The 3rd hand – a simple but useful tool for beating heart total endoscopic coronary bypass grafting (BH-TECAB)
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《血管的通路杂志》
a Department of Cardiothoracic Surgery, Medical University Vienna, Wuahringer Gürtel 18-20, A-1090, Vienna, Austria
b Department of Cardiothoracic and Vascular Anaesthesia & Intensive Care, Medical University of Vienna, Wuahringer Gürtel 18-20, A-1090, Vienna, Austria
Abstract
The transition to totally endoscopic arterial bypass grafting (TECAB) by computer enhanced instrumentation systems brings the loss of an assisting hand for grasping the pedicle of the internal thoracic artery (ITA) and holding the threads, since only two robotic arms are positioned in the thoracic cavity. That is why exact planning of every step during surgery is mandatory. Especially the positioning of the IMA pedicle during beating heart procedures is imperative for friction-free workflow during the anastomosis. Stay sutures may partially overcome this problem. However, the pedicle hanging on stay sutures still tends to sway around, repositioning is limited. To aid in better workflow, we developed an easy-to-use and cheap holder for the IMA pedicle without the need of any additional port. By inserting a steel wire through the stabilizing system, the pedicle can be easily fixed onto it thus positioned and repositioned wherever it is needed during sewing the anastomosis.
Key Words: Da Vinci; Robotic surgery; TECAB; Beating heart
1. Introduction
Totally endoscopic coronary arterial bypass grafting (TECAB) by computer enhanced instrumentation systems is increasingly performed by several groups since 2000. The safety and effectiveness of the da Vinci surgical system (Intuitive Surgical, Mountain View, CA) is proven for arrested (AH), as well as beating heart (BH) TECAB [1,2]. The transition, however, from conventional surgery to total endoscopic procedures causes substantial changes in surgical procedure and operative workflow, which is caused mainly by the limited number of telemanipulator arms and thus resulting in a lack of assisting or holding moves.
In this report, we describe a simple and cheap, but effective method for having a third hand during suturing of the anastomosis during BH-TECAB without the need for an additional port.
2. Technique
For a BH-TECAB procedure performed by means of the da Vinci telemanipulator system (Intuitive Surgical, Mountain View, CA) 4 ports are inserted. One port is inserted at the 4th intercostal space in the anterior axillary line for the 30° scope and one at the 2nd and 6th intercostal space, respectively, slightly medially to the anterior axillary line, for the two surgical arms (Fig. 1). Once the left internal thoracic artery (ITA) is dissected free, a 4th port is made paraxyphoidal for insertion of the endostabilizer (Medtronic, Minneapolis, MN). The endostabilizer consists of a straight shaft and two shoes for stabilization. The back of the endostabilizer holds 2 ports for the EndoStabilizer Suction Lines and vacuum hoses (Medtronic, Minneapolis, MN) and 2 ports with Luer fittings. One of these is used for the Multi-link Irrigator (Medtronic, Minneapolis, MN) to provide clear vision on the anastomotic site.
The free 4th, which is usually closed, is then plugged with a regular Luer lock with a rubber membrane, like it is used on central venous catheters (Arrow International Inc, Reading, PA). Through this sealing membrane a monofil (CrNi) stainless steel wire size 5 (Ethicon, Johnson&Johnson Medical, St Stevens Woluwe, Belgium), used for closure of sternotomy, is inserted after cutting off the needle. Under direct vision, the steel wire is advanced into the thoracic cavity and positioned and bended by two large needle drivers (Intuitive Surgical, Mountain View, CA) as needed. The steel wire should be positioned 1 to 2 cm above the more medially (i.e. right) sided foot of the stabilizer. The ITA pedicle is then grasped and the left rim of the fascia fixed to the steel wire with two endoclips (Weck Hemoclip Traditional, Research Triangle Park, NC), thus serving as a 3rd hand (Fig. 2, Video 1).
Video 1. Video clip showing the positioning of the 3rd hand and the start of the anastomosis.
By bending the wire, the rim of the ITA can easily be positioned side to side to the opened LAD as desired. The two instrument arms can now be solely used for sewing the anastomosis with 7-0 Prolene 7 cm (Ethicon, Johnson &Johnson Medical, St Stevens Woluwe, Belgium). No further grasping of the ITA pedicle is needed to keep it still in comparison to the moving surrounding.
3. Discussion
During implementation of a robotic program, the learning curve constantly decreases the procedure time in TECAB surgery [3,4]. However, several differences compared to open coronary bypass surgery are evident. There is particularly one main limitation the surgeon has to cope with especially in beating heart TECAB surgery: As most of the existing da Vinci systems have only two arms, which are occupied by a forceps and the needle holder instruments, there is the lack of an assisting hand to hold the mammary artery pedicle from the inside as well as from the outside, as this would require the placement of additional ports.
Stay sutures can overcome this problem partially, but the pedicle still tends to move at every heartbeat until the first couple of stitches have been made.
