Total endoscopic computer enhanced coronary artery bypass grafting

Objective: In an effort to minimize access in coronary artery bypass (CAB) surgery, a total endoscopic approach using computer enhanced technology was developed. Methods: By July 1999 the da Vinci telemanipulation system (Int uitive Surgical, Mountain View, CA) was used in 66 patients with coronary a rtery disease. In 12 patients undergoing routine coronary artery bypass gra fting (CABG) (group 1) the internal thoracic artery (ITA) to left anterior descending artery (LAD) anastomosis was performed remotely using the system . In 32 patients (group 2) endoscopic dissection of the ITA was performed f ollowed by a conventional minimally invasive direct coronary artery bypass (MIDCAB) operation. In 22 patients (group 3) the complete operation was per formed endoscopically through 4 ports (total endoscopic coronary artery byp ass, TECAB). Port-Access cardiopulmonary bypass with cardioplegic arrest wa s used for TECAB. Results: In group 1 the time for performing the ITA to LA D anastomosis was 17 +/- 10 min. Mean graft now was 38 +/- 25 ml/min. One a nastomosis leaked and was repaired manually. In group 2 in 31/32 patients ( 96%) the ITA harvest was successfully performed with the system at mean of 61 +/- 27 min. There was a substantial learning curve associated with ITA t ake-down. In one patient a dissection caused insufficient free ITA graft no w which necessated additional vein grafting. Postoperative angiography demo nstrated graft patency in all cases. In the TECAB group, the operation coul d be completed through four ports in 18 of the 22 patients (82%) with opera ting rimes in the range 220-507 min. In four patients. elective conversion to a minithoracotomy was required due to failure to identify the LAD (1), b leeding from the anastomosis (1), grafting of a diagonal branch (1) and tor sion of the pedicle (1). One patient required reoperation for bleeding from an ITA side-branch. Median intubation rime was 13 h and stay on ICU and ho spitalization were 20 h and 7 days, respectively. A 3-month follow-up angio graphy revealed patent grafts in all TECAB patients. Conclusion: Endoscopic ITA harvesting and performing of arterial anastomoses can be safely perfor med with the da Vinci(TM) system. TECAB is possible on the arrested heart w ith good functional results. However, a substantial learning curve has to b e overcome which is reflected in long operation times and an initial signif icant conversion rate. (C) 2000 Elsevier Science B.V. All rights reserved.