28. Robotic Coronary Artery Bypass Grafting

Elan A. Sherazee, MD and Bob Kiaii, MD
University of California Davis, Sacramento, CA, USA

Essential Operative Steps

  1. General double lumen endotracheal anesthesia or single lumen with endotracheal blocker
  2. Lines and monitoring
  3. Intraoperative TEE
  4. Place patient in a 30o right lateral decubitus position
  5. The left lung is deflated
  6. 7mm camera port inserted in the 4th or 5th intercostal space at the anterior axillary line
  7. 7mm working port inserted in the 2nd or 3rd intercostal space anterior to the anterior axillary line
  8. 7mm working port inserted in the 6th or 7th intercostal space anterior to the anterior axillary line
  9. The endoscopic ports are adapted to the da Vinci robotic system
  10. 5mm Airseal port inserted in the 7th intercostal space
  11. Using robotic assistance, the LIMA is harvested all the way from the 1st rib to the 6th rib
  12. All branches of the LIMA are controlled with electrocautery or clips as required
  13. Systemic heparinization
  14. The distal aspect of the LIMA is clipped and cut
  15. The pericardium is opened and the left anterior coronary is visualized
  16. The best intercostal space is marked to provide the best access to the LAD coronary artery
  17. The endoscopic instruments are removed, the robotic arms are detached, and the endoscopic ports are removed
  18. A non-rib spreading incision is made in the 4th intercostal space and a soft tissue retractor is placed
  19. The Octopus Nuvo stabilizer is inserted in the 5th intercostal space (typically the inferior port) stabilizing the left anterior
    descending coronary artery
  20. A silastic snare is placed proximally
  21. The LAD coronary artery is opened
  22. Using the LIMA, an end-to-side anastomosis is created manually using 7-0 or 8-0 prolene
  23. The pedicle of the LIMA is anchored to the surface of myocardium
  24. The flow through the artery is checked with using flow measuring device (ie. Transonic doppler) ultrasound
  25. The Octopus stabilizer is removed, and protamine is administered
  26. Two Blake drains are placed through the 7th and 5th intercostal space ports and lay in the left pleural cavity
  27. The 4th intercostal space incision is closed
  28. Hemostasis is confirmed and the lung is reinflated
  29. The intercostal space is infiltrated with liposomal Bupivacaine
  30. The incision is closed in layers

Potential Complications and Pitfalls
Hemostasis: Meticulous hemostasis must be maintained to avoid blood staining the tissue which makes the dissection more
difficult. Bleeding is often magnified on the robotic camera, gently holding pressure for 10 minutes with the tip of the robotic
instrument is usually adequate. Be patient. If bleeding continues and the source is clearly visible, apply a clip to the vessel and
cauterize the distal end or apply a 7-0 prolene suture if indicated. If bleeding is severe or the patient is hemodynamically
unstable, convert to a sternotomy.

Robotic-assisted takedown of the IMA:

A successful IMA harvest depends on appropriate patient selection. A preoperative CT of the chest is important to assess adequate space around the heart, normal position/axis of the heart, and an anteroposterior to transverse ratio >0.45 (<0.45 can compromise instrument maneuverability). The left subclavian artery may have a degree of stenosis but cannot be utilized if occluded.

Begin by scoring the pleura to uncover the artery. Then, start dissecting at the first rib and dissect from the known to unknown
location. The safe areas are on top of the ribs where no intercostal arteries are present. The landmark to end the LIMA dissection
is the bifurcation (around the 6th intercostal space). Clip branches on the artery side and use bipolar forceps on the chest wall
side. Be cautious of the following structures: the subclavian artery, left internal thoracic vein, and phrenic nerve.

Give systemic heparin and then place hemalock clips to control the vessel distally prior to transection. If the IMA is
skeletonized, as opposed to pedicled, there is more length but also a higher risk of conduit injury and the need for more clips
to manage branches.

To determine the optimal intercostal space to perform the thoracotomy for best exposure of the LAD, temporarily stop
insufflation to allow the mediastinum to return to a more normal anatomical location and insert a long needle under direct
visualization into the intercostal space.

Indications for robotic revascularization:

  1. Complex left anterior descending artery disease: ostial bifurcation, calcified, long lesions, and chronic occlusions
  2. Multivessel disease utilizing bilateral internal thoracic artery or hybrid technique (generally left IMA to LAD grafting
    plus percutaneous coronary intervention to non-LAD vessels)
  3. Distal left main disease when the left main and circumflex arteries could be stented after the LIMA has been grafted to
    the LAD
  4. High risk for open sternotomy approach

Absolute contraindications:

  1. Extensive pleural symphysis
  2. Previous left lung surgery

Relative Contraindications:

  1. Severe obesity
  2. Significant cardiac enlargement (insufficient space in the thoracic cavity)
  3. Thick chest wall
  4. Previous history of CABG
  5. Diffuse distal coronary disease
  6. Intramyocardial coronary arteries
  7. Severe pulmonary disease (intolerance to single-lung ventilation)

Template Dictation
Preoperative Diagnosis: [INDICATION: Coronary artery disease]
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed:

  1. Robot assisted harvest of LIMA
  2. Minimally invasive off pump beating heart coronary artery bypass x 1 (LIMA-LAD)
  3. Left anterior mini thoracotomy
  4. Intraoperative TEE
  5. Bilateral lower extremity vein mapping
  6. Multi-level left rib block with liposomal bupivacaine
  7. Evaluation of LIMA-LAD graft with flow probe device

Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] presented with New York Heart Association class [Class] and Canadian
Cardiovascular Society grade for angina [Class] symptoms.
Cardiac catheterization confirmed evidence of [XX]% left anterior descending disease and [XX]% obtuse marginal branch of
circumflex disease, and [XX]% right coronary artery disease.
The patient’s echocardiogram confirmed normal left ventricular function. CT scan of the chest confirmed suitability to undergo
robotic assisted surgical revascularization. After a team discussion with the cardiologists, the decision was made that the best
revascularization strategy would be a combined approach of performing a hybrid procedure which would include minimally
invasive robotic assisted surgical revascularization of their left anterior descending coronary artery with the left internal
mammary artery followed by percutaneous coronary intervention of the [right coronary artery/left main coronary artery
This was discussed with the patient and their family. The patient was fully aware of the risks versus anticipated benefits of
surgery and agreed to proceed with robotic assisted surgical revascularization of the LAD artery with the LIMA and then
percutaneous coronary intervention of the [right coronary artery/left main coronary etc]. The patient was taken to the
operating room on an elective basis.

Description of the Procedure: The patient was taken to the operating room on [DATE] and was placed upon the operating
room table in the supine position. The patient, procedure, and site were confirmed with all those present. General anesthesia
was administered, and the patient was intubated with a double lumen endotracheal tube. Preoperative antibiotics were
Monitoring was initiated with the following: Swan Ganz catheter via the right internal jugular vein, radial artery line,
continuous electrocardiography, TEE, foley catheter, and nasopharyngeal temperature probe.
Preoperative transesophageal echocardiogram was performed to evaluate cardiac and valve function.

The patient was positioned in a 30o right lateral decubitus position. The patient’s chest, abdomen, legs, and groin were prepped
and draped in the normal fashion. The left lung was then deflated. In the 5th intercostal space anterior to the anterior axillary
line, a 7mm port was inserted. The intrathoracic area was insufflated with carbon dioxide.

Under the direct visualization of the endoscope, two 7mm ports were inserted, one in the 3rd intercostal space and another in
the 7th intercostal space anterior to the anterior axillary line. The endoscopic ports were then adapted to the da Vinci
robotic System. In the 7th intercostal space, a 5 mm Airseal port was inserted for insufflation

Using robotic assistance, the left internal mammary artery was harvested all the way from the first rib to the sixth rib. All the
branches were controlled using electrocautery. After systemic heparinization, the distal aspect of the left internal thoracic artery
was clipped and cut. Next, the pericardium was opened, and the left anterior coronary was visualized. The 4th intercostal space
was shown to provide the best access to the left anterior descending coronary artery and was appropriately marked.
The endoscopic instruments were then removed. The robotic arms were then detached from the endoscopic ports, and the
endoscopic ports were removed.

In the 4th intercostal space, a small non rib spreading incision was made. The soft tissue retractor was then placed. The IMA
pedicle was identified, detached from the pericardium, and delivered through the incision. Two suspension sutures were placed
to prevent the pedicle from twisting. The IMA length and flow were assessed and found to be adequate for anastomosis. Next,
the Octopus Nuvo stabilizer (Medtronic) was inserted through the 5th intercostal space and stabilization of the left anterior
descending coronary artery was achieved. A silastic snare was placed proximally. The left anterior descending coronary was
opened. This artery measured about [BLANK]mm in diameter, with no disease at this location or distally. Using the left
internal mammary artery, an end-to-side anastomosis was fashioned using running 7-0 prolene suture. After completion of the
anastomosis, the pedicle of the left internal mammary artery was anchored to the surface of the myocardium. Next, the flow
through this artery was checked using doppler ultrasound and a flow of [BLANK]cc/min was confirmed. The Octopus
stabilizer was removed and protamine sulfate was administered. Next, a total of 2 Blake drains were inserted in the left pleural
cavity through the 7th and 5th intercostal space ports. The 4th intercostal space port was closed using interrupted 3-0 vicryl and
4-0 monocryl sutures.

With hemostasis confirmed in the left pleural cavity, the left lung was reinflated, and the intercostal space was infiltrated with
0.25% liposomal Bupivacaine. Next, the incision was closed by approximating the intercostal using 1-0 vicryl sutures, the deep
layer using 0 vicryl suture, the subcutaneous layer using 2-0 vicryl suture, and the skin layer using 4-0 monocryl subcuticular

Instrument, sponge, and needle counts were reported as being correct. The patient tolerated the procedure well, was transferred
to the ICU in stable condition, and extubated.

Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
Technical Data:

  1. LIMA harvest time: [BLANK] minutes
  2. Left anterior descending coronary artery: [BLANK]mm diameter with left internal thoracic artery graft using robotic
    assistance and off-pump technique
  3. LIMA with flow rate of [BLANK]cc/min
  4. Intraoperative cardiac catheterization showed [BLANK]

Figure 1: Port placement for robotic assisted coronary bypass grafting (Image by Dr. Sarah Chen, used with permission).

Multiple Choice Question(s)
What is an indication for robotic assisted coronary artery bypass grafting?

A. An isolated LAD lesion

B. Anteroposterior to transverse ratio <0.45

C. Previous left lung surgery

D. Diffuse distal coronary disease

E. Diffuse right coronary disease

Answer: A. Per the 2018 European Society of Cardiology/European Association for Cardiothoracic Surgery Guidelines on
myocardial revascularization, the indication for minimally invasive coronary artery bypass (which would include roboticassisted surgery) includes isolated LAD lesions or in the context of hybrid revascularization

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