Robotic Pedicled LIMA Harvesting

This video submission is from the 2025 CTSNet Innovation Video Competition. Watch all entries from the competition, including the winning videos.   

Robotic harvesting of the left internal mammary artery (LIMA) in a pedicled fashion can offer optimal conduit quality while minimizing trauma to the vessel; however, achieving this safely and efficiently requires precise preoperative planning and attention to intraoperative ergonomics. In this video, the authors present a standardized approach that integrates 3D imaging, patient-specific modeling, and a stepwise robotic technique. 
 
The procedure began with preoperative electrocardiogram-gated computed tomography (CT) imaging, followed by 3D reconstruction and 3D printing of a patient-specific chest model. This allowed for a detailed assessment of the LIMA course, including tortuosity and caliber changes, and aided in planning the subsequent grafting phase to the left anterior descending artery (LAD). Additionally, the authors identified cutoff measurements predictive of difficult instrument access. 
 
The patient was positioned laterally, with the left shoulder and arm supported loosely to allow the upper limb to fall below the plane of the table, thereby reducing shoulder interference with the robotic arms. Long robotic trocars were used to maximize arm mobility while maintaining port geometry. The camera port is typically placed in the fourth or fifth intercostal space, with the working ports inserted under direct vision in a slightly linear arrangement. 
 
The harvest began with wide dissection of the thoracic fascia to avoid a tunnel-like approach, extending both cranially and caudally. Tension on the pedicle was minimized by freeing collaterals in the intercostal spaces via clipping and cautery, allowing the mammary to fall away from the chest wall by gravity. The long trocar in arm 2 can be adjusted externally or internally to accommodate sharp proximal angles or distal reach. 
 
For the proximal LIMA, the medial and thymic branches were identified and divided early to prevent steal phenomenon or vessel tethering. Because this area often contains dense mediastinal fat, the authors used a near-skeletonized approach proximally to enhance visualization of the vessel and its branches while keeping the artery under constant view. Distally, a major branch at the fifth to sixth intercostal space was routinely clipped, and the dissection continued to the bifurcation, which was divided. Hemostasis was confirmed at both the chest wall and port sites. 

Given emerging evidence suggesting possible long-term disadvantages of complete skeletonization, the pedicled approach is a safe and effective alternative in robotic surgery. It preserves conduit integrity and may reduce the risk of vessel trauma, particularly early in the learning curve. 

References

1. Wertan MC, Sicouri S, Yamashita Y, et al. Step-by-step technique of robotic-assisted minimally invasive direct coronary artery bypass. Ann Cardiothorac Surg. 2024;13(5):442-451. doi:10.21037/acs-2024-rcabg-0034
2. Zhang Z, Liu M, Liang S, et al. The application of 3D printing technology in minimally invasive coronary artery bypass. [preprint]. Posted June 6, 2025. doi:10.21203/rs.3.rs-6339716/v1
3. Shafiq A, Maniya MT, Duhan S, Jamil A, Hirji SA. Skeletonized versus pedicled harvesting of internal mammary artery: a systematic review and meta-analysis. Curr Probl Cardiol. 2024;49:102160.

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