Surg Today (2015) 45:1–7 DOI 10.1007/s00595-014-0961-x
REVIEW ARTICLE
Ultra-minimally invasive cardiac surgery: robotic surgery and awake CABG Norihiko Ishikawa • Go Watanabe
Received: 21 February 2013 / Accepted: 10 December 2013 / Published online: 2 October 2014 Ó Springer Japan 2014
Abstract The recognition of the significant advantages of minimizing surgical trauma has resulted in the development of minimally invasive surgical procedures. Endoscopic surgery confers the benefits of minimally invasive surgery upon patients, and surgical robots have enhanced the ability and precision of surgeons. Consequently, technological advances have facilitated totally endoscopic robotic cardiac surgery, which has allowed surgeons to operate endoscopically, rather than through a median sternotomy, during cardiac surgery. Thus, repairs for structural heart conditions, including mitral valve plasty, atrial septal defect closure, multivessel minimally invasive direct coronary artery bypass grafting and totally endoscopic coronary artery bypass graft surgery (CABG), can be totally endoscopic. On the other hand, general anesthesia remains a risk in patients who have severe carotid artery stenosis before surgery, as well as in those with a history of severe cerebral infarction or respiratory failure. In this study, the potential of a new awake CABG protocol using only epidural anesthesia was investigated for realizing day surgery and was found to be a promising modality for ultra-minimally invasive cardiac surgery. We herein review robot-assisted cardiac surgery and awake off-pump coronary artery bypass grafting as ultra-minimally invasive cardiac surgeries.
N. Ishikawa (&) G. Watanabe Department of General and Cardiothoracic Surgery, Kanazawa University, 13-1 Takara-machi, Kanazawa 920-8641, Japan e-mail: [email protected]
Keywords Endoscopy Da Vinci surgical system Anesthesia Awake surgery Robotic surgery
Robotic surgery Improvements in endoscopic surgery have resulted in the development of minimally invasive procedures for digestive surgery and urology. The success of closed-chest cardiopulmonary bypass (CPB) and cardioplegic arrest have stimulated the development of minimally invasive cardiac surgery [1]. Especially for repairs of structural heart disease, such as mitral valve surgery and congenital heart surgery, the minimally invasive approach is now universal. On the other hand, compared with coronary artery bypass graft surgery (CABG) using CPB, off-pump coronary artery bypass grafting (OPCAB) has reduced the incidence of various complications and factors that cause major morbidities [2]. However, most OPCAB proceeds via a full median sternotomy [3, 4]. Minimally invasive direct coronary artery bypass grafting (MIDCAB) with complete revascularization through a left lateral thoracotomy without CPB is less invasive, but MIDCAB has been limited to a single vessel because only one internal mammary artery can be harvested through a thoracotomy. Endoscopic surgery confers the benefit of minimally invasive surgery upon patients [5], but issues such as limited observation on a fixed two-dimensional (2D) monitor and the loss of instrumental freedom still need to be overcome. Surgical robots have been developed to enhance the surgical ability and precision by enabling intra-cardiac maneuvers, IMA harvesting and endoscopic anastomosis of the coronary artery. Thus, totally endoscopic repair of structural heart pathologies using techniques such as mitral valve plasty, atrial septal defect
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(ASD) closure, multivessel MIDCAB and totally endoscopic CABG have become a reality [6].
The da Vinci surgical system The da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA) comprises a surgeon’s console, a surgical cart and a vision cart. The surgeon at the console manipulates two master handles at the master remote console and is able to acquire high-resolution, binocular, three-dimensional, magnified views of surgical field equivalent to those obtained during open surgery. The system can be downscaled by adjusting the ratio of the motions of the handles to that of the surgical instruments, and a motion filter prevents unintended movements caused by human tremors. These technical advantages permit high-precision microsutures to be used in a deep surgical field through a small incision. The three generations of the da Vinci system (standard, S and Si; Fig. 1) are essentially the same, but the fourth arm in the da Vinci S system is uniquely equipped, and the vision system has been upgraded to a high-definition 3D monitor. The latest da Vinci Si system has dual-console capability to support training and collaboration, as well as a further enhanced high-definition
Fig. 1 The da Vinci surgical system
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vision system. The Ministry of Health, Labour and Welfare of Japan approved the da Vinci S and the da Vinci Si as medical devices for robotic thoracoscopic and laparoscopic procedures in 2009 and 2012, respectively, but they are not yet approved for cardiac surgical procedures.
