Invited commentary

Abstract

Both early and late pain problems are among the reasons why some surgeons have abandoned the conventional MIDCABG procedure. Other surgeons continue to perform MIDCABG but combine it with endoscopic takedown of the internal thoracic artery. The present study supports the hypothesis that the endoscopic (and robotic) procedure significantly reduces postoperative pain. This is not due to the analgesic regimen because the patients who experienced the least pain also had the lowest postoperative consumption of analgesics, a fact that strengthens the conclusion of this article.Assessing pain is difficult. Although the authors have used an “objective” questionnaire and the VAS and VRS, there is still potential for bias depending on who is asking for enrollment and how; and also on who assesses pain postoperatively and how. In the present study this is partly overcome; for instance, the postoperative interviewer is blinded to the procedure of the patient. The study populations are also somewhat “unclean,” as the group with conventional MIDCABGs is a mixture of randomized and nonrandomized patients. It is not clear when the nonrandomized patients enrolled, if they were historical controls, how they were selected, and so forth. But in spite of some shortcomings in the study design, the conclusions of the paper appear to be solid: there is indeed a reduction in postoperative pain with endoscopic, robotic takedown of the LIMA.There are several reasons why this is an important paper. First, it has confirmed what everybody believed but without solid evidence: endoscopic LIMA takedown reduces pain. MIDCABG through the left anterior small thoracotomy should be combined with endoscopy. Second, the conclusions of the present paper have far wider importance than to just endoscopic surgery using robotics. Endoscopic takedown of the LIMA can also be performed by conventional endoscopic techniques. Third, postoperative quality of life is an important endpoint when different surgical techniques are evaluated; this may be even more important in the future. Some of the new minimally invasive techniques may not reduce classic endpoints such as mortality and early morbidity but may have significant influence on postoperative recovery and quality of life. And finally, improved postintervention quality of life is important when choosing between surgery or endovascular procedures. Both early and late pain problems are among the reasons why some surgeons have abandoned the conventional MIDCABG procedure. Other surgeons continue to perform MIDCABG but combine it with endoscopic takedown of the internal thoracic artery. The present study supports the hypothesis that the endoscopic (and robotic) procedure significantly reduces postoperative pain. This is not due to the analgesic regimen because the patients who experienced the least pain also had the lowest postoperative consumption of analgesics, a fact that strengthens the conclusion of this article. Assessing pain is difficult. Although the authors have used an “objective” questionnaire and the VAS and VRS, there is still potential for bias depending on who is asking for enrollment and how; and also on who assesses pain postoperatively and how. In the present study this is partly overcome; for instance, the postoperative interviewer is blinded to the procedure of the patient. The study populations are also somewhat “unclean,” as the group with conventional MIDCABGs is a mixture of randomized and nonrandomized patients. It is not clear when the nonrandomized patients enrolled, if they were historical controls, how they were selected, and so forth. But in spite of some shortcomings in the study design, the conclusions of the paper appear to be solid: there is indeed a reduction in postoperative pain with endoscopic, robotic takedown of the LIMA. There are several reasons why this is an important paper. First, it has confirmed what everybody believed but without solid evidence: endoscopic LIMA takedown reduces pain. MIDCABG through the left anterior small thoracotomy should be combined with endoscopy. Second, the conclusions of the present paper have far wider importance than to just endoscopic surgery using robotics. Endoscopic takedown of the LIMA can also be performed by conventional endoscopic techniques. Third, postoperative quality of life is an important endpoint when different surgical techniques are evaluated; this may be even more important in the future. Some of the new minimally invasive techniques may not reduce classic endpoints such as mortality and early morbidity but may have significant influence on postoperative recovery and quality of life. And finally, improved postintervention quality of life is important when choosing between surgery or endovascular procedures.