studied were flow, length, and time of dissection of each vessel.

Results:

Blood flow measurements were performed with mean heart rate of 100 ± 16 bpm and mean arterial pressure of 89.7 ± 13 mm Hg. The mean blood flow of endoscopic dissection of the internal thoracic artery was 170.2 ± 66.3 mL/min and by direct view was 180.8 ± 70.5 (p = 0.26). Thus, there was no statistically significant difference between the flows, showing no inferiority between the methods.

Conclusions:

The minimally invasive dissection of the internal thoracic artery was shown to be not inferior to the dissection by open technique in relation to the blood flow in the present experimental model. In addition, the model that we replicated was shown to be adequate for the development of the learning curve and improvement of the endoscopic abilities.

The learning curve of robotic coronary arterial bypass surgery: A report from the STS database

BACKGROUND

There is limited data to inform minimum case requirements for training in robotically assisted coronary artery bypass grafting (RA-CABG). Current recommendations rely on nonclinical endpoints and expert opinion.

OBJECTIVES

To determine the minimum number of RA-CABG procedures required to achieve stable clinical outcomes.

METHODS

We included isolated RA-CABG in the Society of Thoracic Surgeons (STS) registry performed between 2014 and 2019 by surgeons without prior RA-CABG experience. Outcomes were approach conversion, reoperation, major morbidity or mortality, and procedural success. Case sequence number was used as a continuous variable in logistic regression with restricted cubic splines with fixed effects. Outcomes were compared between operations performed earlier versus later in case sequences using unadjusted and adjusted metrics.

RESULTS

There were 1195 cases performed by 114 surgeons. A visual inflection point occurs by a surgeon's 10th procedure for approach conversion, major morbidity or mortality, and overall procedural success after which outcomes stabilize. There was a significant decrease in the rate of approach conversion (7.7% and 2.5%), reoperation (18.9% and 10.8%), and major morbidity or mortality (21.7% and 12.9%), as well as an increase in the rate of procedural success (72.9% and 85.3%) with increasing experience between groups. In a multivariable logistic regression model, case sequences of >10 were an independent predictor of decreased approach conversion (odds ratio [OR]: 0.27; 95% confidence interval [CI]: 0.09-0.84) and increased rate procedural success (OR: 1.96; 95% CI: 1.00-3.84).

CONCLUSIONS

The learning curve for RA-CABG is initially steep, but stable clinical outcomes are achieved after the 10th procedure.

Comparison of postoperative outcomes between robotic mitral valve replacement and conventional mitral valve replacement

BACKGROUND

Robotic mitral valve surgery continues to become widespread all over the world in direct proportion to the developing technology. In this study, we aimed to compare the postoperative results of robotic mitral valve replacement and conventional mitral valve replacement.

METHODS

A total of consecutive 130 patients who underwent robotic mitral valve replacement and conventional mitral valve replacement with full sternotomy between 2014 and 2020 were included in our study. All patients were divided into two groups: Group I, with 64 patients who underwent robotic mitral valve replacement and Group II, with 66 patients with conventional full sternotomy. General demographic data (age, gender, body weights, etc.), comorbidities (hypertension, diabetes mellitus, chronic obstructive pulmonary disease, peripheral artery disease, hyperlipidemia, etc.), intraoperative variables (cardiopulmonary bypass times, and cross-clamp times), postoperative ventilation times, drainage amounts, transfusion amount, inotropic need, revision, arrhythmia, intensive care and hospital stay times, and mortality were analyzed retrospectively.

RESULTS

There was no significant difference between demographic data, such as age, gender, body kit index, and preoperative comorbid factors of both patient groups (p > .05). Cardiopulmonary bypass time (204.12 ± 45.8 min) in Group I was significantly higher than Group II (98.23 ± 17.8 min) (p < .001). Cross-clamp time in Group I (143 ± 27.4 min) was significantly higher than Group II (69 ± 15.2 min) (p < .001). Drainage amount in Group I (290 ± 129 cc) was significantly lower than Group II (561 ± 136 cc) (p < .001). The erythrocyte suspension transfusion requirement was 0.4 ± 0.3 units in Group I; it was 0.9 ± 1.2 units in Group II, and this requirement was found to be significantly lower in Group I (p = .014). While the mean mechanical ventilation time was 5.3 ± 3.9 h in Group I, it was 9.6 ± 4.2 h in Group II. It was significantly lower in Group I (p = .001). Accordingly, intensive care stay (p = .006) and hospital stay (p = .003) were significantly lower in Group I. In the early postoperative period, three patients in Group I and four patients in Group II were revised due to bleeding. In the postoperative hospitalization period, neurological complications were observed in one patient in Group I and two patients in Group II. Two patients in Group I returned to the sternotomy due to surgical difficulties. Two patients died in both groups postoperatively, and there was no significant difference in mortality (p = .97).

