Robotic-Assisted Minimally Invasive Bypass Grafting: Clipless Technique for Internal Thoracic Artery Harvesting

Introduction 

This video shows a clipless technique for internal thoracic artery harvesting during robotic-assisted coronary artery bypass. 

Patient Data  

A 49-year-old male presented to the authors  with stable angina. Coronary angiography revealed double vessel disease involving the proximal left anterior descending artery (LAD) and circumflex artery. The Heart Team made the decision to proceed with hybrid revascularization. 

Patient Setup 

The patient was in the supine position, and intercostal spaces were marked for reference. CO₂ was insufflated into the left pleural cavity to collapse the left lung before the insertion of the 3D camera and working port. The 3D camera port was positioned at the fourth intercostal space, while the two working ports (for scalpel and bipolar forceps) were placed at the second and sixth intercostal spaces, respectively.  

Pericardial Opening and Target Visualization 

Before proceeding with left internal thoracic artery (LITA) harvesting, the authors suggested performing a pericardial window 2 cm below the phrenic nerve to evacuate pericardial fluid. Then, an anterior pericardiotomy was performed to visualize LAD target for revascularization. If a large fat pad is present, the authors suggest mobilizing it laterally. 

Clipless LITA Harvesting  

In the first step of LITA harvesting, the endothoracic fascia was opened distally to visualize the internal thoracic artery. This maneuver was continued until the distal end was reached. In the second step, the endothoracic fascia was opened from the distal to proximal end until the phrenic pedicle was visualized. The third step involved separating the internal thoracic artery from the medial satellite vein; the authors suggest sliding the micro-bipolar forceps on the vein itself, again from the distal to proximal end. 

In the fourth step, the thoracic artery was fully separated anteriorly from the thoracic vein and superiorly from the thoracic wall. This step was completed first with superficial bites, dividing the LITA from the lateral satellite vein, followed by completely separating LITA from the surrounding tissues. A spatula in the right arm gently pulled the LITA down to enhance visualization of the side branches. In the final step, the LITA was ligated with endoscopic clips and separated with bipolar forceps. A bulldog clamp was used to easily recover the LITA when divided. If available, the same maneuver can be completed using robotic scissors or disposable endoscopic scissors. 

LITA-LAD Anastomosis

A small left-anterior thoracotomy was made at the fourth intercostal space.  A soft-tissue retractor and costal-retractor were positioned, and a vacuum coronary stabilizer was then introduced from the former working port incision at the sixth intercostal space. The LAD was opened with a beaver blade, and a 1.75 mm shunt was inserted into the lumen before performing the anastomosis. The anastomosis of the internal thoracic artery to the LAD was completed using a continuous 8-0 polypropylene suture. 

Postoperative coronary angiography performed for the second step of hybrid revascularization showed the patency of the LITA-LAD graft. 

References

1. Rosati F, Baudo M, Di Bacco L, Oosterlinck W, Torregrossa G, Tomasi C, Boldini F, Muneretto C, Benussi S. Patient complexity does not affect surgical learning curve and clinical outcomes during early experience in robotic assisted coronary surgery. J Robot Surg. 2025 May 28;19(1):245
2. Aerden A, Marynissen M, Oosterlinck W, Haenen L, Deferm H, De Praetere H. Robotic-assisted MIDCAB procedure through a minithoracotomy: Step-by-step instructions. Multimed Man Cardiothorac Surg. 2022 Nov 4;2022

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