Invited Commentary

Abstract

This study by Kiaii and associates [1Kiaii B. McClure R.S. Stitt L. et al.Prospective angiographic comparison of direct, endoscopic and telesurgical approaches to harvesting the internal thoracic artery.Ann Thorac Surg. 2006; 82: 624-629Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar] evaluates the early patency rate of left internal thoracic artery (LITA) bypass grafts to the left anterior descending coronary artery after different harvesting protocols. The authors compare the results of 150 patients that underwent either a standard open direct take-down, or an endoscopic or robot-assisted (telesurgical) conduit harvest. All patients underwent off-pump surgery. By design, the study was nonrandomized, and selection bias for one or the other method cannot be excluded. This may explain the differences in age and gender among groups. The important finding of the study is that endoscopic or robot-assisted telesurgical harvest of the left internal thoracic artery (LITA) is safe and yields comparable patency rates compared with a standard open manual approach through a median sternotomy. In all groups, a sufficient length of conduit was harvested and no graft was injured during take-down. All grafts were patent intraoperatively as demonstrated by open graft flow and transit-time Doppler flow measurements after the anastomosis was performed. No conversions to an open technique were necessary in the endoscopic or robot-assisted group. Graft occlusions did occur postoperatively, however, as angiographic patency was 98% (49/50) on postoperative day 1 in both the open and endoscopic groups. It is of note that in the robot-assisted group, the angiographic follow-up was not complete (43/50, 86%), and two grafts were occluded (41/43) for a patency rate of 95%. All grafts were obviously patent intraoperatively, so postoperative occlusion may be attributable to factors other than the technique of take-down, such as quality of anastomosis, run-off, and quality of the target vessel, although secondary thrombosis owing to graft injury (ie, dissection) cannot be ruled out. Although the authors state that robotic assistance facilitates thoracoscopic take-down, this was not reflected in the actual time used for take-down in the present study, which was even prolonged in the robot-assisted group. This may be because the Zeus system that was used does not provide the same range of motion as current state-of-the-art telemanipulator technology. The technique of endoscopic LITA take-down was introduced a decade ago to facilitate graft take-down and avoid excessive rib spreading in minimally invasive bypass procedures performed through a small anterolateral minithoracotomy. The potential advantages of an endoscopic LITA harvest are less pain, better visualization, and better access to the proximal and distal portion of the graft [2Bucerius J. Metz S. Walther T. et al.Endoscopic internal thoracic artery dissection leads to significant reduction of pain after minimally invasive direct coronary artery bypass graft surgery.Ann Thorac Surg. 2002; 73: 1180-1184Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 3Duhaylongsod F.G. Mayfield W.R. Wolf R.K. Thoracoscopic harvest of the internal thoracic artery a multicenter experience in 218 cases.Ann Thorac Surg. 1998; 66: 1012-1017Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar]. However, the limitations of endoscopic surgery, such as monocular vision, limited dexterity, impaired hand-eye alignment, working with fulcrums, and impaired tactile feedback, as well as increased difficulties in the handling of complications such as bleeding and injury of the graft have prevented its widespread use. By contrast, current telemanipulation systems with stereoscopic vision and 6° of freedom for motion, allow for an easy endoscopic LITA take-down in 30 to 40 minutes. The authors are credited for once more demonstrating the safety of the endoscopic and robot-assisted approach for LITA harvest, which may further increase the acceptance of limited-access coronary bypass surgery—a surgical approach that can meet the interventional challenge [4Thiele H. Oettel S. Jacobs S. et al.Comparison of bare-metal stenting with minimally invasive bypas surgery for stenosis of the left anterior descending coronary artery 5 years follow up.Circulation. 2005; 112: 3445-3450Crossref PubMed Scopus (63) Google Scholar].