Robotic Multivessel Totally Endoscopic Coronary Artery Bypass for Advanced Hybrid Coronary Revascularization

In this new CTSNet President’s Series, Dr. Husam Balkhy, president of ISMICS, showcases cutting-edge, totally endoscopic cardiac procedures from the University of Chicago. Watch for more videos in this series coming soon.  

A fifty-two-year-old patient with triple vessel disease (TVD) involving the left anterior descending artery (LAD), diagonal branch (D), left circumflex artery (LCX) and right coronary artery (RCA) was positioned in the supine position with a roll placed under the left chest. General anesthesia was induced using a single-lumen endotracheal tube with a left bronchial blocker. With both lungs deflated, CO2 was insufflated by a blunt needle into the left pleural space to create a pneumothorax. A 12 mm camera port was inserted into the fourth intercostal space. A 8 mm right arm port was inserted into the second intercostal space, and an 8 mm left arm port was inserted into the sixth intercostal space under direct camera vision.  

The da Vinci Si was docked from the right side of the patient. Posterior and anterior pericardiotomies were made to expose the target arteries. The right and left internal thoracic arteries (ITAs) were harvested in a skeletonized fashion. A 12 mm robotic port was placed in the left subcostal area, and the EndoWrist Stabilizer was introduced. A 12 mm AirSeal port was placed in the left anterior second intercostal space. The LAD and obtuse marginal (OM) were exposed, and the surfaces of the arteries were dissected using low-energy electrocautery. Silastic snares were placed around the vessels.  

After systemic heparinization, the ITAs were transected. The LAD was exposed and temporarily occluded for myocardial ischemic preconditioning to check the tolerance for ischemia. After four minutes of ischemic preconditioning, the snare was released. The left internal thoracic artery (LITA) was anastomosed to the LAD using a short 7-0 Pronova running suture in an end-to-side configuration. The graft flow was measured using a flexible transit-time flowmetry probe. The diagonal branch was then exposed, and a silastic snare was circled around it. The LITA was anastomosed to the diagonal branch in a side-to-side configuration.  

The pericardium was closed using a V-loc suture. The heart was gently lifted with the EndoWrist Stabilizer without any hemodynamic compromise. The OM was exposed, and an end-to-side anastomosis was made between the right internal thoracic artery (RITA) and the OM using a short 7-0 Pronova running suture. After the EndoWrist Stabilizer was gently released, the graft flow was measured.  

The postoperative course was uneventful, and the patient was discharged on postoperative day two without any complications. A follow-up coronary angiogram showed patent LITA and RITA grafts. A percutaneous coronary intervention (PCI) was performed for the RCA.  

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