Surgical techniques for structural heart diseases During ultra-minimally invasive cardiac surgery, patients are intubated for single-lung ventilation after general anesthesia is induced. Assisted bicaval venous drainage proceeds first like a minimally invasive cardiac surgery (MICS) procedure. The right internal jugular vein is cannulated, and the right femoral artery and vein are cannulated in the right groin. Cardiac arrest and myocardial protection are maintained using a transthoracic aortic cross-clamp. Intermittent antegrade cold blood cardioplegic solution is directly administered through the anterior chest via an angiocatheter. During totally endoscopic mitral valve repair, a rightsided approach is taken through one 12-mm port for the robotic camera, three 8-mm ports for the robotic instruments and atrial retractor and another 12-mm port for the delivery of sutures or the annuloplasty band. A transthoracic aortic cross-clamp is inserted through a 5-mm skin incision, and mitral valve plasty proceeds using standard techniques. The posterior leaflet lesion is resected and resutured, and the loop technique is applied to the anterior leaflet lesion using robotic instruments (Fig. 2). Annuloplasty bands are placed into the atrium with interrupted sutures for all patients.
Fig. 2 An intraoperative view of robot-assisted mitral valve plasty
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Totally endoscopic ASD closure The ultra-minimally invasive CPB setting is almost identical to that of mitral valve surgery, except for the need for an additional bicaval venous clamp. The right atrium is exposed using a retraction suture, never using a robotic atrial retractor. All ASD closures, such as direct closure or patch plasty with pericardium, proceed using standard techniques.
Surgical technique for ischemic heart disease When harvesting the IMA, the patients are intubated for single-lung ventilation under general anesthesia. A robotic camera port is created in the left chest, and carbon dioxide insufflation maintains the pressure between 6 and 12 mmHg before the robotic camera is introduced. Two more instrument ports are created for robotic instruments. The mediastinum is then separated from the chest wall, and the right IMA is harvested in a skeletonized fashion in a similar manner to that used during open surgery. The left IMA is then similarly dissected out. Similarly, coronary artery bypass surgery can be performed through a mini thoracotomy (ThoraCAB). After harvesting the IMA with robotic assistance, a 5- to 15-cm anterolateral thoracotomy is performed on the left anterior chest. The anastomotic maneuver used for the coronary artery is the same as that employed during the MIDCAB procedure. The distal anastomosis is hand sewn using a heart stabilizer, and multivessel anastomosis can be achieved during ThoraCAB. During totally endoscopic coronary artery bypass grafting (TECAB), we perform beating heart TECAB with U-clips (Medtronic, Minneapolis, MN, USA), as described by Srivastava et al. [7]. An EndoWrist stabilizer (Intuitive Surgical, Sunnyvale, CA, USA) is mounted on the fourth arm of the da Vinci via a fifth port placed below the xiphoid process. After securing the proximal and distal control of the target coronary artery, interrupted coronary anastomosis is achieved using robotic instruments and eight small U-clips (Fig. 3). For distal anastomosis, several methods have been reported. For example, Bonaros et al. [8] performed a running suture technique using 7-0 polypropylene sutures, and Balkhy et al. [9] used a coronary anastomotic connector (C-Port FREX A distal anastomotic device; Cardica, Redwood city, CA).
Awake CABG The low mortality and morbidity and good long-term outcomes conferred by CABG are superior even to those of
Fig. 3 An intraoperative view of totally endoscopic CABG
percutaneous coronary intervention (PCI). Moreover, OPCAB has been widely applied [22]. The Japanese outcomes have been extremely favorable, with low rates of mortality and complications such as cerebral infarction and renal failure [23]. Blomberg described using CABG to treat ischemic heart disease, with a focus on the coronary vasodilatory and sympathoinhibitory effects accompanying deeper thoracic epidural anesthesia (TEA) [24]. This approach should eliminate stress on the heart. We use TEA without general anesthesia, and have adopted an anterior approach to CABG. The feasibility of awake OPCAB accompanied by TEA for fast-track patient recovery is described below. Technique Anesthesia One day before surgery, an epidural catheter is placed at the T1–2 or T2–3 interspace. On the day of surgery, a mixture of 40 mL of 2 % lidocaine and 5 mg of fentanyl citrate is continuously infused via the epidural catheter to provide a sympathetic, motor and sensory block from the 6th cervical to the 8th thoracic level. Since general anesthesia is not used, the patient remains conscious, and surgery proceeds without endotracheal intubation. Surgical technique Single-vessel disease of the left anterior descending (LAD) coronary artery is treated using the rib cage lifting technique according to the method described by Karagoz et al. [25]. The left rib cage is lifted via a low partial sternotomy, and the IMA is anastomosed to the LAD. For patients with severe chronic obstructive lung disease, single-vessel bypass grafting proceeded without incising the pleural cavity, which reduced the risk of pneumothorax.
