Interactive Cardiovascular and Thoracic Surgery 2:87-90(2003)
© 2003 European Association of Cardio-Thoracic Surgery
A unilateral approach to bilateral thoracoscopic internal mammary artery harvesting
Thomas A. Vassiliades, Jr*
The Pensacola Heart Institute, 5151 North Ninth Avenue, Suite 200, Pensacola, FL 32504, USA
* Tel.: +1-850-857-1734; fax: +1-850-857-1745
vassiliades{at}pol.net
Received September 11, 2002;
received in revised form November 12, 2002;
accepted November 19, 2002
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Abstract
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A technique of harvesting both internal mammary arteries thoracoscopically using three unilateral ports is described. Bilateral thoracoscopic internal mammary artery (IMA) harvesting was performed using a unilateral approach in 18 patients. The mean harvest time for harvesting was 52.3±17.5 min for the contralateral LIMA and 35.6±6.7 min for the ipsilateral RIMA. The mean free flow for the 36 harvested arteries was 58.7±13.6 cc/min. Bilateral thoracoscopic IMA harvesting, from a single side, is safe and reproducible. Satisfactory length of both arterial conduits can be obtained with half the ports and in less time than harvesting from each side.
Key Words: Thoracoscopy; Coronary artery bypass
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1. Introduction
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Since the first clinical reports of thoracoscopic internal mammary artery harvesting [1-4], this essential tool of the minimally invasive cardiac surgeon has undergone much technical iteration [5–9]. A technique for thoracoscopic harvesting of both internal mammary arteries from a unilateral approach is described.
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2. Materials and methods
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As part of a multi-vessel endoscopic atraumatic coronary artery bypass (endoACAB) procedure, 18 patients over the course of 6 months underwent bilateral thoracoscopic internal mammary artery (IMA) harvesting using three right-sided ports. Informed consent was obtained in all patients. Patients were selected based on the following criteria: multi-vessel coronary artery disease with an ejection fraction of at least 30%, the absence of severe pulmonary disease ( predicted) or previous chest surgery and a body mass index (BMI) of  . Our technique of thoracoscopic IMA harvesting has been previously described in detail [10]. Patients were intubated using a double-lumen endotracheal tube allowing deflation of either lung during the procedure. The ports were placed in the third, fifth and seventh intercostal spaces between the mid and anterior axillary lines. The third intercostal port also functioned as a fourth intercostal port when dissecting the distal end of the IMA. Before beginning the IMA dissection, the mediastinal attachments from the heart to the underside of the sternum were divided. The left pleural space was then opened. With the endoscope, the grasper and the cautery advanced past the midline, the ventilation was changed from left to right lung. The exposure and dissection of the left IMA (LIMA) was performed first. Dissection was nearly identical to the open technique and was accomplished using an endoscopic grasper (Computer Motion Inc., Goleta, CA, USA) and an electrocautery with an accompanying smoke evacuator (Genzyme Corp., Cambridge, MA, USA). After completely harvesting the LIMA, the right lung was deflated and the left lung was once again ventilated. With the endoscopic instruments pulled back into the right pleural space, the RIMA was harvested (Fig. 1). The pericardium was opened thoracoscopically and the target coronary arteries were clearly identified. Placement of the incision(s) was determined by dropping a finder probe through the skin toward the anticipated anastomotic site. All 40 anastomoses were performed through a non-rib-spreading, muscle-sparing mini-thoracotomy under direct vision using an off-pump technique. Adequate free flow and anastomotic patency were verified intra-operatively using the transit time technique (Medistim butterfly flow probe, Medtronic, Minneapolis, MN, USA). Grafts were judged to be acceptable if they exhibited a characteristic diastolic flow pattern and a pulsatility index (PI) of  . Results are expressed as a mean±standard error of the mean.