CONCLUSION

According to conventional methods, robotic mitral valve replacement is an effective and reliable method since total perfusion and cross-clamp times are longer, drainage amount and blood transfusion need are less, and ventilation time, intensive care, and hospital stay time are shorter.

Robotic totally endoscopic coronary artery bypass grafting: current status and future prospects

Introduction: Totally endoscopic coronary artery bypass grafting (TECAB) can only be performed in a reproducible manner using robotic technology. This operation has been developed for more than 20 years seeing three generations of surgical robots. TECAB can be carried out beating heart but also on the arrested heart. Single and multiple grafts can be placed and TECAB can be combined with percutaneous coronary intervention in hybrid procedures.Areas covered: This review outlines indications for the procedure, the surgical technique, and the postoperative care. Intra- and postoperative results as available in the literature are reported. Further areas focus on technological development, training methods, learning curves as well as on cost. Finally, we give an outlook on the potential future of this operation.Expert opinion: Robotic TECAB represents a complex, sophisticated but safe, and over-the-years grown procedure. Even though results seem to be in line with conventional coronary surgery worldwide adoption still has been slow probably due to procedure times, costs and learning curves. Main advantages of TECAB are minimized surgical trauma and subsequent reduction of postoperative healing time. With the current introduction of new robotic devices, a new era of procedure development is on its way.

Factors causing prolonged mechanical ventilation and peri-operative morbidity after robot-assisted coronary artery bypass graft surgery

Robot-assisted coronary artery bypass graft [robot-assisted (coronary artery bypass grafting (CABG)] surgery is the latest treatment for coronary artery disease. However, the surgery extensively affects cardiac and pulmonary function, and the risk factors associated with peri-operative morbidity, including prolong mechanical ventilation (PMV), have not been fully examined. In this retrospective cohort study, a total of 382 patients who underwent robot-assisted internal mammary artery harvesting with mini-thoracotomy direct-vision bypass grafting surgery (MIDCABG) from 2005 to 2012 at our tertiary care hospital were included. The definition of PMV was failure to wean from mechanical ventilation more than 48 h after the surgery. Risk factors for PMV, and peri-operative morbidity and mortality were analyzed with a multivariate logistic regression model. Forty-three patients (11.3%) developed PMV after the surgery, and the peri-operative morbidity and mortality rates were 38 and 2.6%, respectively. The risk factors for PMV were age, left ventricular ejection fraction (LVEF), the duration of one-lung ventilation for MIDCABG (beating time), and peak airway pressure at the end of the surgery. Furthermore, age and anesthesia time were found to be independent risk factors for peri-operative morbidity, whereas age, LVEF, and anesthesia time were the risk factors for peri-operative mortality. These findings may help physicians to properly choose patients for this procedure, and provide more attention to patients with higher risk after surgery to achieve better clinical outcomes.

A review of hybrid coronary revascularization

Purpose

Hybrid coronary revascularization is an emerging treatment strategy for coronary artery disease. We will review the reasons for the development of this strategy, describe surgical techniques, and review outcomes. Finally, we will discuss the future of hybrid revascularization and explain why it will grow as a treatment modality.

Methods

For this review, we conducted an unstructured review of the literature for articles related to hybrid coronary revascularization, bypass surgery, and percutaneous coronary interventions.

Results

Hybrid coronary revascularization has been shown in large series to have excellent results. These include fast recovery time, low mortality and rates of complications, and excellent surgical graft patency. There may be increased need for revascularization over conventional bypass surgery.

Conclusions

The combination improved surgical techniques including a robotic surgery platform, as well as the ever-improving efficacy and durability of coronary stents have made hybrid coronary revascularization an attractive option for many patients. It offers a minimally invasive approach to surgery while avoiding the poor patency of saphenous vein grafts. In appropriately selected patients, this may be an ideal treatment strategy that minimizes risks and maximizes short- and long-term benefits.