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Fig. 4 A completely conscious patient maintains spontaneous respiration during awake OPCAB surgery
Pneumothorax caused by damaged pleura represents the biggest obstacle to awake OPCAB, and Kato et al. [26] recently developed a novel technique using a biomaterial celled neo-pleura that decreases the risk of pneumothorax. During the procedure, the gastroepiploic artery (GEA) is harvested through a subxyphoid mini-incision and anastomosed to the LAD [27]. We apply the OPCAB technique for total revascularization via a full median sternotomy to treat multivessel disease (Fig. 4). The primary strategy is to anastomose the left IMA to the LAD branch. The left IMA is harvested using the skeletonization technique, and the radial artery (RA) serves as the second graft. The RA graft is harvested under either additional local anesthesia of the antebrachial region or an axillary block. The GEA serves as the third graft. A deep epidural block is sufficient for harvesting the GEA graft. Most patients have not reported pain even with stomach traction.
Comments Carpentier performed the first robotic mitral valve plasty using the da Vinci system in 1998. Mohr performed the first coronary anastomosis and mitral valve repair 1 week later, and Chitwood performed the first complete da Vinci mitral repair in North America in 2000. The robotic system is now commonly used for mitral valve surgery [10] that customarily proceeds through a small thoracotomy. However, totally endoscopic mitral valve plasty has recently become popular. Two Food and Drug Administration trials led to the approval of the da Vinci system for use during mitral valve surgery in the USA [11, 12]. Advances in 3D visualization and instrumentation have progressed to allow for totally endoscopic mitral procedures. These two series demonstrated that robotic mitral valve surgery is safe, has excellent short-term results and good mid-term durability.
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The application of robot-assisted coronary surgery ranges from IMA harvesting with a hand-sewn anastomosis (ThoraCAB), to TECAB performed either on- or off-pump. Loulmet demonstrated the feasibility of TECAB on an arrested heart using the da Vinci system in 1998, and Falk described the first off-pump TECAB in 2000. Srivastava reported the largest series of 150 ThoraCABs performed at a single institution. The short-term patency rates of OPCAB and conventional CABG are similar [13, 14]. In addition, OPCAB is associated with a reduced postoperative hospital stay, less blood and blood component usage and an earlier return to a normal lifestyle compared with CABG. Minimally invasive direct coronary artery bypass grafting (MIDCAB) confers all the benefits of OPCAB while avoiding the morbidity caused by a median sternotomy. However, MIDCAB is limited to single-vessel revascularization, because of the extensive length of the harvested left IMA. The bilateral IMA can be harvested less invasively via ThoraCAB aided by a surgical robot and multivessel bypass grafting can follow. While all of these reports have been encouraging, it should be kept in mind that these reports of robot-assisted coronary surgery have mostly involved carefully selected patient populations requiring limited revascularization, usually of the anterior wall. The indications for CABG and PCI for multivessel coronary artery disease remain controversial [15, 16]. Bonatti et al. described the feasibility and safety of simultaneous hybrid coronary revascularization [17], which might be an evolutionary step toward a hybrid procedure comprising PCI and ultra-minimally or minimally invasive CAG, such as ThoraCAB and TECAB. However, TECAB continues to pose many challenges, and various devices are being developed to overcome them. Surgical robots still have several limitations, specifically related of their use in cardiac surgery [18]. These include incomplete and delayed motion tracking, which might negatively affect the dexterity and the quality of a precise maneuver. However, a clear learning curve overcomes this problem. The lack of tactile feedback can also be an issue, but visual feedback can provide adequate information. The cost is another drawback; there are higher costs related to the purchase or the systems and instruments, as well as the maintenance of the system. However, this may be justified by the reductions in the patient hospital stay and morbidity. The system may require a longer time for the procedure; MIhaljevic et al. [19] reported a longer procedural time due to the complexity of robotic mitral valve plasty compared with median sternotomy and small thoracotomy. Robot-assisted cardiac surgery is now being performed in Japan at both Kanazawa University, the National Cerebral and Cardiovascular Center and at Tokyo Medical University. Kanazawa University introduced the da Vinci