A fourth robotic arm, which can be added to the da Vinci surgical system seems to be a promising tool. Especially during suturing of the anastomosis, the fourth arm was reported as a superb improvement [5]. However, the upgrade to a fourth armed system is rather expensive and an additional port is needed. That was the reason why we developed a cheaper method for holding the ITA pedicle without the need of an extra incision.
This new utility accomplishes, especially during the first stitches around the heel of the anastomosis, the two vessels to laying closely together avoiding any extra tension on the suture. The ITA pedicle can be parachuted to the LAD after the first stitches smoothly, reducing the risk for creating loops of the Prolene suture on the backside of the anastomosis. During the anastomosis, the steel wire can be bent to any position with large needle drivers. Prior to the last stitches at the tip of the anastomosis, the pedicle can easily be freed by pulling off the endoclips.
Acknowledgements
We acknowledge the sponsorship of the Karl Wlaschek Privatstiftung for purchasing the da Vinci system and adapting the operating theater. We are indebted to Tamara Esterer C.R.N., Anna Homolkova C.R.N. and Alex Strohmeier C.R.N. for their extra efforts and innovative approach.
References
Falk V, Diegeler A, Walther T, Banusch J, Brucerius J, Raumans J, Autschbach R, Mohr FW. Total endoscopic computer enhanced coronary artery bypass grafting. Eur J Cardiothorac Surg 2000; 17:38–45.
Mohr F, Falk V, Diegeler A, Walther T, Gummert JF, Bucerius J, Jacobs S, Autschbach R. Computer enhanced robotic cardiac surgery: experience in 148 patients. J Thorac Cardiovasc Surg 2001; 121:842–853.
Bonatti J, Schachner T, Bernecker O, Chevtchik O, Bonaros N, Ott H, Friedrich G, Weidinger F, Laufer G. Robotic totally endoscopic coronary artery bypass: program development and learning curve issues. J Thorac Cardiovasc Surg 2004; 127:504–510.
Jacobs S, Holzhey D, Kiaii BB, Onnasch JF, Walther T, Mohr FW, Falk V. Limitations for manual and telemanipulator assisted motion tracking-implications for endoscopic beating heart surgery. Ann Thorac Surg 2003; 76:2029–2035.
Dogan S, Aybek T, Risteski P, Mierdl S, Stein H, Herzog C, Khan MF, Dzemali O, Moritz A, Wimmer-Greinecker G. Totally endoscopic coronary artery bypass graft. Surg Endosc 2004; 18:1587–1591.(Wilfried Wisser, Tatjana )
b Department of Cardiothoracic and Vascular Anaesthesia & Intensive Care, Medical University of Vienna, Wuahringer Gürtel 18-20, A-1090, Vienna, Austria
Abstract
The transition to totally endoscopic arterial bypass grafting (TECAB) by computer enhanced instrumentation systems brings the loss of an assisting hand for grasping the pedicle of the internal thoracic artery (ITA) and holding the threads, since only two robotic arms are positioned in the thoracic cavity. That is why exact planning of every step during surgery is mandatory. Especially the positioning of the IMA pedicle during beating heart procedures is imperative for friction-free workflow during the anastomosis. Stay sutures may partially overcome this problem. However, the pedicle hanging on stay sutures still tends to sway around, repositioning is limited. To aid in better workflow, we developed an easy-to-use and cheap holder for the IMA pedicle without the need of any additional port. By inserting a steel wire through the stabilizing system, the pedicle can be easily fixed onto it thus positioned and repositioned wherever it is needed during sewing the anastomosis.
Key Words: Da Vinci; Robotic surgery; TECAB; Beating heart
1. Introduction
Totally endoscopic coronary arterial bypass grafting (TECAB) by computer enhanced instrumentation systems is increasingly performed by several groups since 2000. The safety and effectiveness of the da Vinci surgical system (Intuitive Surgical, Mountain View, CA) is proven for arrested (AH), as well as beating heart (BH) TECAB [1,2]. The transition, however, from conventional surgery to total endoscopic procedures causes substantial changes in surgical procedure and operative workflow, which is caused mainly by the limited number of telemanipulator arms and thus resulting in a lack of assisting or holding moves.
In this report, we describe a simple and cheap, but effective method for having a third hand during suturing of the anastomosis during BH-TECAB without the need for an additional port.
2. Technique
For a BH-TECAB procedure performed by means of the da Vinci telemanipulator system (Intuitive Surgical, Mountain View, CA) 4 ports are inserted. One port is inserted at the 4th intercostal space in the anterior axillary line for the 30° scope and one at the 2nd and 6th intercostal space, respectively, slightly medially to the anterior axillary line, for the two surgical arms (Fig. 1). Once the left internal thoracic artery (ITA) is dissected free, a 4th port is made paraxyphoidal for insertion of the endostabilizer (Medtronic, Minneapolis, MN). The endostabilizer consists of a straight shaft and two shoes for stabilization. The back of the endostabilizer holds 2 ports for the EndoStabilizer Suction Lines and vacuum hoses (Medtronic, Minneapolis, MN) and 2 ports with Luer fittings. One of these is used for the Multi-link Irrigator (Medtronic, Minneapolis, MN) to provide clear vision on the anastomotic site.