Implementation of robotic rectal surgery training programme: importance of standardisation and structured training

Purpose

A structured training programme is essential for the safe adoption of robotic rectal cancer surgery. The aim of this study is to describe the training pathway and short-term surgical outcomes of three surgeons in two centres (UK and Portugal) undertaking single-docking robotic rectal surgery with the da Vinci Xi and integrated table motion (ITM).

Methods

Prospectively, collected data for consecutive patients who underwent robotic rectal cancer resections with the da Vinci Xi and ITM between November 2015 and September 2017 was analysed. The short-term surgical outcomes of the first ten cases of each surgeon (supervised) were compared with the subsequent cases (independent). In addition, the Global Assessment Score (GAS) forms from the supervised cases were analysed and the GAS cumulative sum (CUSUM) charts constructed to investigate the training pathway of the participating surgeons.

Results

Data from 82 patients was analysed. There were no conversions to open, no anastomotic leaks and no 30-day mortality. Mean operation time was 288 min (SD 63), median estimated blood loss 20 (IQR 20–20) ml and median length of stay 5 (IQR 4–8) days. Thirty-day readmission and reoperation rates were 4% (n = 3) and 6% (n = 5) respectively. When comparing the supervised cases with the subsequent solo cases, there were no statistically significant changes in any of the short-term outcomes with the exception of mean operative time, which was significantly shorter in the independent cases (311 vs 275 min, p = 0.038). GAS form analysis and GAS CUSUM charting revealed that ten proctoring cases were enough for trainee surgeons to independently perform robotic rectal resections with the da Vinci Xi.

Conclusions

Our results show that by applying a structured training pathway and standardising the surgical technique, the single-docking procedure with the da Vinci Xi is a valid, reproducible technique that offers good short-term outcomes in our study population.

Comparative Analysis of Perioperative and Mid-Term Results of TECAB and MIDCAB for Revascularization of Anterior Wall

OBJECTIVE

Totally endoscopic coronary artery bypass (TECAB) and minimally invasive direct coronary artery bypass (MIDCAB) grafting through minithoracotomy are currently the two minimally invasive surgical techniques of left ventricular anterior wall revascularization. We aimed to compare both techniques in terms of perioperative and mid-term results.

METHODS

Arrested heart TECAB was carried out in 204 patients with a median (range) age of 60 (53-76) years and a median (range) EuroSCORE I of 2 (0-3). Minimally invasive direct coronary artery bypass was performed in 60 patients with a median (range) age of 66 (54-75) years and a median (range) EuroSCORE I of 2 (1-5). Both techniques were used for single or sequential internal mammary artery grafts to the anterior wall. Operative times, conversion rates, and surgical complications as well as mid-term results were compared between the groups after a median follow-up of 36 months.

RESULTS

No perioperative deaths were noted. Rates of myocardial infarction (TECAB: 1.5% vs MIDCAB: 0%, P = 0.463) and stroke (TECAB: 1.5% vs MIDCAB: 0%, P = 0.454) were not significantly different between the groups. Total operative times were longer in the TECAB compared with the MIDCAB group [292 (250-345) minutes in TECAB versus 201 (173-289) minutes in MIDCAB (P < 0.001)]. Intensive care unit stay and total length of stay were similar between the groups. There was no difference in mid-term survival (TECAB: 1.5% vs MIDCAB: 1.7%, P = 0.298) and freedom from major adverse cardiac and cerebrovascular events (TECAB: 12.4% vs MIDCAB: 5.1%, P = 0.358).

CONCLUSIONS

Robotically assisted arrested heart TECAB and robotic MIDCAB perform equally in terms of perioperative results and mid-term follow-up in this single-center patient cohort.

Novel Dry-Lab Training Method for Totally Endoscopic Coronary Anastomosis: A Pilot Study

OBJECTIVE

We describe our original dry-lab training system for nonrobotic and beating heart endoscopic coronary artery anastomosis.