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system in 2005 and started robotic surgery with IMA harvesting, and progressively developed robotic cardiac procedures. They had completed 170 surgeries by July 2013. The total number of procedures included 23 cases of IMA harvesting, 34 of ThoraCAB, eight of TWCAB, 56 of mitral valve plasty, 35 of ASD closure, 10 of cardiac tumor resection, five of mitral valve plasty?ASD closure and one case of mitral valve plasty?ThoraCAB. Our experience has shown that these procedures lead to a reduced hospital stay, less blood loss and a lower rate of complications than conventional procedures [20, 21]. In Japan, the application of the da Vinci surgical system for cardiac surgery has not been approved, probably because the efficacy of robotic cardiac surgery is still controversial, and because endoscopic cardiac surgery has not yet been approved. A robotassisted cardiac surgery clinical trial with the aim of gaining approval from the Ministry of Health, Labour and Welfare of Japan is presently underway at both Kanazawa University and the National Cerebral and Cardiovascular Center. As of September 2013, 35 consecutive patients had undergone ThoraCAB at Kanazawa University. Successful robot-assisted IMA harvesting was achieved in all patients. There was an average of 1.7 ± 0.8 grafts (range one to three grafts) per patient. No patient needed mechanical ventilation for more than 24 h. There were no deaths, strokes or myocardial infarctions, and none of the patients required conversion to median sternotomy. On the other hand, TECAB was performed in five patients at our institute during the same period, and there were similarly no deaths, strokes or myocardial infarctions, nor any other complications in these patients. Seventy-two (5.7 %) of the 1260 patients who underwent OPCAB via an anterior approach at our institution between March 2003 and May 2009, provided their informed consent to undergo awake OPCAB [28, 29]. In 67 of these 72 patients (93 %), awake OPCAB with full consciousness and spontaneous breathing was accomplished. Five patients had to be administered general anesthesia. Ten patients (14.9 %) were able to leave the operating room in a wheelchair. The time to drink water, the time to walk and the hospital stay were significantly shorter in the awake OPCAB group than in the general anesthesia group. There were no surgical or postoperative complications or deaths. Karagoz has described the advantages of awake OPCAB [25, 30], and Chakravarthy reported conscious cardiac surgery with cardiopulmonary bypass using TEA [32]. The aims with regard to the hemodynamics are to depress the heart rate and blood pressure and stabilize the cardiac function after blocking the sympathetic nerve cardiac branch. This creates an essentially stress-free situation for the patients during the procedure. Accordingly, the cardiac
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oxygen consumption is decreased, and the coronary artery and IMA become dilated. With a focus on the vasodilatory effects and the inhibition of sympathetic nerve activity, TEA is the ideal type of anesthesia for CABG. Yashiki et al. [32] reported a lower incidence of postoperative atrial fibrillation in awake OPCAB compared with standard OPCAB with general anesthesia because of its vagal dominance. Furthermore, ensuring consciousness provides a good way to monitor the cerebral perfusion, which allows the early detection of neurological complications and enables appropriate treatment. Toda et al. [33] described the efficient management of intraoperative cerebral blood flow in awake OPCAB, and indicated that it was equally effective as a percutaneous coronary intervention. This procedure is effective for treating high-risk cerebral ischemia, cerebrovascular lesions and patients for whom general anesthesia should be avoided, such as those with respiratory insufficiency or a high probability of developing complications. The mechanism of cerebral blood flow autoregulation is impaired in patients with severe carotid artery stenosis, and cerebral infarction of the watershed type has occurred due to a blood pressure decrease during surgery [34]. Moreover, in patients with a history of severe cerebral infarction, general anesthesia might trigger impaired cognitive function. Yachi et al. [35] reported greater postoperative stability from the viewpoint of coagulability in awake OPCAB compared with standard OPCAB. In addition, patients with severe respiratory failure are at risk of respiratory complications with general anesthesia. The postoperative course of all of our patients was uneventful, thus supporting the notion that awake OPCAB is safe. In fact, the postoperative consciousness level after awake OPCAB was high enough for some patients to leave the operating room in a wheelchair (Fig. 5) and all of our patients could drink water, walk and return to a normal life
Fig. 5 An awake patient leaves the operating room in a wheelchair
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significantly sooner than after CABG under general anesthesia. Not only general surgery, but also cardiac surgical procedures such as MICS and OPCAB have been performed with minimally invasive surgery. The MICS procedure and OPCAB can avoid the potential risks caused by full sternotomy and CPB. The robotic procedure is the one of new generation minimally invasive surgeries, and endoscopic cardiac surgery has become possible using this new innovative procedure. Awake OPCAB is another trend in minimally invasive surgery, and is accompanied by TEA, obviating the trauma associated with endotracheal intubation and general anesthesia. These procedures are promising modalities of ultra-minimally invasive cardiac surgery.
