Suturing and knotting techniques for thoracoscopic cardiac surgery

The preceding description of E-CABG may seem excessively detailed, even redundant, for trained cardiac surgeons; however, the authors' extensive experience with training surgeons on endoscopic techniques suggests that, despite a high level of proficiency and dexterity that a surgeon may possess in open surgery, becoming equally proficient and dexterous in the endoscopic environment is not simple. Participating in an in-depth, systematic endoscopic microvascular surgery training program in a laboratory setting is essential before applying the previously described E-CABG techniques in humans. The E-CABG procedure is one of the most challenging endoscopic techniques. Successful completion of this procedure requires that the surgeon be motivated to succeed and willing to invest the time and effort necessary to develop the new skills. Also critical is the avoidance of the temptation to use devices and systems that promise to obviate the need to bother with learning these difficult endoscopic skills. Long term results of the minimally invasive approach remain to be defined. However, some early studies of port-access procedures are encouraging. To date, a prospective randomized clinical trial comparing conventional LAD bypass to E-CABG has not been conducted. Although most investigators believe that long term patency of the IMA to the LAD using either technique should be the same, this is as yet unproven. Nonetheless, the adaption of endoscopic skills by the cardiac surgeon will further advance the evolution of this specialty.