METHODS

All the materials used for this training were commercially available. We selected a boxed machine, which can produce pulsatile movements of artificial vessels, and on its roof, we installed a two-dimensional home video camera and a monitor. A multiple-holed plate was placed in front of the machine, and through these holes, a trainee inserted endoscopic surgical instruments and anastomosed the artificial vessels by running fashion while watching the monitor. This training program has four stages. During the first stage, a trainee has to demonstrate mastery in conducting a conventional off-pump coronary artery anastomosis without assistance. The second stage is the "nonbeating" version, and the third stage is the "beating" version with the model mentioned previously. After a trainee gets accustomed to the third stage, the original artificial vessel is replaced with an extremely fragile one, and this is the fourth stage. Our trainee conducted one hundred fourth-stage anastomoses and each procedure was recorded with the video camera. We analyzed several factors from the videos and evaluated the efficacy of the training method. We compared the outcomes of the first 50 consecutive anastomoses with the following 50 ones and described the learning curves.

RESULTS

The comparison showed a significant decrease in anastomotic time and vessel injury. We considered the quality of anastomosis acceptable after 47 anastomoses, and anastomotic time fell below 15 minutes at the 81st training at the fourth stage.

CONCLUSIONS

Our dry-lab system might be an effective training method for endoscopic coronary anastomosis.

Minimally Invasive Cardiovascular Surgery: Incisions and Approaches

Throughout the modern era of cardiac surgery, most operations have been performed via median sternotomy with cardiopulmonary bypass. This paradigm is changing, however, as cardiovascular surgery is increasingly adopting minimally invasive techniques. Advances in patient evaluation, instrumentation, and operative technique have allowed surgeons to perform a wide variety of complex operations through smaller incisions and, in some cases, without cardiopulmonary bypass. With patients desiring less invasive operations and the literature supporting decreased blood loss, shorter hospital length of stay, improved postoperative pain, and better cosmesis, minimally invasive cardiac surgery should be widely practiced. Here, we review the incisions and approaches currently used in minimally invasive cardiovascular surgery.

Robotics and surgery: A sustainable relationship?

Robotic surgery is increasingly being employed to overcome the disadvantages associated with use of conventional techniques such as laparoscopy. However, despite significant promise, there are some clear disadvantages and robust evidence base supporting the use of robotic assistance remains lacking. In this paper, the advantages and drivers for robotics will be discussed, its drawbacks and its future role in surgery.

Videoscope-assisted cardiac surgery

Videoscope-assisted cardiac surgery (VACS) offers a minimally invasive platform for most cardiac operations such as coronary and valve procedures. It includes robotic and thoracoscopic approaches and each has strengths and weaknesses. The success depends on appropriate hardware setup, staff training, and troubleshooting efficiency. In our institution, we often use VACS for robotic left-internal-mammary-artery takedown, mitral valve repair, and various intra-cardiac operations such as tricuspid valve repair, combined Maze procedure, atrial septal defect repair, ventricular septal defect repair, etc. Hands-on reminders and updated references are provided for reader's further understanding of the topic.

Defining the Learning Curve for Robotic-Assisted Endoscopic Harvesting of the Left Internal Mammary Artery

Objective

Robotic-assisted techniques are continuing to cement their role in coronary surgery, particularly in facilitating the endoscopic harvesting of the left internal mammary artery (LIMA), regardless of how the subsequent bypass grafting is performed. As more surgeons attempt to become trained in robotic-assisted procedures, we sought to better define the learning curve associated with robotic-assisted endoscopic LIMA harvest.

Methods

Between January 2011 and July 2012, a total of 77 patients underwent robotic-assisted minimally invasive direct coronary artery bypass surgery at our institution. The LIMA was harvested endoscopically in all patients, using standard robotic instruments, followed by direct grafting to anterior wall myocardial vessels via a small thoracotomy. Intraoperative times for various components of the procedure were collated and analyzed.

Results

The mean ± SD time taken to insert and position the ports for the robotic instruments was 3.9 ± 1.4 minutes. The mean ± SD LIMA harvest time was 31.8 ± 10.1 minutes, and the mean ± SD total robotic time was 44.2 ± 12.9 minutes. All time variables consistently continued to decrease as the experience of the operating surgeon increased, with the greatest magnitude of improvement being evident within the first 20 cases. The logarithmic learning curves for LIMA harvest time and total robot time during our entire experience were both calculated as 90%, correlating to an expected 10% improvement in performance for each doubling of cases completed.

Conclusions

Coronary surgeons can rapidly become proficient in robotic-assisted endoscopic LIMA harvest, with significant improvement in operative times evident within the first 20 cases completed. These data may be useful in designing appropriate training programs for newer surgeons seeking to gain experience in robotic-assisted coronary surgery.