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7 pump coronary artery bypass. Asian Cardiovasc Thorac Ann. 2013;21:14–21. 34. Selnes OA, Goldsborough MA, Borowicz LM, McKhann GM. Neurobehavioural sequelae of cardiopulmonary bypass. Lancet. 1999;8:1601–6. 35. Yachi T, Watanabe G, Tomita S. Activation of coagulation and fibrinolysis after off-pump coronary artery bypass grafting with or without endotracheal general anesthesia. Innovations. 2010;5:444–9.
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REVIEW ARTICLE
Ultra-minimally invasive cardiac surgery: robotic surgery and awake CABG Norihiko Ishikawa • Go Watanabe
Received: 21 February 2013 / Accepted: 10 December 2013 / Published online: 2 October 2014 Ó Springer Japan 2014
Abstract The recognition of the significant advantages of minimizing surgical trauma has resulted in the development of minimally invasive surgical procedures. Endoscopic surgery confers the benefits of minimally invasive surgery upon patients, and surgical robots have enhanced the ability and precision of surgeons. Consequently, technological advances have facilitated totally endoscopic robotic cardiac surgery, which has allowed surgeons to operate endoscopically, rather than through a median sternotomy, during cardiac surgery. Thus, repairs for structural heart conditions, including mitral valve plasty, atrial septal defect closure, multivessel minimally invasive direct coronary artery bypass grafting and totally endoscopic coronary artery bypass graft surgery (CABG), can be totally endoscopic. On the other hand, general anesthesia remains a risk in patients who have severe carotid artery stenosis before surgery, as well as in those with a history of severe cerebral infarction or respiratory failure. In this study, the potential of a new awake CABG protocol using only epidural anesthesia was investigated for realizing day surgery and was found to be a promising modality for ultra-minimally invasive cardiac surgery. We herein review robot-assisted cardiac surgery and awake off-pump coronary artery bypass grafting as ultra-minimally invasive cardiac surgeries.
N. Ishikawa (&) G. Watanabe Department of General and Cardiothoracic Surgery, Kanazawa University, 13-1 Takara-machi, Kanazawa 920-8641, Japan e-mail: [email protected]
Keywords Endoscopy Da Vinci surgical system Anesthesia Awake surgery Robotic surgery
Robotic surgery Improvements in endoscopic surgery have resulted in the development of minimally invasive procedures for digestive surgery and urology. The success of closed-chest cardiopulmonary bypass (CPB) and cardioplegic arrest have stimulated the development of minimally invasive cardiac surgery [1]. Especially for repairs of structural heart disease, such as mitral valve surgery and congenital heart surgery, the minimally invasive approach is now universal. On the other hand, compared with coronary artery bypass graft surgery (CABG) using CPB, off-pump coronary artery bypass grafting (OPCAB) has reduced the incidence of various complications and factors that cause major morbidities [2]. However, most OPCAB proceeds via a full median sternotomy [3, 4]. Minimally invasive direct coronary artery bypass grafting (MIDCAB) with complete revascularization through a left lateral thoracotomy without CPB is less invasive, but MIDCAB has been limited to a single vessel because only one internal mammary artery can be harvested through a thoracotomy. Endoscopic surgery confers the benefit of minimally invasive surgery upon patients [5], but issues such as limited observation on a fixed two-dimensional (2D) monitor and the loss of instrumental freedom still need to be overcome. Surgical robots have been developed to enhance the surgical ability and precision by enabling intra-cardiac maneuvers, IMA harvesting and endoscopic anastomosis of the coronary artery. Thus, totally endoscopic repair of structural heart pathologies using techniques such as mitral valve plasty, atrial septal defect
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(ASD) closure, multivessel MIDCAB and totally endoscopic CABG have become a reality [6].
The da Vinci surgical system The da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA) comprises a surgeon’s console, a surgical cart and a vision cart. The surgeon at the console manipulates two master handles at the master remote console and is able to acquire high-resolution, binocular, three-dimensional, magnified views of surgical field equivalent to those obtained during open surgery. The system can be downscaled by adjusting the ratio of the motions of the handles to that of the surgical instruments, and a motion filter prevents unintended movements caused by human tremors. These technical advantages permit high-precision microsutures to be used in a deep surgical field through a small incision. The three generations of the da Vinci system (standard, S and Si; Fig. 1) are essentially the same, but the fourth arm in the da Vinci S system is uniquely equipped, and the vision system has been upgraded to a high-definition 3D monitor. The latest da Vinci Si system has dual-console capability to support training and collaboration, as well as a further enhanced high-definition
Fig. 1 The da Vinci surgical system
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vision system. The Ministry of Health, Labour and Welfare of Japan approved the da Vinci S and the da Vinci Si as medical devices for robotic thoracoscopic and laparoscopic procedures in 2009 and 2012, respectively, but they are not yet approved for cardiac surgical procedures.
