Robotic totally endoscopic coronary artery bypass: A word of caution implicated by a five-year follow-up

Long-term results of robotic-assisted coronary artery bypass grafting with composite arterial grafts for multiple coronary anastomoses: 10-year experience

Currently, robotic-assisted coronary artery bypass grafting (RACABG) is a feasible choice for myocardial revascularization. Acceptable outcomes have been reported for RACABG with single target vessels; however, the long-term benefits of multivessel RACABG with composite arterial grafts have rarely been studied. Therefore, our study investigated the long-term results of multivessel RACABG with composite arterial grafts by reviewing the clinical data of patients from Taichung Veterans General Hospital. From December 2005 to June 2015, 562 patients underwent robotic-assisted robotic minimally invasive direct coronary bypass (MIDCAB) at Taichung Veterans General Hospital. Two major composite arterial graft configurations (i.e., inverted T-graft and Y-graft) were used. Data regarding the short-term and long-term outcomes of robotic-assisted MIDCAB were obtained from the medical records. For data regarding long-term outcomes of the patients not followed up at our institution, telephone interviews were conducted in June 2019. The in-hospital mortality rate and complication rate were 2.5% and 17.6%, respectively. We completed the follow-up for 486 patients (86.4%), and postoperative coronary imaging-based evaluation performed for 157 patients. The 5-year and 10-year survival rates were 82.7% and 65.2%, respectively. The 5-year and 10-year major adverse cardiac and cerebral events-free survival rates were 86.9% and 70.9%, respectively. The 5-year patency rate of various coronary anastomoses was 85.1-100%. Our study revealed that multivessel robotic-assisted MIDCAB with composite arterial grafts provided acceptable long-term outcomes, irrespective of the composite graft configuration.

Minimally invasive and robotic coronary artery bypass grafting-a 25-year review

During the mid-1990s cardiac surgery started exploring minimally invasive methods for coronary artery bypass grafting (CABG) and has over a 25-year period developed highly differentiated and less traumatic operations. Instead of the traditional sternotomy mini-incisions on the chest or ports are placed, surgery on the beating heart is applied, sophisticated remote access heart lung machine systems as well as videoscopic units are available, and robotic technology enables completely endoscopic approaches. This review describes these methods, reports on the cumulative intra- and postoperative outcome of these procedures, and gives an integrated view on what less invasive coronary bypass surgery can achieve. A total of 74 patient series published on the topic between 1996 and 2019 were reviewed. Six main versions of minimal access and robotically assisted CABG were applied in 11,135 patients. On average 1.3±0.6 grafts were placed and the operative time was 3 hours 42 min ± 1 hour 15 min. The procedures were carried out with a hospital mortality of 1.0% and a stroke rate of 0.6%. The revision rate for bleeding was 2.5% and a renal failure rate of 0.9% was noted. Wound infections occurred at a rate of 1.2% and postoperative hospital stay was 5.6±2.2 days. It can be concluded that less invasive and robotically assisted versions of coronary bypass grafting are carried out with an adequate safety level while surgical trauma is significantly reduced.

Minimally invasive coronary surgery

Minimally invasive options for coronary artery bypass graft (CABG) surgery progressed dramatically in the last decades. Minimally invasive CABG surgery is presented trough these forms: minimally invasive direct coronary artery bypass (MIDCAB), endoscopic atraumatic coronary artery bypass (EndoACAB), robot-assisted direct coronary artery bypass (RADCAB), total endoscopic coronary artery bypass (TECAB), and hybrid coronary revascularisation (HCR). Unfortunately, these are still limited only to the specialised centres across the world and have not been accepted by the majority of cardiac surgeons. A surgeon who is starting to practice minimally invasive CABG surgery needs to be ready for long duration of the interventions, higher rate of conversions to sternotomy and significant learning curve. Excellent results that have been published on the subject of minimally invasive revascularisation methods support the potential of these alternative approaches to evolve in the near future.

