Da Vinci lives: Continued experience with robotically enhanced minimally invasive bypass surgery (Endo MIDCAB) using the Da Vinci System

Objective: Minimally invasive off-pump coronary bypass surgery through anterolateral minithoracotomy (MIDCAB) is a well established procedure for single vessel disease. Surgical trauma is even more reduced by robotically enhanced endoscopic LIMA harvest (Endo-MIDCAB). Here we report about a consecutive series of Endo-MIDCAB procedures at our center.

Methods: Between 2004 and 2011 63 patients underwent Endo-MIDCAB surgery for single vessel (n=58, 92%) or multi-vessel (n=5, 8%) bypass grafting. Mean patient age was 60±7.9 years (84% male). After port placement LIMA preparation was performed using the Da Vinci Telemanipulator system under 3-D endoscopic control from a remote workstation in the operating room. After opening of the pericardium the target vessel was located and access site determined. After minimally invasive small anterolateral minithoracotomy LIMA to LAD bypass was achieved in off-pump technique by stabilisation of the coronary vessel, shunt insertion and hand sewn anastomosis followed by flow-measurement.

Results: Endo-MIDCAB could successfully be performed in 95.2% of patients through anterolateral mini-thoracotomy with robotically enhanced endoscopic LIMA harvest. Three patients were converted to median sternotomy, one due to deep intra-myocardial LAD position, 2 multi-vessel patients due to LIMA dissection. Two patients underwent re-operation for bleeding from the chest wall and another patient developed a wound infection. In hospital mortality was 0%. Two patients underwent planned hybrid procedures with consecutive PCI and coronary stent implantations. Flow measurements showed sufficient bypass flow in all patients (mean flow 37.7±14.9ml/min). All patients were discharged from hospital in good conditions.

Conclusion: Endo MIDCAB can be successfully performed in patients with single or even multi-vessel disease. Robotically enhanced endoscopic LIMA preparation using the Da Vinci system allows for atraumatic and safe preparation of the complete length of the vessel and for exact determination of the access site. Anastomosis can then safely be performed hand-sewn through an anterolateral MIDCAB incision thereby favourably reducing surgical trauma.