Surgical techniques for structural heart diseases During ultra-minimally invasive cardiac surgery, patients are intubated for single-lung ventilation after general anesthesia is induced. Assisted bicaval venous drainage proceeds first like a minimally invasive cardiac surgery (MICS) procedure. The right internal jugular vein is cannulated, and the right femoral artery and vein are cannulated in the right groin. Cardiac arrest and myocardial protection are maintained using a transthoracic aortic cross-clamp. Intermittent antegrade cold blood cardioplegic solution is directly administered through the anterior chest via an angiocatheter. During totally endoscopic mitral valve repair, a rightsided approach is taken through one 12-mm port for the robotic camera, three 8-mm ports for the robotic instruments and atrial retractor and another 12-mm port for the delivery of sutures or the annuloplasty band. A transthoracic aortic cross-clamp is inserted through a 5-mm skin incision, and mitral valve plasty proceeds using standard techniques. The posterior leaflet lesion is resected and resutured, and the loop technique is applied to the anterior leaflet lesion using robotic instruments (Fig. 2). Annuloplasty bands are placed into the atrium with interrupted sutures for all patients.
Fig. 2 An intraoperative view of robot-assisted mitral valve plasty
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Totally endoscopic ASD closure The ultra-minimally invasive CPB setting is almost identical to that of mitral valve surgery, except for the need for an additional bicaval venous clamp. The right atrium is exposed using a retraction suture, never using a robotic atrial retractor. All ASD closures, such as direct closure or patch plasty with pericardium, proceed using standard techniques.
Surgical technique for ischemic heart disease When harvesting the IMA, the patients are intubated for single-lung ventilation under general anesthesia. A robotic camera port is created in the left chest, and carbon dioxide insufflation maintains the pressure between 6 and 12 mmHg before the robotic camera is introduced. Two more instrument ports are created for robotic instruments. The mediastinum is then separated from the chest wall, and the right IMA is harvested in a skeletonized fashion in a similar manner to that used during open surgery. The left IMA is then similarly dissected out. Similarly, coronary artery bypass surgery can be performed through a mini thoracotomy (ThoraCAB). After harvesting the IMA with robotic assistance, a 5- to 15-cm anterolateral thoracotomy is performed on the left anterior chest. The anastomotic maneuver used for the coronary artery is the same as that employed during the MIDCAB procedure. The distal anastomosis is hand sewn using a heart stabilizer, and multivessel anastomosis can be achieved during ThoraCAB. During totally endoscopic coronary artery bypass grafting (TECAB), we perform beating heart TECAB with U-clips (Medtronic, Minneapolis, MN, USA), as described by Srivastava et al. [7]. An EndoWrist stabilizer (Intuitive Surgical, Sunnyvale, CA, USA) is mounted on the fourth arm of the da Vinci via a fifth port placed below the xiphoid process. After securing the proximal and distal control of the target coronary artery, interrupted coronary anastomosis is achieved using robotic instruments and eight small U-clips (Fig. 3). For distal anastomosis, several methods have been reported. For example, Bonaros et al. [8] performed a running suture technique using 7-0 polypropylene sutures, and Balkhy et al. [9] used a coronary anastomotic connector (C-Port FREX A distal anastomotic device; Cardica, Redwood city, CA).
Awake CABG The low mortality and morbidity and good long-term outcomes conferred by CABG are superior even to those of
Fig. 3 An intraoperative view of totally endoscopic CABG
percutaneous coronary intervention (PCI). Moreover, OPCAB has been widely applied [22]. The Japanese outcomes have been extremely favorable, with low rates of mortality and complications such as cerebral infarction and renal failure [23]. Blomberg described using CABG to treat ischemic heart disease, with a focus on the coronary vasodilatory and sympathoinhibitory effects accompanying deeper thoracic epidural anesthesia (TEA) [24]. This approach should eliminate stress on the heart. We use TEA without general anesthesia, and have adopted an anterior approach to CABG. The feasibility of awake OPCAB accompanied by TEA for fast-track patient recovery is described below. Technique Anesthesia One day before surgery, an epidural catheter is placed at the T1–2 or T2–3 interspace. On the day of surgery, a mixture of 40 mL of 2 % lidocaine and 5 mg of fentanyl citrate is continuously infused via the epidural catheter to provide a sympathetic, motor and sensory block from the 6th cervical to the 8th thoracic level. Since general anesthesia is not used, the patient remains conscious, and surgery proceeds without endotracheal intubation. Surgical technique Single-vessel disease of the left anterior descending (LAD) coronary artery is treated using the rib cage lifting technique according to the method described by Karagoz et al. [25]. The left rib cage is lifted via a low partial sternotomy, and the IMA is anastomosed to the LAD. For patients with severe chronic obstructive lung disease, single-vessel bypass grafting proceeded without incising the pleural cavity, which reduced the risk of pneumothorax.