The use of robotics in minimally invasive spine surgery

The field of spine surgery has changed significantly over the past few decades as once technological fantasy has become reality. The advent of stereotaxis, intra-operative navigation, endoscopy, and percutaneous instrumentation have altered the landscape of spine surgery. The concept of minimally invasive spine (MIS) surgery has blossomed over the past ten years and now robot-assisted spine surgery is being championed by some as another potential paradigm altering technological advancement. The application of robotics in other surgical specialties has been shown to be a safe and feasible alternative to the traditional, open approach. In 2004 the Mazor Spine Assist robot was approved by FDA to assist with placement of pedicle screws and since then, more advanced robots with promising clinical outcomes have been introduced. Currently, robotic platforms are limited to pedicle screw placement. However, there are centers investigating the role of robotics in decompression, dural closure, and pre-planned osteotomies. Robot-assisted spine surgery has been shown to increase the accuracy of pedicle screw placement and decrease radiation exposure to surgeons. However, modern robotic technology also has certain disadvantages including a high introductory cost, steep learning curve, and inherent technological glitches. Currently, robotic spine surgery is in its infancy and most of the objective evidence available regarding its benefits draws from the use of robots in a shared-control model to assist with the placement of pedicle screws. As artificial intelligence software and feedback sensor design become more sophisticated, robots could facilitate other, more complex surgical tasks such as bony decompression or dural closure. The accuracy and precision afforded by the current robots available for use in spinal surgery potentially allow for even less tissue destructive and more meticulous MIS surgery. This article aims to provide a contemporary review of the use of robotics in MIS surgery.

A review of hybrid coronary revascularization

Purpose

Hybrid coronary revascularization is an emerging treatment strategy for coronary artery disease. We will review the reasons for the development of this strategy, describe surgical techniques, and review outcomes. Finally, we will discuss the future of hybrid revascularization and explain why it will grow as a treatment modality.

Methods

For this review, we conducted an unstructured review of the literature for articles related to hybrid coronary revascularization, bypass surgery, and percutaneous coronary interventions.

Results

Hybrid coronary revascularization has been shown in large series to have excellent results. These include fast recovery time, low mortality and rates of complications, and excellent surgical graft patency. There may be increased need for revascularization over conventional bypass surgery.

Conclusions

The combination improved surgical techniques including a robotic surgery platform, as well as the ever-improving efficacy and durability of coronary stents have made hybrid coronary revascularization an attractive option for many patients. It offers a minimally invasive approach to surgery while avoiding the poor patency of saphenous vein grafts. In appropriately selected patients, this may be an ideal treatment strategy that minimizes risks and maximizes short- and long-term benefits.

Long-Term Clinical and Computed Tomography Angiographic Follow-up After Totally Endoscopic Coronary Artery Bypass Grafting

OBJECTIVE

Totally endoscopic coronary artery bypass grafting was shown to be feasible and safe, with excellent clinical and angiographic mid-term results. Data on long-term outcome are lacking. Therefore, we aimed to investigate the long-term rate of major adverse cardiac and cerebrovascular events and left internal mammary artery patency rate in patients undergoing arrested heart totally endoscopic coronary artery bypass grafting.

METHODS

From 2001 to 2012, a total of 208 arrested heart-totally endoscopic coronary artery bypass grafting patients were prospectively included. Mean ± SD age was 58.8 ± 9.4 years, and mean ± SD Society of Thoracic Surgeons score was 0.5 ± 0.5%. Major adverse cardiac and cerebrovascular events were defined as a composite of death, myocardial infarction, stroke, re-percutaneous coronary intervention, re-coronary artery bypass graft, and target vessel revascularization. Left internal mammary artery patency was assessed using cardiac computed tomography and depicted according to the established Fitzgibbon classification. Mean ± SD follow-up was 6.9 ± 2.3 years.

RESULTS

At 1, 5, and 10 years, survival rate was 100%, 98.3%, and 95.8%, respectively. The freedom from clinical events at 1, 5, and 10 years were major adverse cardiac and cerebrovascular events (93.5%, 85.9%, and 83.0%), myocardial infarction (99.0%, 97.4%, and 95.9%), target vessel revascularization (96.0%, 94.3%, and 91.7%), re-percutaneous coronary intervention (94.5%, 91.6%, and 84.2%), and re-coronary artery bypass graft (100%, 99.5%, and 99.5%), respectively. Left internal mammary artery patency rate at 1, 5, and 10 years was 100%, 94.9%, and 88.1%, respectively.

