Srivastava Sudhir, Gadasalli Suresh, Agusala Madhava, Kolluru Ram, Naidu Jayaram, Shroff Manish, Barrera Reyna, Quismundo Shaune, Srivastava Vishwa
Cardiac Surgical Associates, Odessa, Texas, USA.
Ann Thorac Surg. 2006 Mar;81(3):800-6; discussion 806. doi: 10.1016/j.athoracsur.2005.08.044.
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.
已证实胸廓内动脉（ITA）可提供更长的移植物通畅率。已有报道通过小切口外侧开胸进行非体外循环冠状动脉旁路移植术（CABG）。本研究探讨在达芬奇机器人系统辅助下，经小切口外侧开胸行CABG时使用双侧胸廓内动脉（BITA）的可行性。
自2002年7月起，150例患者经小切口外侧开胸并在机器人辅助下获取BITA进行CABG。单肺通气后，于腋前线内侧2至3厘米处的第三、第五和第七肋间做三个1至2厘米的切口。插入摄像头和器械臂后，以完全骨骼化的方式获取双侧胸廓内动脉。做一个小的前外侧开胸切口，扩大摄像头端口切口。使用镍钛合金手术夹在跳动的心脏上进行远端吻合。采用肋间冷冻镇痛和局部麻醉药输注进行疼痛管理。
148例患者完成了计划的动脉血运重建。每位患者的平均动脉移植物数量为2.6±0.8。所有冠状动脉均可通过BITA作为原位或复合移植物到达。无死亡、中风、心肌梗死或伤口感染。7例患者新发房颤。4例患者需要探查术后出血情况。术后平均住院时间为3.6±2.9天。
在经小切口外侧开胸进行多支血管CABG获取BITA时发现，达芬奇机器人系统是安全可行的。有必要对移植物通畅情况进行进一步随访。积极的管理策略可能会减轻术后疼痛。该方法恢复快。这种保留胸骨的方法可能是向闭式胸廓冠状动脉旁路移植术迈出的进化一步。
