Robotic-Assisted Three-Vessel Minimally Invasive Coronary Artery Bypass

The patient was a 77-year-old man who presented with progressive shortness of breath. Coronary angiography demonstrated significant proximal left anterior descending artery stenosis, proximal left circumflex artery stenosis, and posterior descending artery stenosis. Given the extent of disease, robotic assisted minimally invasive coronary artery revascularization was planned. 

The procedure was performed entirely without cardiopulmonary bypass. The graft configuration was as follows: the left internal thoracic artery was grafted to the left anterior descending artery, while the right internal artery served as inflow for a no-touch saphenous vein composite I-graft, sequentially revascularizing the posterior descending artery and the ramus branch. 

The patient was positioned supine with slight elevation of the left chest. General anesthesia was induced, and a double-lumen endotracheal tube was placed to allow for one-lung ventilation. With both lungs deflated, a blunt needle was inserted into the left pleural space, and CO2 insufflation was initiated. An 8 mm camera port was placed in the fifth intercostal space at the anterior axillary line. The right robotic arm port was inserted in the third intercostal space, and the left robotic arm port was inserted in the sixth intercostal space.  

The robotic system was docked from the patient’s right side. The posterior and anterior pericardium was opened, and the target left anterior descending artery (LAD) was identified. Fat beneath the sternum was dissected, and the right pleural space was entered. The right internal thoracic artery was identified and harvested in a skeletonized fashion. After completing the distal dissection of the right internal thoracic artery, the left internal thoracic artery harvesting was performed in a similar fashion.  

After systemic heparinization, both internal thoracic arteries were clipped and divided distally. The robotic system was undocked, and all robotic ports were removed. A left anterolateral thoracotomy was performed in the fifth intercostal space. Papaverine solution was administered to the left internal thoracic artery, and pericardial stay sutures were placed to elevate the heart toward the incision. 

The left anterior descending artery was identified and stabilized. The anterior surface of the artery was dissected using low-energy electrocautery. A silastic snare was placed proximally. The target artery was occluded with the snare. A small coronary arteriotomy was made, and a 2 mm shunt was inserted into the artery to maintain distal perfusion and create a clear, non-blood operative field. An end-to-side anastomosis between the left internal thoracic artery and LAD was performed using a 7-0 Prolene continuous suture. A small right minithoracotomy was created in the second intercostal space. The right internal thoracic artery was brought out from the incision, and a no-touch saphenous vein graft was anastomosed end-to-end to the right internal thoracic artery, creating an I-composite graft. The composite graft was then returned to the chest and directed toward the left thoracotomy. 

Deep pericardial sutures were placed near the inferior vena cava (IVC) and the left lower pulmonary vein. The operative table was then moved to the  Trendelenburg position. A deep pericardial suture near the IVC was gently retracted toward the feet, elevating the apex toward the left shoulder and exposing  the posterior wall. The posterior descending artery was stabilized. A side-to-side anastomosis between the composite graft and the posterior descending artery (PDA) was performed using a 7-0 Prolene running suture. 

The table was then rotated toward the patient’s right side. A deep pericardial suture placed near the left pulmonary vein was retracted toward the patient’s left side, elevating the apex toward the right and exposing the lateral wall. The ramus branch was identified and stabilized. An end-to-side anastomosis between the composite graft and the ramus branch was performed using a 7-0 Prolene running suture. After protamine administration, intercostal cryoablation nerve blocks were performed for postoperative pain control. The patient was extubated in the operating room. The postoperative course was uneventful, and he was discharged on postoperative day five. 

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