CONCLUSIONS

Arrested heart-totally endoscopic coronary artery bypass grafting shows excellent clinical long-term results with a left internal mammary artery patency rate comparable with conventional coronary artery bypass graft at 10 years after surgery.

Repeat Revascularization After Minimally Invasive Coronary Artery Bypass Grafting: Is It a Problem?

OBJECTIVE

Minimally invasive coronary artery bypass grafting (MICS CABG) via a small left thoracotomy is a novel technique for coronary revascularization that is increasingly used around the world. However, multivessel MICS CABG is difficult, and concerns about repeat revascularization (RR) have been raised. This longitudinal study describes the rates of RR among patients who have undergone MICS CABG and identifies targets for improvement.

METHODS

A prospective observational study was performed on the 306 MICS CABG patients operated on by a single surgeon from 2005 to 2015. Minimally invasive coronary artery bypass grafting was performed through a small left thoracotomy, using the in situ left internal mammary artery, ± a radial artery, and 1 to 3 saphenous veins anastomosed proximally to the aorta. Patients were followed annually. We examined the difference between the first half and second half of the series to ascertain the effects of a learning curve.

RESULTS

Eighty percent of the procedures were performed off-pump. The median number of grafts performed were 2, and the left anterior descending, diagonals, obtuse marginals, and posterior interventricular artery were the distal targets in 94%, 12%, 44%, and 26%, respectively. The graftability index (#grafts/#diseased vessels) was 0.93. Revascularization of targets smaller than 1.5 mm decreased from 69% to 50% (P = 0.002) between the series' first and second halves. Overall, RR was needed in 21 patients (6.9%) and was performed at a mean ± SD of 1.7 ± 1.6 years postoperatively. The culprit lesion was attributed to the index surgical procedure ("graft-associated") in 52%, to a stent stenosis or progression of native disease in 43%, and was unidentified in 5%. Patients with graft-associated RR had a lower graftability index at operation (0.73 vs 0.94) and more frequent involvement of the circumflex system (0.8 vs 0.3). The overall rate of RR at 3 years decreased from 11% in the first half to 2.6% in the second half (P = 0.001).

CONCLUSIONS

The need for RR is part of the learning curve with MICS CABG, involves a graft in half of the cases, is more common in patients who had a lower graftability index at operation, and markedly improves with experience.

Robotic Versus Conventional Coronary Artery Bypass Grafting: Direct Comparison of Long-Term Clinical Outcome

OBJECTIVE

Robotic coronary artery bypass grafting (CABG) was shown to be a safe and feasible method for the treatment of coronary artery disease in highly selected patients. However, long-term outcome data comparing robotic CABG with conventional CABG are still missing. Therefore, we aimed to compare robotic with conventional CABG in terms of perioperative and long-term outcomes.

METHODS

Of 2947 consecutive elective patients with coronary artery disease operated at a single center between 2001 and 2013, 280 underwent robotic CABG. After propensity score matching, 134 pairs of robotic versus conventional CABG (age = 62 ± 10 years, log EuroScore = 2.4 ± 2.4% vs. mean ± SD age = 63 ± 10 years, log EuroScore 2.5 ± 1.7%, respectively; all P > 0.05) were formed. The mean ± SD follow-up was 6.6 ± 3.2 years.

RESULTS

There was no difference in perioperative mortality (robotic = 0% vs. conventional = 1.5%, P = 0.154), myocardial infarction (robotic = 0% vs. conventional = 2.2%, P = 0.08), and stroke rate (robotic = 0% vs. conventional = 0.7%, P = 0.318) between the groups. Longer cardiopulmonary bypass (robotic = 112 ± 100 minutes vs. conventional = 67 ± 48 minutes, P < 0.0001) and cross-clamp times (robotic = 68 ± 54 minutes vs. conventional = 38 ± 27 minutes, P < 0.0001) were observed in robotic patients. Long-term follow-up yielded equivalent results in terms of survival (1, 5, and 10 years: robotic = 99.3%, 96.9%, and 81.3% vs. conventional = 96.3%, 92.2%, and 82.6%, respectively; log-rank P = 0.187) and freedom from major adverse cardiac and cerebral events at 1, 5, and 10 years after procedure (robotic = 90.6%, 77.7%, 70.1% vs. conventional = 94.1%, 82.2%, 66.6%; log-rank P = 0.790).

