MINIMALLY INVASIVE THORACOSCOPICALLY ASSISTED CORONARY-ARTERY BYPASS-SURGERY

Objective: Minimally invasive techniques have been widely used in othe r surgical fields including video-assisted thoracic surgery (VATS) in thoracic surgery, These concepts are now being applied to cardiac surg ery. The opportunities to make cardiac surgery less invasive include e limination of the median sternotomy incision, elimination of cardiopul monary bypass and no manipulation of the aorta. Materials and methods: From January 1992 through September 1996, various aspects of minimall y invasive cardiac surgery have been examined in the inanimate endosco pic trainer, animal model. human cadaver and in human clinical studies . Techniques of endoscopic sutured anastomosis as well as alternatives to suturing were first perfected in the inanimate trainer, Twenty ani mals then underwent endoscopic coronary artery bypass using the left i nternal mammary artery to the left anterior descending with circulator y support from an axial flow pump. Fifty eight minimally invasive coro nary artery bypass procedures have been performed in humans using thor acoscopic assistance for internal mammary artery harvest. Results: One hundred fifty endoscopic coronary anastomoses were performed in the i nanimate trainer with the endoscopic suturing technique being the pref erred method. Time required to perform an anastomosis decreased from g reater than 60 min to a mean of 20 min as technique and instruments we re developed. In animals, methods of access as well as enabling surgic al instruments to allow crossclamp of the aorta and performance of the anastomosis were developed, Fifty-eight humans underwent coronary art ery bypass using the left internal mammary artery placed to the left a nterior descending under direct vision through a limited anterior thor acotomy on a beating heart. The procedure ii;as successful in 52 patie nts with conversions required in six patients, Techniques were develop ed for immobilization for performance of the anastomosis. Discussion: The ability to perform an endoscopic anastomosis still remains the rat e limiting step for totally endoscopic coronary artery bypass surgery. The present MIDCAB (minimally invasive direct coronary artery bypass grafting) procedure is a significant advance in cardiac surgery, but s till has limitations that make performance of an exact anastomosis sti ll somewhat difficult and applicable only to single-vessel disease. Pr esent efforts are directed toward extending the MIDCAB procedure by va rious immobilization and circulatory support devices and combining the MIDCAB procedure with catheter techniques for treating more advanced disease. (C) 1997 Elsevier Science B.V.