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Fig. 4 A completely conscious patient maintains spontaneous respiration during awake OPCAB surgery
Pneumothorax caused by damaged pleura represents the biggest obstacle to awake OPCAB, and Kato et al. [26] recently developed a novel technique using a biomaterial celled neo-pleura that decreases the risk of pneumothorax. During the procedure, the gastroepiploic artery (GEA) is harvested through a subxyphoid mini-incision and anastomosed to the LAD [27]. We apply the OPCAB technique for total revascularization via a full median sternotomy to treat multivessel disease (Fig. 4). The primary strategy is to anastomose the left IMA to the LAD branch. The left IMA is harvested using the skeletonization technique, and the radial artery (RA) serves as the second graft. The RA graft is harvested under either additional local anesthesia of the antebrachial region or an axillary block. The GEA serves as the third graft. A deep epidural block is sufficient for harvesting the GEA graft. Most patients have not reported pain even with stomach traction.
Comments Carpentier performed the first robotic mitral valve plasty using the da Vinci system in 1998. Mohr performed the first coronary anastomosis and mitral valve repair 1 week later, and Chitwood performed the first complete da Vinci mitral repair in North America in 2000. The robotic system is now commonly used for mitral valve surgery [10] that customarily proceeds through a small thoracotomy. However, totally endoscopic mitral valve plasty has recently become popular. Two Food and Drug Administration trials led to the approval of the da Vinci system for use during mitral valve surgery in the USA [11, 12]. Advances in 3D visualization and instrumentation have progressed to allow for totally endoscopic mitral procedures. These two series demonstrated that robotic mitral valve surgery is safe, has excellent short-term results and good mid-term durability.
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The application of robot-assisted coronary surgery ranges from IMA harvesting with a hand-sewn anastomosis (ThoraCAB), to TECAB performed either on- or off-pump. Loulmet demonstrated the feasibility of TECAB on an arrested heart using the da Vinci system in 1998, and Falk described the first off-pump TECAB in 2000. Srivastava reported the largest series of 150 ThoraCABs performed at a single institution. The short-term patency rates of OPCAB and conventional CABG are similar [13, 14]. In addition, OPCAB is associated with a reduced postoperative hospital stay, less blood and blood component usage and an earlier return to a normal lifestyle compared with CABG. Minimally invasive direct coronary artery bypass grafting (MIDCAB) confers all the benefits of OPCAB while avoiding the morbidity caused by a median sternotomy. However, MIDCAB is limited to single-vessel revascularization, because of the extensive length of the harvested left IMA. The bilateral IMA can be harvested less invasively via ThoraCAB aided by a surgical robot and multivessel bypass grafting can follow. While all of these reports have been encouraging, it should be kept in mind that these reports of robot-assisted coronary surgery have mostly involved carefully selected patient populations requiring limited revascularization, usually of the anterior wall. The indications for CABG and PCI for multivessel coronary artery disease remain controversial [15, 16]. Bonatti et al. described the feasibility and safety of simultaneous hybrid coronary revascularization [17], which might be an evolutionary step toward a hybrid procedure comprising PCI and ultra-minimally or minimally invasive CAG, such as ThoraCAB and TECAB. However, TECAB continues to pose many challenges, and various devices are being developed to overcome them. Surgical robots still have several limitations, specifically related of their use in cardiac surgery [18]. These include incomplete and delayed motion tracking, which might negatively affect the dexterity and the quality of a precise maneuver. However, a clear learning curve overcomes this problem. The lack of tactile feedback can also be an issue, but visual feedback can provide adequate information. The cost is another drawback; there are higher costs related to the purchase or the systems and instruments, as well as the maintenance of the system. However, this may be justified by the reductions in the patient hospital stay and morbidity. The system may require a longer time for the procedure; MIhaljevic et al. [19] reported a longer procedural time due to the complexity of robotic mitral valve plasty compared with median sternotomy and small thoracotomy. Robot-assisted cardiac surgery is now being performed in Japan at both Kanazawa University, the National Cerebral and Cardiovascular Center and at Tokyo Medical University. Kanazawa University introduced the da Vinci