CONCLUSIONS

Long-term outcomes of robotic CABG are comparable with conventional CABG for selected patients. Longer operative times of robotic CABG do not influence the excellent long-term outcomes.

Long-term results after robotically assisted coronary bypass surgery

BACKGROUND

Robotically-assisted coronary bypass grafting (CABG) was introduced in 1998 and dedicated centers have continuously applied and developed this minimally invasive method of coronary bypass surgery. While short-term results are relatively well published, data on long-term outcome are limited. In this literature review, we assessed the outcomes after robotic CABG following the first postoperative year.

METHODS

We searched PubMed for articles containing the terms "robotic" or "robotically assisted" and "coronary bypass". A total of 11 papers contained long-term results. We specifically investigated survival, graft patency, freedom from angina and re-intervention, as well as freedom from major adverse cardiac and cerebrovascular events (MACCE).

RESULTS

Five-year survival after robotic CABG was consistently consistently greater than 90% and graft patency between 3 and 5 years was reported to be above 90%. Fifteen percent to 26% of patients re-experienced angina at 3 to 5 years postoperatively. Long-term freedom from re-intervention reached the range and the 5-year freedom from MACCE rate was approximately 75%.

CONCLUSIONS

According to data in the literature, long-term results after CABG carried out with the assistance of a surgical robot appear to be in line with results achieved after conventional CABG.

A systematic review on robotic coronary artery bypass graft surgery

BACKGROUND

Robotic-assisted coronary artery bypass graft surgery (CABG) has been performed over the past decade. Despite encouraging results from selected centres, there is a paucity of robust clinical data to establish its clinical safety and efficacy. The present systematic review aimed to identify all relevant clinical data on robotic CABG. The primary endpoint was perioperative mortality, and secondary endpoints included perioperative morbidities, anastomotic complications, and long-term survival.

METHODS

Electronic searches were performed using three online databases from their dates of inception to 2016. Relevant studies fulfilling the predefined search criteria were categorized according to surgical techniques as (I) totally endoscopic coronary artery bypass without cardiopulmonary bypass (TECAB off-pump); (II) TECAB on-pump; and robotic-assisted mammary artery harvesting followed by minimally invasive direct coronary artery bypass (robotic MIDCAB).

RESULTS

The present systematic review identified 44 studies that fulfilled the study selection criteria, including nine studies in the TECAB off-pump group and 16 studies in the robotic MIDCAB group. Statistical analysis reported a pooled mortality of 1.7% for the TECAB off-pump group and 1.0% for the robotic MIDCAB group. Intraoperative details such as the number and location of grafts performed, operative times and conversion rates, as well as postoperative secondary endpoints such as morbidities, anastomotic complications and long-term outcomes were also summarized for both techniques.

CONCLUSIONS

A number of technical, logistic and cost-related issues continue to hinder the popularization of the robotic CABG procedure. Current clinical evidence is limited by a lack of randomized controlled trials, heterogeneous definition of techniques and complications, as well as a lack of robust clinical follow-up with routine angiography. Nonetheless, the present systematic review reported acceptable perioperative mortality rates for selected patients at specialized centres. These results should be considered as a useful benchmark for future studies, until further data is reported in the form of randomized trials.

Reviewing hybrid coronary revascularization: challenges, controversies and opportunities

Two main approaches to myocardial revascularization currently exist, coronary artery bypass and percutaneous coronary intervention. In patients with advanced coronary artery disease, coronary artery bypass surgery is associated with improved long term outcomes while percutaneous coronary intervention is associated with lower periprocedural complications. A new approach has emerged in the last decade that attempts to reap the benefits of bypass surgery and stenting while minimizing the shortcomings of each approach. This new approach, hybrid coronary revascularization, has shown encouraging early results. Minimally invasive techniques for bypass surgery have played a large part of bringing this approach into contemporary practice.

