JRSM >
Volume 96, Number 8 >
Pp. 400-401
1 Directorate of Cardiothoracic Surgery, Anaesthetic Unit, St Mary's Hospital,
Praed Street, London W2 1NY, UK
2 Directorate of Cardiothoracic Surgery, the Academic Surgical Unit, St Mary's
Hospital, Praed Street, London W2 1NY, UK
Correspondence to: Roberto P Casula E-mail: roberto.casula{at}st-marys.nhs.uk
The introduction of telemanipulation systems has increased surgical dexterity and accuracy, providing seven degrees of freedom of motion, tremor filtration and three-dimensional visualization.1 With the aid of a new-generation articulated coronary stabilizer, cardiac surgeons are now able to perform completely endoscopic coronary artery bypass grafting without thoracotomy.2 At St Mary's Hospital we have used the Da Vinci Surgical System (Intuitive Surgical, Mountainview, CA). The surgeon works at a master unit where his/her hands movements are accurately reproduced by the slave instruments inside the chest. We report the first two UK cases.
CASE HISTORIES
Case 1
A male ex-smoker aged 45 had a 9-month history of angina on exertion and
his exercise test was positive. Comorbidity included hypertension,
hypercholesterolaemia and obesity. Cardiac catheterization and angiography
showed preserved ventricular function and a proximal occlusion of the left
anterior descending (LAD) coronary artery not suitable for angioplasty. For
this reason a minimally invasive approach was considered.
Case 2
A very active man of 41 with hypercholesterolaemia reported 2 years of
angina on limited exertion and his exercise test was positive. A percutaneous
angioplasty to his LAD territory had failed and he was not keen to have
coronary bypass grafting through a full sternotomy.
OPERATIVE AND POSTOPERATIVE MANAGEMENT
The patient was placed supine on the operating table and the left hemithorax was slightly raised by placing an inflatable bag under the left scapula. The procedure was performed under general anaesthesia, with double-lumen endotracheal intubation to allow single right lung ventilation. Initially a 12 mm port was inserted via the fourth intercostal space at the level of the anterior axillary line. A 3D camera at 30° ‘looking up’ was inserted into the chest. Intrathoracic insufflation was started at plus 5 mmHg and increased to 12 mmHg. With the aid of the 3D camera another two 8 mm ports were inserted under direct vision via the second and sixth intercostal spaces. These latest ports allowed right and left instrument positioning. The left internal mammary artery was dissected off the chest wall from its bifurcation distally up to the level of the first rib. The patient was heparinized (15 000 units) and the distal left internal mammary artery was skeletonized in its distal few centimetres to allow application of an endovascular ‘bulldog’ clamp. The pericardium was opened from above the diaphragm up to the level of the pulmonary artery. The LAD artery was identified. The left internal mammary artery was transected after distal application of a clip, and its flow was visually assessed. The camera was then changed to 30° ‘looking down’. A 12 mm port was placed under the left costal arch for introduction of an endoscopic stabilizer (Intuitive Surgical, Mountainview, CA) which functions by applying suction to the epicardium and improves visibility by continuous irrigation. Two silastic loops were placed proximally and distally to the chosen arteriotomy site. An arteriotomy was performed and the left internal mammary to LAD anastomosis was fashioned with running 7-0 Prolene (Ethicon, UK) (Figure 1). Two chest drains were placed via the previously inserted ports. The total surgical times were 4 and 5 hours. LAD artery occlusion times were 45 and 35 minutes. Both patients were fully mobilized by the fourth postoperative day and they were discharged home on days six and five. On review three weeks after surgery they had recovered completely.
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COMMENT
The usual indication for minimally invasive coronary bypass surgery (MIDCAB) is isolated disease of the left anterior descending artery.3 The aim, by avoiding sternotomy, cardiopulmonary bypass and aortic manipulation, is to reduce morbidity, length of stay and cost without compromising the quality of the surgical procedure. Randomized trials have shown MIDCAB to be effective, with a trend to superiority over transcutaneous angioplasty/stent in terms of reintervention rates and freedom from angina recurrence.4 Relative contraindications are an intramyocardial course of the left anterior descending artery and a small diffusely diseased vessel. Usually this procedure has been done via an anterolateral thoracotomy, which can be very uncomfortable in the early postoperative period. Robotic harvesting of the left internal mammary artery, with manual microvascular anastomosis to the left anterior descending artery, required smaller skin incisions and avoids spreading of the ribs. Totally endoscopic bypass surgery (TECAB) has been much aided by development of the articulated endoscopic stabilizer, and surgeons elsewhere have achieved preliminary clinical and angiographic patency results comparable with those of conventional surgical revascularization techniques.5
The preservation of chest integrity via a TECAB approach offers a superior cosmetic result (Figure 2) and a faster and less painful recovery. Further randomized trials are required to evaluate the efficacy and effectiveness of this procedure.6,7 Refinements and miniaturization may allow expansion of the current application—selected cases of single-vessel left anterior descending artery disease—to multivessel procedures.
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Acknowledgments
We acknowledge the contribution of all members of the staff in Theatre 8, of S Martin and of Drs G Symons and J Hood in the development of the robotic cardiac programme at St Mary's Hospital since February 2001. We also thank Chris Priest and the Medical Illustration Department of the Chelsea and Westminster Hospital.
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