Systematic review of robotic-assisted, totally endoscopic coronary artery bypass grafting

BACKGROUND

Advancements in surgical robotic technology over the last two decades have enabled coronary artery bypass grafting to be performed totally endoscopically, and have the potential to significantly change clinical practice in the future.

METHODS

A systematic review of studies reporting clinical outcomes of total endoscopic coronary artery bypass grafting (TECABG) was performed.

RESULTS

14 appraised studies included 880 beating heart TECABGs, 360 arrested heart TECABGs, 633 one-vessel operations and 357 two-vessel operations. Patients were generally low-risk. There was a significant learning curve. The weighted means for short-term beating heart and arrested heart TECABG results respectively were: intraoperative exclusion rate of 5.7% and 1.9%, intraoperative conversion rate of 5.6% and 15.0%, all-cause mortality of 1.2% and 0.4%, stroke of 0.7% and 0.8%, myocardial infarction of 0.8% and 1.8%, new onset atrial fibrillation of 10.7% and 5.1% and post-operative reintervention rate of 2.6% and 2.3%. The overall rate of short term postoperative graft patency for beating heart and arrested heart TECABG was 98.3% and 96.4% respectively.

CONCLUSIONS

Appropriate patient selection was important in minimizing the risk of intraoperative and postoperative complications. Short-term outcomes of both beating and arrested heart TECABG were acceptable, but results so far have been heterogeneous. There were fewer studies reporting intermediate to long-term outcomes, but results were encouraging, and further investigation and development of the procedure is warranted.

Total Endoscopic Beating-Heart Coronary Artery Bypass Grafting Using A New 3D Imaging System

OBJECTIVE

: Since 1999, the authors of this study have performed total endoscopic beating-heart coronary artery bypass. They have developed a new three-dimensional (3D) endoscopic imaging system and have used it successfully in three patients.

METHODS

: From January 2004, a new 3D endoscopic imaging system was used. This device, composed of an optical high-resolution, 3D endoscope and two liquid crystal monitors, gives bright, natural, 3D imaging and enables quick, precise manipulation. After the 15-mm port for the 3D endoscope was inserted through fourth intercostal space (ICS) in the posterior axillary line, the left internal thoracic artery (LITA) was taken down endoscopically in semiskeletonized fashion, using two instrumental 5-mm ports (third and sixth anterior axillary ICS). The pericardium was then opened, and the left anterior descending artery was identified. Another 10-mm port for an endoscopic needle holder was inserted through fourth ICS in the midclavicular line. Three ports were placed in the fourth ICS in line for the anastomosis. An original suction stabilizer was inserted through the first instrumental port, and the left anterior descending artery was immobilized. A conventional end-to-side anastomosis was done with 8-0 Prolene running sutures.

RESULTS

: The average LITA harvesting time was significantly shortened from 68 minutes with two-dimensional imaging to 36 minutes with new 3D imaging. The average anastomotic time was shortened from 34 minutes with two-dimensional imaging and 27 minutes with former 3D imaging to 17 minutes with new 3D imaging. There were no complications and no operative deaths.

CONCLUSIONS

: This new 3D endoscopic imaging system facilitates quick, precise anastomosis and is a useful device for endoscopic coronary bypass surgery.

Lessons learned from robotic-assisted coronary artery bypass surgery: risk factors for conversion to median sternotomy

OBJECTIVE

Robotic-assisted coronary artery bypass is a minimally invasive alternative to traditional coronary artery bypass surgery via median sternotomy with an associated learning curve. The purpose of this study was to investigate the reasons for conversion to sternotomy.

METHODS

From October 2009 to June 2012, two surgeons at one US academic institution performed 271 consecutive robotic-assisted coronary artery bypass procedures. For all cases, isolated, off-pump left internal mammary artery (LIMA) to left anterior descending coronary artery grafting was planned via a 3- to 4-cm sternal-sparing thoracotomy after robotic internal mammary artery harvest and pericardiotomy.

RESULTS

Conversion to sternotomy occurred in 15 of 271 (5.5%) patients. The most common reason was technical difficulty with the anastomosis, which occurred in 6 (40.0%) patients. Others included LIMA dissection, 2 (13.3%); wrong vessel grafted, 2 (13.3%); ventricular fibrillation and cardiac arrest, 1 (6.7%); equipment malfunction, 1 (6.7%); adhesions, 1 (6.7%); and other. Two underwent emergent conversion. Six underwent multivessel bypass after conversion instead of hybrid coronary revascularization. No mortality occurred among converted patients. Two patients had postoperative myocardial infarction and one had a superficial sternal wound infection. Conversion rate was relatively stable among the four different time quartiles (range, 3.0%-7.4%), although the reasons for conversion were different.