The midterm outcome and MACE of robotically enhanced grafting of left anterior descending artery with left internal mammary artery

BACKGROUND

We assessed the midterm outcome and the incidence of major adverse cardiovascular events in UK's largest Da Vinci assisted robotic coronary revascularisation cohort. This study was set up at the Imperial College NHS Trust, St. Mary's Hospital, London, United Kingdom.

METHOD

Benchmarking approach through retrospective audit of the regional outcomes against standards in the published literature. Data was collected from the patient's records, communication with the primary care physicians and the national strategic tracing service. The results were compared with the published literature. Patients who underwent robotic assisted coronary revascularisation were included. Other robotic procedures or minimally invasive revascularisation without the use of the Da Vinci robot were excluded. The main outcome measure was the midterm survival up to five years and the incidence of major adverse cardiovascular events (MACE) up to three years.

RESULTS

Since April 2002, one hundred consecutive patients underwent either off pump robotic assisted single vessel small thoracotomy (SVST, n=88), or off pump total endoscopic coronary artery bypass grafting (TCAB, n=12). All patients were operated on by the same primary surgeon but different assisting surgeons. All patients received a left internal mammary arterial (LIMA) graft as planned. The primary outcome of total one month and three years MACE and up to five year survival was 0, 9 and 96% respectively.

CONCLUSIONS

The procedural success rates in terms of morbidity and mortality up to five years are compatible to the outcomes observed outside the United Kingdom. These results are not inferior to that of conventional off pump single vessel coronary surgery or percutaneous coronary intervention to the LAD.

Systematic review of robotic-assisted, totally endoscopic coronary artery bypass grafting

BACKGROUND

Advancements in surgical robotic technology over the last two decades have enabled coronary artery bypass grafting to be performed totally endoscopically, and have the potential to significantly change clinical practice in the future.

METHODS

A systematic review of studies reporting clinical outcomes of total endoscopic coronary artery bypass grafting (TECABG) was performed.

RESULTS

14 appraised studies included 880 beating heart TECABGs, 360 arrested heart TECABGs, 633 one-vessel operations and 357 two-vessel operations. Patients were generally low-risk. There was a significant learning curve. The weighted means for short-term beating heart and arrested heart TECABG results respectively were: intraoperative exclusion rate of 5.7% and 1.9%, intraoperative conversion rate of 5.6% and 15.0%, all-cause mortality of 1.2% and 0.4%, stroke of 0.7% and 0.8%, myocardial infarction of 0.8% and 1.8%, new onset atrial fibrillation of 10.7% and 5.1% and post-operative reintervention rate of 2.6% and 2.3%. The overall rate of short term postoperative graft patency for beating heart and arrested heart TECABG was 98.3% and 96.4% respectively.

CONCLUSIONS

Appropriate patient selection was important in minimizing the risk of intraoperative and postoperative complications. Short-term outcomes of both beating and arrested heart TECABG were acceptable, but results so far have been heterogeneous. There were fewer studies reporting intermediate to long-term outcomes, but results were encouraging, and further investigation and development of the procedure is warranted.

Combined Totally Endoscopic Robotic Coronary Bypass and Mitral Valve Repair via Right-Sided Ports

We present a case of combined coronary artery bypass grafting and mitral valve (MV) repair using a robotic totally endoscopic right-sided approach. A 61-year-old man presented with fatigue due to significant mitral regurgitation and was found to have a tight stenosis in the mid left anterior descending artery. Using the da Vinci robotic system, the patient underwent a left internal mammary artery graft to the left anterior descending artery using the C-Port Flex A distal anastomotic device followed by a MV repair. Both procedures were performed endoscopically via right chest ports and right femorofemoral bypass successfully. The patient was discharged from the hospital 3 days postoperatively and returned to normal activity within 3 weeks after surgery. This case study shows the feasibility of using an endoscopic robotic approach in selected patients undergoing combined MV coronary artery bypass grafting surgery.

