Use of bilateral internal thoracic arteries in CABG through lateral thoracotomy with robotic assistance in 150...

Internal thoracic arteries (ITA) have been shown to offer longer graft patency. Off-pump coronary artery bypass graft surgery (CABG) through small lateral thoracotomy has been reported. The present study deals with feasibility of using bilateral ITAs (BITA) in CABG through small lateral thoracotomy facilitated by the da Vinci robotic system.

Since July 2002, 150 patients underwent CABG through small lateral thoracotomy using robotic assistance for harvesting of BITA. After single lung ventilation, three 1- to 2-cm incisions were made in the third, fifth, and seventh intercostal spaces 2 to 3 cm medial to the anterior axillary line. After insertion of camera and instrument arms, both ITAs were harvested in a completely skeletonized fashion. A small anterolateral thoracotomy was done, enlarging the camera port incision. Distal anastomoses were performed on a beating heart using nitinol surgical clips. Intercostal cryoanalgesia and local anesthetic infusion were used for pain management.

Planned arterial revascularization was completed in 148 patients. Mean number of arterial grafts per patient was 2.6 +/- 0.8. All coronary arteries could be reached with BITA as in situ or composite grafts. There was no mortality, stroke, myocardial infarction, or wound infection. Seven patients had new onset atrial fibrillation. Four patients required exploration of postoperative bleeding. Mean postoperative length of stay was 3.6 +/- 2.9 days.

The da Vinci robotic system was found to be safe and feasible for BITA harvesting in multivessel CABG through small lateral thoracotomy. Further follow-up for graft patency is necessary. Postoperative pain may be reduced with aggressive management strategies. The approach offers fast recovery. This sternum-sparing approach may be an evolutionary step toward closed-chest coronary artery bypass graft surgery.