Endoscopic Coronary Artery Bypass
Robotic coronary unroofing incisions. Click to enlarge.
The robot can be used to bypass blocked or narrowed coronary arteries. Our favored approach is to use the robotic to perform the entire bypass procedure. The TECAB operation involves only small incisions (7-15mm) and is totally endoscopic. The internal mammary artery on the chest wall is detached from the chest and the anastomosis (the connection between the mammary artery to the blocked coronary artery to bring new blood to it) is done with the robotic instruments by the surgeon at the console. We usually use suture for this exactly the same way that would be done with traditional approaches. Due to the need for extensive training, experience, high-level teamwork, and major institutional support, the TECAB is performed by a relatively small number of surgical teams in the country. We have all of the above. The procedure can be performed either off-pump (no heart-lung machine) or on-pump (with the heart-lung machine) depending on the patient and anatomy. What is most important long term is that the anastomosis (connection) of the two vessels goes well!
Robotic Assisted Minimally Invasive Direct Coronary Artery Bypass (Robotic MIDCAB or ROBOCAB)
Incisions for robotic MIDCAB. Click to enlarge.
An alternative to the TECAB is a Robotic MIDCAB. In this procedure, the robot is used to detach the internal mammary artery off the chest wall and make it available to use as a bypass. A mini-thoracotomy is made on the anterior left chest under the breast and a standard handsewn connection is made, usually off-pump (without the heart-lung machine or stopping the heart or with the heart beating). This is a much easier procedure than a TECAB and may be better for some patients with anatomy not ideal for TECAB. Although the procedure usually is done for single vessel bypass, multivessel bypass can be performed or coronary stents used some vessels (hybrid approach, see below).
Hybrid TECAB/Robotic MIDCAB with Coronary Stenting
Our program now offers simultaneous Robotic TECAB or MIDCAB combined with stenting to other coronary arteries. This is done in a hybrid operating room that has all the capabilities of a cath lab and of an operating room. Most patients with coronary artery disease have multiple vessels involved. My feeling is that minimally invasive bypass surgery is most applicable to performing one vessel bypass (left internal mammary artery to left anterior descending coronary artery-the main artery on the front of the heart). This is the bypass graft with the best long term results which have been shown to be much more durable than stenting. Although there are programs that do additional bypasses minimally invasively and robotically, I feel these procedures take too long with little added benefit in patients who are appropriate for stents to those other vessels. Of course, this is just my opinion. The fact that we offer both the robotic bypass and the stent at the same time on the same day is unique. This approach also allows us to perform an angiogram on the surgical bypass graft to make sure it is working well.