Is totally endoscopic coronary artery bypass safe, feasible and effective?

A best evidence topic was written according to a structured protocol. The question addressed was whether totally endoscopic coronary artery bypass (TECAB) is safe, effective and feasible. A total of 171 papers were found, of which eight represented the best evidence. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The da Vinci robotic system was utilized in seven retrospective studies and one multicentre prospective trial, comprising 724 patients undergoing TECAB. Patient-related outcomes, including the incidence of major adverse cardiac events, graft patency and survival, were investigated. From the studies evaluated, TECAB appears to be safe operation with low complication rates and excellent early- and mid-term graft patencies. The incidence of internal thoracic artery injury was documented in four studies and ranged from 0 to 10%. Re-exploration for bleeding was necessary in 1-15% of patients. Conversion to open techniques was performed in 0-24% of cases. There was no in-hospital mortality in the majority of studies, but this reached 2.1% in a large series of 228 patients. Target-vessel reintervention rates varied between 0 and 12.1% according to the institutional experience. Pre- and post-discharge graft patencies were excellent at 93-100 and 92-100%, respectively. Intraoperative variables, such as time taken for internal thoracic artery harvest, anastomosis, cross-clamp, cardiopulmonary bypass (CPB) and the overall operation were as follows: internal thoracic artery harvest time (range 5-187 min), anastomosis time (range 6-82 min), cross-clamp time (range 30-223 min), CPB time (range 41-268 min) and operative time (range 84-600 min). TECAB is a technically demanding and time-consuming procedure associated with a significant learning curve. Proctoring and structured training programmes are currently supported by European and international societies to encourage wider uptake of the procedure. In conclusion, TECAB represents a feasible alternative to conventional coronary artery bypass in selected patients. It is associated with low morbidity and excellent mid-term graft patency. Larger, prospective and multicentre trials are required to assess the long-term and patient-reported outcomes of TECAB.

Multivessel beating heart robotic myocardial revascularization increases morbidity and mortality

OBJECTIVE

The vast majority of reports describing beating heart robotic myocardial revascularization (total endoscopic coronary artery bypass) contain very small numbers of patients undergoing single-vessel bypass. We present a large series of patients undergoing multivessel total endoscopic coronary artery bypass.

METHODS

We performed a retrospective clinical review of 106 patients undergoing total endoscopic coronary artery bypass (72% multivessel) at 1 institution by 1 experienced cardiac surgeon/physician assistant team. These results were compared with the expected clinical outcomes from conventional coronary artery bypass grafting calculated using the Society of Thoracic Surgeons risk calculator.

RESULTS

Of the 106 patients, 1% underwent quadruple total endoscopic coronary artery bypass, 8% triple, 63% double, and 28% single. The emergent conversion rate for hemodynamic instability was 6.6%. The postoperative renal failure rate (doubling of baseline serum creatinine or dialysis required) was 7.5%. Overall, 23 patients (21.7%) exhibited at least 1 major morbidity/mortality (4 deaths). The number of vessels bypassed (single/double/triple/quadruple) correlated positively with the surgical/operating room time, the lung separation time, vasoactive medication use, blood use, a postoperative ventilation time longer than 24 hours, intensive care unit length of stay, and hospital length of stay. An increased surgical time was significantly associated with major morbidity (P = .011) and mortality (P = .043). A comparison with the Society for Thoracic Surgeons expected outcomes revealed a similar hospital length of stay but an increased incidence of prolonged ventilation (P = .003), renal failure (P < .001), morbidity (P = .045), and mortality (P = .049).

CONCLUSIONS

Our results suggest that addressing multivessel coronary artery disease using total endoscopic coronary artery bypass offers no obvious clinical benefits and might increase the morbidity and mortality.