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system in 2005 and started robotic surgery with IMA harvesting, and progressively developed robotic cardiac procedures. They had completed 170 surgeries by July 2013. The total number of procedures included 23 cases of IMA harvesting, 34 of ThoraCAB, eight of TWCAB, 56 of mitral valve plasty, 35 of ASD closure, 10 of cardiac tumor resection, five of mitral valve plasty?ASD closure and one case of mitral valve plasty?ThoraCAB. Our experience has shown that these procedures lead to a reduced hospital stay, less blood loss and a lower rate of complications than conventional procedures [20, 21]. In Japan, the application of the da Vinci surgical system for cardiac surgery has not been approved, probably because the efficacy of robotic cardiac surgery is still controversial, and because endoscopic cardiac surgery has not yet been approved. A robotassisted cardiac surgery clinical trial with the aim of gaining approval from the Ministry of Health, Labour and Welfare of Japan is presently underway at both Kanazawa University and the National Cerebral and Cardiovascular Center. As of September 2013, 35 consecutive patients had undergone ThoraCAB at Kanazawa University. Successful robot-assisted IMA harvesting was achieved in all patients. There was an average of 1.7 ± 0.8 grafts (range one to three grafts) per patient. No patient needed mechanical ventilation for more than 24 h. There were no deaths, strokes or myocardial infarctions, and none of the patients required conversion to median sternotomy. On the other hand, TECAB was performed in five patients at our institute during the same period, and there were similarly no deaths, strokes or myocardial infarctions, nor any other complications in these patients. Seventy-two (5.7 %) of the 1260 patients who underwent OPCAB via an anterior approach at our institution between March 2003 and May 2009, provided their informed consent to undergo awake OPCAB [28, 29]. In 67 of these 72 patients (93 %), awake OPCAB with full consciousness and spontaneous breathing was accomplished. Five patients had to be administered general anesthesia. Ten patients (14.9 %) were able to leave the operating room in a wheelchair. The time to drink water, the time to walk and the hospital stay were significantly shorter in the awake OPCAB group than in the general anesthesia group. There were no surgical or postoperative complications or deaths. Karagoz has described the advantages of awake OPCAB [25, 30], and Chakravarthy reported conscious cardiac surgery with cardiopulmonary bypass using TEA [32]. The aims with regard to the hemodynamics are to depress the heart rate and blood pressure and stabilize the cardiac function after blocking the sympathetic nerve cardiac branch. This creates an essentially stress-free situation for the patients during the procedure. Accordingly, the cardiac
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oxygen consumption is decreased, and the coronary artery and IMA become dilated. With a focus on the vasodilatory effects and the inhibition of sympathetic nerve activity, TEA is the ideal type of anesthesia for CABG. Yashiki et al. [32] reported a lower incidence of postoperative atrial fibrillation in awake OPCAB compared with standard OPCAB with general anesthesia because of its vagal dominance. Furthermore, ensuring consciousness provides a good way to monitor the cerebral perfusion, which allows the early detection of neurological complications and enables appropriate treatment. Toda et al. [33] described the efficient management of intraoperative cerebral blood flow in awake OPCAB, and indicated that it was equally effective as a percutaneous coronary intervention. This procedure is effective for treating high-risk cerebral ischemia, cerebrovascular lesions and patients for whom general anesthesia should be avoided, such as those with respiratory insufficiency or a high probability of developing complications. The mechanism of cerebral blood flow autoregulation is impaired in patients with severe carotid artery stenosis, and cerebral infarction of the watershed type has occurred due to a blood pressure decrease during surgery [34]. Moreover, in patients with a history of severe cerebral infarction, general anesthesia might trigger impaired cognitive function. Yachi et al. [35] reported greater postoperative stability from the viewpoint of coagulability in awake OPCAB compared with standard OPCAB. In addition, patients with severe respiratory failure are at risk of respiratory complications with general anesthesia. The postoperative course of all of our patients was uneventful, thus supporting the notion that awake OPCAB is safe. In fact, the postoperative consciousness level after awake OPCAB was high enough for some patients to leave the operating room in a wheelchair (Fig. 5) and all of our patients could drink water, walk and return to a normal life
Fig. 5 An awake patient leaves the operating room in a wheelchair
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significantly sooner than after CABG under general anesthesia. Not only general surgery, but also cardiac surgical procedures such as MICS and OPCAB have been performed with minimally invasive surgery. The MICS procedure and OPCAB can avoid the potential risks caused by full sternotomy and CPB. The robotic procedure is the one of new generation minimally invasive surgeries, and endoscopic cardiac surgery has become possible using this new innovative procedure. Awake OPCAB is another trend in minimally invasive surgery, and is accompanied by TEA, obviating the trauma associated with endotracheal intubation and general anesthesia. These procedures are promising modalities of ultra-minimally invasive cardiac surgery.
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