CONCLUSIONS

Conversion to sternotomy is an infrequent complication of robotic-assisted coronary artery bypass, most commonly because of technical difficulties during the LIMA harvest and the LIMA to left anterior descending anastomosis. Anatomic and patient variables as well as inherent technical problems with minimally invasive procedures make conversion unavoidable in some patients.

Surgical Outcomes of Congenital Atrial Septal Defect Using da VinciTM Surgical Robot System

BACKGROUND

Minimally invasive cardiac surgery has emerged as an alternative to conventional open surgery. This report reviews our experience with atrial septal defect using the da VinciTM surgical robot system.

MATERIALS AND METHODS

This retrospective study included 50 consecutive patients who underwent atrial septal defect repair using the da VinciTM surgical robot system between October 2007 and May 2011. Among these, 13 patients (26%) were approached through a totally endoscopic approach and the others by mini-thoracotomy. Nineteen patients had concomitant procedures including tricuspid annuloplasty (n=10), mitral valvuloplasty (n=9), and maze procedure (n=4). The mean follow-up duration was 16.9±10.4 months.

RESULTS

No remnant interatrial shunt was detected by intraoperative or postoperative echocardiography. The atrial septal defects were mainly repaired by Gore-Tex patch closure (80%). There was no operative mortality or serious surgical complications. The aortic cross clamping time and cardiopulmonary bypass time were 74.1±32.2 and 157.6±49.7 minutes, respectively. The postoperative hospital stay was 5.5±3.3 days.

CONCLUSION

The atrial septal defect repair with concomitant procedures like mitral valve repair or tricuspid valve repair using the da VinciTM system is a feasible method. In addition, in selected patients, complete port access can be helpful for better cosmetic results and less musculoskeletal injury.

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.

Modular training in laparoscopic colorectal surgery maximizes training opportunities without clinical compromise

BACKGROUND

Laparoscopic surgery is increasingly proposed as the gold standard technique for colorectal resections and is offered to greater numbers of patients. To meet the rising service demands, more trainees and established consultants need to learn the technique. We sought to establish whether it is feasible and safe to train on a large proportion of patients without adversely affecting clinical outcome or smooth running of clinical service.

METHODS

Between September 2006 and July 2008, four senior trainees of the Wessex Specialist Registrar training rotation were involved in training in laparoscopic colorectal surgery. Major colorectal resections were separated into clearly defined modules for training purposes. Right and left hemicolectomies each comprised two modules, and low anterior resection comprised three modules. Prospective data on consecutive patients undergoing laparoscopic colorectal surgery were collected. Data included type of surgery, module of procedure performed by trainee or trainer, body mass index (BMI), conversion rates, median operative time, complications, length of hospital stay, and mortality.

RESULTS

During the study period 227 colorectal resections were attempted laparoscopically. Of these, 216 (96%) proved suitable for training and 97% were completed laparoscopically. Some 23% of patients were American Society of Anesthesiologists score (ASA)≥3; 35% had a BMI≥28; 38% had a history of previous laparotomy. Trainees performed 96% (142/148) of right hemicolectomy modules, 99% (154/156) of left hemicolectomy modules, and 67% (128/192) of rectal resection modules. Each trainee was competent to do right and left hemicolectomy at the end of the training period. Four patients (2%) required further surgery for postoperative complications. Of the procedures completed by the trainees, 155/171 (91%) cancer resections were potentially surgically curative, and R0 resections were achieved in 99%. The readmission rate was 10% (22/216) and median length of hospital stay was 4 days. Postoperative mortality was zero.

CONCLUSIONS

Using a modular approach it is possible to provide effective training during almost all laparoscopic colorectal resections while achieving good clinical outcomes for the patients.