Robotic coronary artery bypass grafting

Robotically assisted surgery enables coronary surgery to be performed totally or partially endoscopically. Using the Da Vinci robotic technology allows minimally invasive treatments. We report on our experience with coronary artery surgery in our department: patients requiring single or double vessel surgical revascularization were eligible. The procedure was performed without cardiopulmonary bypass on a beating heart. From April 2004 to May 2008, 55 consecutive patients were enrolled in the study, and were operated on by a single surgical team. Operative outcomes included operative time, estimated blood loss, transfusions, ventilation time, intensive care unit (ICU) and hospital length of stay. Average operative time was 270 ± 101 min with an estimated blood loss of 509 ± 328 ml, a postoperative ventilation time of 6 ± 12 h, ICU stay of 52 ± 23 h, and a hospital stay of 7 ± 3 days. Nine patients (16%) were converted to open techniques, and transfusion was required in four patients (7%). Follow-up was complete for all patients up to 1 year. There was one hospital death (1.7%) and two deaths at follow-up. Coronary anastomosis was controlled in 48 patients by either angiogram or computed tomography scan, revealing occlusion or anastomotic stenoses (>50%) in six patients. Overall permeability was 92%. Major adverse events occurred in 12 patients (21%). One-year survival was 96%. Our initial experience with robotically assisted coronary surgery is promising: it avoids sternotomy and with a methodical approach we were able to implement the procedure safely and effectively in our practice, combining minimal mortality with excellent survival.

Robotically-assisted coronary artery bypass grafting

Objectives. Robotic surgery enables to perform coronary surgery totally endoscopically. This report describes our experience using the da Vinci system for coronary artery bypass surgery. Methods. Patients requiring single-or-double vessel revascularization were eligible. The procedure was performed without cardiopulmonary bypass on a beating heart. Results. From April 2004 to May 2008, fifty-six patients were enrolled in the study. Twenty-four patients underwent robotic harvesting of the mammary conduit followed by minimal invasive direct coronary artery bypass (MIDCAB), and twenty-three patients had a totally endoscopic coronary artery bypass (TECAB) grafting. Nine patients (16%) were converted to open techniques. The mean total operating time for TECAB was 372 ± 104 minutes and for MIDCAB was 220 ± 69 minutes. Followup was complete for all patients up to one year. There was one hospital death following MIDCAB and two deaths at follow up. Forty-eight patients had an angiogram or CT scan revealing occlusion or anastomotic stenoses (>50%) in 6 patients. Overall permeability was 92%. Conclusions. Robotic surgery can be performed with promising results.

Robotic approaches to the posterior spine

STUDY DESIGN

This anatomic study described robotic approaches to the posterior thoracolumbar spine in a porcine model. Ergonomics, control, and approach and technical difficulties were noted.

OBJECTIVE

The objective of this study was to develop a robotic approach to the posterior thoracolumbar spine maximizing surgeon ergonomics and control.

SUMMARY OF BACKGROUND DATA

Surgery is both physically and mentally demanding, and strains from ergonomics and the aging process may negatively impact surgical skills. In spine surgery, control and precision are extremely important due to the close proximity to the spinal cord. The da Vinci robotic surgery system has offered better ergonomics and control in urology, gynecology, and cardiac surgery, and is rapidly gaining adoption. To date, there have been no published reports of da Vinci robotic spine surgery, motivating us to assess its potential in posterior spine surgery.

METHODS

Posterior spine da Vinci approaches were tested on a pig without spinal pathology with an open subperiosteal dissection. A laser instrument and prototype robotic burr and rongeur instruments were tested on laminotomy, laminectomy, disc incision, and dural suturing procedures.

RESULTS

Open dissection of the posterior spine provided sufficient access to successfully perform laminotomy, laminectomy, disc incision, and dural suturing procedures. Prototype burr and rongeur instruments were effective with good control. The laser instrument coagulated the epidural venous plexus and incised the anulus. Robot ergonomics allowed the surgeon to perform procedures for a full day with significantly less fatigue and reduced hand tremor.

CONCLUSION

The da Vinci could perform the major noninstrumented procedures of the posterior spine with improved ergonomics and control. Surgeon fatigue and tremor were reduced. With some modification of prototype and commercial instruments a posterior spine surgery instrument kit can be developed. Future clinical studies can better assess patient and surgeon benefits of using the da Vinci robot for posterior spine surgeries.