Totally robotic sutured coronary artery bypass grafting: How we do it

Abstract

Central MessageTotally endoscopic coronary artery bypass provides the benefit of multiarterial grafting while minimizing the risk of wound infection and stroke. We present our technique to reproducibly perform a totally robotic sutured coronary anastomosis.See Commentaries on pages 173 and 174. Totally endoscopic coronary artery bypass provides the benefit of multiarterial grafting while minimizing the risk of wound infection and stroke. We present our technique to reproducibly perform a totally robotic sutured coronary anastomosis. See Commentaries on pages 173 and 174. While the production of distal anastomotic connectors has been suspended, a hand-sewn technique has become essential to continue to perform off-pump closed chest multiarterial bypass surgery.1Kitahara H. Nisivaco S. Balkhy H.H. Graft patency after robotically assisted coronary artery bypass surgery.Innovations (Phila). 2019; 14: 117-123Crossref PubMed Scopus (10) Google Scholar,2Balkhy H.H. Nisivaco S. Kitahara H. McCrorey M. Patel B. Robotic beating heart totally endoscopic coronary artery bypass in higher-risk patients: can it be done safely?.Innovations (Phila). 2018; 13: 108-113Crossref PubMed Google Scholar Totally endoscopic coronary artery bypass (TECAB) provides the benefit of multiarterial grafting while minimizing the risk of wound infection and stroke. Here we describe our technique for reproducibly performing a totally robotic sutured coronary anastomosis. Patient setup, anesthesia management, port insertion, and internal thoracic artery (ITA) harvesting have been described previously.3Hashimoto M. Wehman B. Balkhy H.H. Robotic totally endoscopic coronary artery bypass: tips and tricks for using an anastomotic device.J Thorac Cardiovasc Surg. 2020; 159e: 57-60Abstract Full Text Full Text PDF Scopus (4) Google Scholar, 4Balkhy H.H. Gummert J.F. Beating heart: totally endoscopic coronary artery bypass surgery; robotic endoscopic multi-vessel anastomotic connectors.in: Chitwood Jr., W. Atlas of Robotic Cardiac Surgery. Springer, London2014: 97-105Crossref Google Scholar, 5Balkhy H.H. Wann L.S. Krienbring D. Arnsdorf S.E. Integrating coronary anastomotic connedtors and troboticws towards a totally endoscopic beating heart approach: review of 120 cases.Ann Thorac Surg. 2011; 92: 821-827Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar In brief, the camera port is placed in the left fourth intercostal space (ICS) and instrument ports are placed in the second and sixth ICSs, all in the anterior-axillary line. The da Vinci Si System (Intuitive Surgical, Sunnyvale, Calif) is docked from the right side, with the robotic cart positioned at 60-degree angle from the table. Continuous CO2 insufflation is required to compress the lung and provide space to conduct the operation. A subcostal fourth arm for the Endo-Wrist stabilizer is inserted, and a 12-mm sealed working port is advanced in the second ICS at the midclavicular line. The coronary target(s) are exposed with the aid of the stabilizer. The overlying epicardium is dissected using low electrocautery and a silastic snare (SaddleLoop; Quest Medical, Allen, Tex) is placed proximally. After heparinization, the ITA conduits are divided distally. A 30-degree down scope is used for the left anterior descending artery anastomosis, and a 30-degree up scope (or 0-degree scope) is chosen for the left circumflex branches. Ischemic preconditioning for 5 to 8 minutes with coronary snaring is recommended, under careful observation with electrocardiographic monitoring, hemodynamic response, and transesophageal echocardiography. During this period, sutures and shunts can be delivered into the chest cavity through the working port. At this time, the distal end of the ITA is clipped onto a silk tie that had been previously secured to the stabilizer to offer a consistent landing zone of the ITA in proximity to the coronary target. (Figure 1, A and B). A bulldog clamp is applied onto the ITA, and at this time