The golden age of minimally invasive cardiothoracic surgery: current and future perspectives

Over the past decade, minimally invasive cardiothoracic surgery (MICS) has grown in popularity. This growth has been driven, in part, by a desire to translate many of the observed benefits of minimal access surgery, such as decreased pain and reduced surgical trauma, to the cardiac surgical arena. Initial enthusiasm for MICS was tempered by concerns over reduced surgical exposure in highly complex operations and the potential for prolonged operative times and patient safety. With innovations in perfusion techniques, refinement of transthoracic echocardiography and the development of specialized surgical instruments and robotic technology, cardiac surgery was provided with the necessary tools to progress to less invasive approaches. However, much of the early literature on MICS focused on technical reports or small case series. The safety and feasibility of MICS have been demonstrated, yet questions remain regarding the relative efficacy of MICS over traditional sternotomy approaches. Recently, there has been a growth in the body of published literature on MICS long-term outcomes, with most reports suggesting that major cardiac operations that have traditionally been performed through a median sternotomy can be performed through a variety of minimally invasive approaches with equivalent safety and durability. In this article, we examine the technological advancements that have made MICS possible and provide an update on the major areas of cardiac surgery where MICS has demonstrated the most growth, with consideration of current and future directions.

Closed chest hybrid coronary revascularization for multivessel disease - current concepts and techniques from a two-center experience

Hybrid coronary revascularization combining minimally invasive coronary surgery and percutaneous coronary intervention (PCI) allows sternal preserving treatment of multivessel coronary disease. The main principle of the technique includes placement of mammary artery graft to the left anterior descending coronary artery (LAD) and performance of PCI in non-LAD target vessels. This principle is based on increasing data showing equivalent results of PCI with coronary revascularization using saphenous vein grafts in selected patients. Providing that perioperative and long-term results are as good as the results of conventional surgical revascularization, this option seems to be quite appealing for patients and referring cardiologists. This concept has been designed to allow rapid rehabilitation and minimize periprocedural pain under concomitant preservation of the patient's body integrity. Robotically assisted endoscopic approaches for hybrid coronary revascularization set the pace for a closed-chest treatment of multivessel coronary disease. The time point of PCI, the use of different anticoagulation protocols as well as the stent selection are some of the variables, which affect outcome. We additionally report on the midterm results of 130 after-closed-chest hybrid-coronary procedures in two institutions. Hybrid procedures using robotic technology and PCI allow closed chest treatment of multivessel coronary artery disease. Single- and double-bypass grafts are feasible and simultaneous interventions can be performed. The overall safety of the procedure seems to be adequate and perioperative clinical results are satisfactory. Intermediate term survival and freedom from angina are excellent.

Early and midterm results of totally endoscopic coronary artery bypass grafting on the beating heart

OBJECTIVE

Despite the early introduction of totally endoscopic coronary artery bypass on the beating heart, only a limited number of cases have been performed. The limiting factor has been the concern about safety and graft patency of the anastomosis. This study describes our experience with totally endoscopic coronary artery bypass on the beating heart with robotic assistance and its early and midterm results.

METHODS

In 365 cases of robotic cardiac operations, 162 patients underwent robotic coronary artery bypass grafting on the beating heart, of whom 60 patients (46 male, 14 female) underwent totally endoscopic coronary artery bypass on the beating heart. The patients' mean age was 56.97 ± 9.7 years (33-77 years). Left internal thoracic artery to left anterior descending anastomosis was performed using the U-Clip device.

RESULTS

We completed 58 totally endoscopic coronary artery bypass procedures, in which 16 patients received hybrid procedures. Two patients had conversions to a minithoracotomy. The average left internal thoracic artery harvesting and anastomosis times were 31.3 ± 10.5 (18∼55) minutes and 11.3 ± 4.7 (5∼21) minutes, respectively. The mean operating room and operation times were 336.1 ± 58.5 (210∼580) minutes and 264.8 ± 65.6 (150∼420) minutes, respectively. The drainage was 164.9 ± 83.2 (70∼450) mL. Before discharge, 50 patients underwent angiography and 8 patients underwent computed tomography angiography, and the study showed that graft patency was 100%. Unexpectedly, the left internal thoracic artery graft developed a collateral branch in 2 patients. After discharge, all patients were followed up by computed tomography angiography. The average follow-up time was 12.67 ± 9.43 (1-40) months. One patient had gastric bleeding after surgery.

CONCLUSIONS

Totally endoscopic coronary artery bypass on the beating heart is a safe procedure in selected patients and produces excellent early and midterm patency of anastomosis.