The free 4th, which is usually closed, is then plugged with a regular Luer lock with a rubber membrane, like it is used on central venous catheters (Arrow International Inc, Reading, PA). Through this sealing membrane a monofil (CrNi) stainless steel wire size 5 (Ethicon, Johnson&Johnson Medical, St Stevens Woluwe, Belgium), used for closure of sternotomy, is inserted after cutting off the needle. Under direct vision, the steel wire is advanced into the thoracic cavity and positioned and bended by two large needle drivers (Intuitive Surgical, Mountain View, CA) as needed. The steel wire should be positioned 1 to 2 cm above the more medially (i.e. right) sided foot of the stabilizer. The ITA pedicle is then grasped and the left rim of the fascia fixed to the steel wire with two endoclips (Weck Hemoclip Traditional, Research Triangle Park, NC), thus serving as a 3rd hand (Fig. 2, Video 1).
Video 1. Video clip showing the positioning of the 3rd hand and the start of the anastomosis.
By bending the wire, the rim of the ITA can easily be positioned side to side to the opened LAD as desired. The two instrument arms can now be solely used for sewing the anastomosis with 7-0 Prolene 7 cm (Ethicon, Johnson &Johnson Medical, St Stevens Woluwe, Belgium). No further grasping of the ITA pedicle is needed to keep it still in comparison to the moving surrounding.
3. Discussion
During implementation of a robotic program, the learning curve constantly decreases the procedure time in TECAB surgery [3,4]. However, several differences compared to open coronary bypass surgery are evident. There is particularly one main limitation the surgeon has to cope with especially in beating heart TECAB surgery: As most of the existing da Vinci systems have only two arms, which are occupied by a forceps and the needle holder instruments, there is the lack of an assisting hand to hold the mammary artery pedicle from the inside as well as from the outside, as this would require the placement of additional ports.
Stay sutures can overcome this problem partially, but the pedicle still tends to move at every heartbeat until the first couple of stitches have been made.
A fourth robotic arm, which can be added to the da Vinci surgical system seems to be a promising tool. Especially during suturing of the anastomosis, the fourth arm was reported as a superb improvement [5]. However, the upgrade to a fourth armed system is rather expensive and an additional port is needed. That was the reason why we developed a cheaper method for holding the ITA pedicle without the need of an extra incision.
This new utility accomplishes, especially during the first stitches around the heel of the anastomosis, the two vessels to laying closely together avoiding any extra tension on the suture. The ITA pedicle can be parachuted to the LAD after the first stitches smoothly, reducing the risk for creating loops of the Prolene suture on the backside of the anastomosis. During the anastomosis, the steel wire can be bent to any position with large needle drivers. Prior to the last stitches at the tip of the anastomosis, the pedicle can easily be freed by pulling off the endoclips.
Acknowledgements
We acknowledge the sponsorship of the Karl Wlaschek Privatstiftung for purchasing the da Vinci system and adapting the operating theater. We are indebted to Tamara Esterer C.R.N., Anna Homolkova C.R.N. and Alex Strohmeier C.R.N. for their extra efforts and innovative approach.
References
Falk V, Diegeler A, Walther T, Banusch J, Brucerius J, Raumans J, Autschbach R, Mohr FW. Total endoscopic computer enhanced coronary artery bypass grafting. Eur J Cardiothorac Surg 2000; 17:38–45.
Mohr F, Falk V, Diegeler A, Walther T, Gummert JF, Bucerius J, Jacobs S, Autschbach R. Computer enhanced robotic cardiac surgery: experience in 148 patients. J Thorac Cardiovasc Surg 2001; 121:842–853.
Bonatti J, Schachner T, Bernecker O, Chevtchik O, Bonaros N, Ott H, Friedrich G, Weidinger F, Laufer G. Robotic totally endoscopic coronary artery bypass: program development and learning curve issues. J Thorac Cardiovasc Surg 2004; 127:504–510.
Jacobs S, Holzhey D, Kiaii BB, Onnasch JF, Walther T, Mohr FW, Falk V. Limitations for manual and telemanipulator assisted motion tracking-implications for endoscopic beating heart surgery. Ann Thorac Surg 2003; 76:2029–2035.
Dogan S, Aybek T, Risteski P, Mierdl S, Stein H, Herzog C, Khan MF, Dzemali O, Moritz A, Wimmer-Greinecker G. Totally endoscopic coronary artery bypass graft. Surg Endosc 2004; 18:1587–1591.(Wilfried Wisser, Tatjana )