Development of Robotic Enhanced Endoscopic Surgery for the Treatment of Coronary Artery Disease

Abstract

Background The introduction of robotic enhanced surgery demanded stepwise development of performed procedures on the basis of growing experience of the operating team. Methods and Results Between May 1999 and January 2001, this new wrist-enhanced instrumentation was used in 201 patients (156 men and 45 women, median age 64±10.5 years, left ventricular ejection fraction 68±12.4%). During the development of robotic enhanced CABG, the patients were divided into 3 groups. Group A (n=156) consisted of patients in whom the robotic system was used to harvesting the left or right internal mammary artery, or both, whereas the anastomoses were performed directly through a small chest incision. In group B (n=37), the harvest of the internal mammary arteries and the coronary anastomoses were performed totally endoscopically. In a third early group C, patient (n=8) were treated with robotic enhanced CABG via a median sternotomy already preoperatively planned, whereas gradual step-by-step application of robotic instrumentation and its feasibility were assessed. The survival rate was 99.4%. One patient (0.6%) died due to pneumonia on postoperative day 16. Conversion rate to median sternotomy was 5%. The left and right internal mammary artery conduits could be successfully harvested in 98% and 100%, respectively. The time of dissection of the left internal mammary artery could be significantly reduced alone by increasing experience. All patients were discharged from the hospital after a mean of 7 days. In 9 patients (4.5%), bleeding required reexploration. Conclusions The introduction of this new surgical tool enables the development of new endoscopic procedures. Our results gained during the development of robotic enhanced CABG motivate us to establish a set standard for the totally endoscopic treatment of patients with 1-vessel coronary artery disease.

Current status of robotically assisted coronary revascularization

“…In concurrence with reports in the literature, we have found that the learning curve for totally endoscopic internal thoracic artery (ITA) dissection is very steep [4,19,20]. Indeed, experience with conventional endoscopy is not absolutely necessary for effective use of the da Vinci system [21].…”

“…The operating times of such procedures are very long (4.2 Ϯ 0.9 minutes), and great technical effort is required for single-vessel revascularization [3][4][5]7]. Moreover, they must compete with other much less time-consuming and technology-dependent revascularization procedures, such as minimally invasive direct coronary artery bypass grafting (MIDCAB; LITA to LAD on the beating heart via a left anterior small thoracotomy) [24] and awake coronary artery bypass grafting (LITA to LAD via a partial lower sternotomy under epidural anesthesia) [25].…”

“…One stage in the process of training the surgical team for totally endoscopic coronary revascularization involves separating the performance of the skills to be mastered into individual steps [4,20]. One major step is the preparation of the ITA with consecutive conversion to a procedure performed through a limited incision under direct vision.…”

“…Although minimally invasive endoscopic procedures are routine in general surgery, orthopedics and traumatology, thoracic surgery, gynecology, and urology, comparable procedures in cardiac surgery have only become possible since the introduction of telemanipulator systems. These computer-enhanced robotic systems have led to a revolution in cardiothoracic surgery that is still in progress and has not yet become the standard of care [1][2][3][4][5].…”

“…However, because enabling instruments were not yet available, totally endoscopic coronary revascularization still was not possible. Only since the development of 3-dimensional visualization systems, in combination with robotically assisted endoscopic instruments, has the evolution of totally endoscopic cardiac surgery truly taken place [3][4][5].…”