Robotic coronary artery bypass grafting

Robotically assisted surgery enables coronary surgery to be performed totally or partially endoscopically. Using the Da Vinci robotic technology allows minimally invasive treatments. We report on our experience with coronary artery surgery in our department: patients requiring single or double vessel surgical revascularization were eligible. The procedure was performed without cardiopulmonary bypass on a beating heart. From April 2004 to May 2008, 55 consecutive patients were enrolled in the study, and were operated on by a single surgical team. Operative outcomes included operative time, estimated blood loss, transfusions, ventilation time, intensive care unit (ICU) and hospital length of stay. Average operative time was 270 ± 101 min with an estimated blood loss of 509 ± 328 ml, a postoperative ventilation time of 6 ± 12 h, ICU stay of 52 ± 23 h, and a hospital stay of 7 ± 3 days. Nine patients (16%) were converted to open techniques, and transfusion was required in four patients (7%). Follow-up was complete for all patients up to 1 year. There was one hospital death (1.7%) and two deaths at follow-up. Coronary anastomosis was controlled in 48 patients by either angiogram or computed tomography scan, revealing occlusion or anastomotic stenoses (>50%) in six patients. Overall permeability was 92%. Major adverse events occurred in 12 patients (21%). One-year survival was 96%. Our initial experience with robotically assisted coronary surgery is promising: it avoids sternotomy and with a methodical approach we were able to implement the procedure safely and effectively in our practice, combining minimal mortality with excellent survival.

Robotically-assisted coronary artery bypass grafting

Objectives. Robotic surgery enables to perform coronary surgery totally endoscopically. This report describes our experience using the da Vinci system for coronary artery bypass surgery. Methods. Patients requiring single-or-double vessel revascularization were eligible. The procedure was performed without cardiopulmonary bypass on a beating heart. Results. From April 2004 to May 2008, fifty-six patients were enrolled in the study. Twenty-four patients underwent robotic harvesting of the mammary conduit followed by minimal invasive direct coronary artery bypass (MIDCAB), and twenty-three patients had a totally endoscopic coronary artery bypass (TECAB) grafting. Nine patients (16%) were converted to open techniques. The mean total operating time for TECAB was 372 ± 104 minutes and for MIDCAB was 220 ± 69 minutes. Followup was complete for all patients up to one year. There was one hospital death following MIDCAB and two deaths at follow up. Forty-eight patients had an angiogram or CT scan revealing occlusion or anastomotic stenoses (>50%) in 6 patients. Overall permeability was 92%. Conclusions. Robotic surgery can be performed with promising results.

Does obesity affect operative times and perioperative outcome of patients undergoing totally endoscopic coronary artery bypass surgery?

More and more patients undergoing coronary artery bypass grafting (CABG) are overweight. This patient group suffers from wound healing problems more often than normal-weight patients. Therefore, avoiding sternotomy in obese patients by using an endoscopic technique could be a promising approach. Robotic technology enables totally endoscopic coronary artery bypass grafting (TECAB) procedures. We investigated whether the intra-operative-times or perioperative-outcome after TECAB-procedure are negatively affected by obesity. Patients [n=127, 101 male, 26 female, median age 59 (31-77) years], undergoing arrested-heart TECAB procedure were enrolled. The median body mass index (BMI) in this patient cohort was 26 (19-38). In detail, 27 patients were normal-weight (BMI <or= 25 kg/m(2)), 67 patients were overweight (BMI 25.1-30 kg/m(2)), 29 patients were obese (BMI 30.1-33.9 kg/m(2)) and four patients were morbidly obese (BMI >or= 34 kg/m(2)). There was no correlation between BMI (1) left internal mammary artery (LIMA) takedown-time [Spearman-rank correlation coefficient (R)=0.02; P=n.s.], (2) lipectomy and pericardiotomy-time (R=0.042, P=n.s.), (3) total operative-time (R=-0.083: P=n.s.), (4) cardiopulmonary-bypass-time (R=-0.012; P=n.s.), (5) aortic-endoocclusion-time (R=-0.055; P=n.s.), (6) mechanical-ventilation-time (R=0.001, P=n.s.), (7) length of ICU-stay (R=0.04; P=n.s.), (8) length of hospital-stay (R=-0.103; P=n.s.) or (9) occurrence of intra- and/or postoperative adverse events. In overweight, obese but also morbidly obese patients the TECAB procedure did not increase operative times or the rate of intra- or postoperative complications. This patient group, therefore, benefits from this less traumatic version of coronary surgery.