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3. Results
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There were no deaths, reoperations for bleeding, conversions to sternotomy, or injuries to the internal mammary arteries. The average blood loss for the procedure was 240±180 cc. The total operating time was 211±14 min with the individual IMA harvest times and free flow (post-harvest/pre-anastomosis) listed in Table 1. Contralateral IMA (LIMA) harvesting was longer than ipsilateral IMA (RIMA) harvesting. The incisions employed were all muscle sparing, non-rib-spreading thoracotomy approaches: 11 bilateral, five right-sided only and two left-sided only. All patients had the RIMA grafted to the main distal part of the right coronary artery (RCA) with one patient undergoing a sequential to the RCA and right ventricular marginal. All patients also had the left anterior descending artery (LAD) grafted using the LIMA with three patients receiving a sequential graft to the LAD and diagonal coronary arteries. The length of IMA harvested (origin to sixth rib) was sufficient in every case. Six patients received stents to the circumflex system as part of a total revascularization hybrid approach. Three patients undergoing the hybrid approach were stented within 36 h following the endoACAB during the same hospitalization. The remaining three hybrid patients had a staged approach with stenting of the circumflex prior to endoACAB in two separate hospitalizations. The primary morbidity was postoperative atelectasis that occurred in seven of the 18 patients. The mean length of stay for all patients was 6.9±4.5 h in the intensive care unit and 54.5±6.5 h in the hospital.
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4. Discussion
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Thoracoscopic internal mammary artery harvesting has become an integral part of minimally invasive coronary artery bypass surgery. Regardless of the planned grafting approach (TECAB: totally endoscopic CAB, or endoACAB: endoscopically assisted atraumatic CAB), harvesting the IMA endoscopically is the least traumatic and most complete method to date. A few centers have reported their experience with bilateral IMA harvest performed thoracoscopically with and without robotic assistance [11–13]. In our early experience with bilateral thoracoscopic IMA harvesting, we have utilized a technique that enables the surgeon to harvest both the left and right IMA from one side or the other.
In bilateral thoracoscopic IMA harvesting, the surgeon has three options: (1) bilateral port placement with unilateral IMA harvesting from each respective side, (2) bilateral thoracoscopic IMA harvesting from a left-sided approach, and (3) bilateral thoracoscopic IMA harvesting from a right-sided approach. The patient's body habitus and coronary anatomy often dictate the preferred approach. For patients with a  , bilateral thoracoscopic IMA harvesting is extremely challenging by virtue of the increased mediastinal adiposity and the thickness of the extra-thoracic, subcutaneous fat. In these obese patients, a staged approach is generally employed. In contrast, patients with a  , and the absence of a pectus deformity can be approached from the left or right side only by endoscopically crossing the midline. In general, the right-sided approach has some advantages over the left-sided technique. In nearly all patients, the heart is largely to the left of midline, particularly in cases of cardiomegaly, so the right-side approach provides additional working space and a more favorable angle to harvest either IMA. It is especially important to examine the plain chest film prior to placing the ports. Since more IMA pedicle length can be obtained by using an ipsilateral harvest approach, the RIMA is best harvested from the right side, as length is usually an issue in contrast to the LIMA pedicle. The operation should begin with dividing most of the fatty attachments between the pericardium and the sternum, essentially creating one large pleural space. If one envisions the human thorax in this way it is easy to understand why bilateral pneumothoraces with carbon dioxide insufflation is of minor concern. It also seems logical to harvest the contralateral IMA first otherwise the harvested ipsilateral IMA, hanging from the chest wall, will be vulnerable to injury. However, another technique that we have used entails dividing the distal end of the IMA at the beginning of the dissection and harvesting from distal to proximal, similar to the corresponding open technique. This latter technique has the advantage of making irrelevant the order of harvesting of the two internal mammary arteries. In all cases, the thoracotomy incision is created to preserve the integrity of the pectoralis major muscle by separating it in the direction of its fibers. Further, the anastomosis is performed under direct vision through the natural intercostal space (15–20 mm) without manipulation of the thoracic skeleton.
Performing bilateral thoracoscopic internal mammary artery harvesting offers an abbreviated learning curve if one already has familiarity with thoracoscopic harvesting of a single ipsilateral IMA. Nonetheless, harvesting of the contralateral IMA presents another magnitude of difficulty as (a) the instruments are usually being manipulated at their furthest extent and (b) movement of the mediastinum caused by respiration can sometimes interact with the surgeon's ability to dissect the IMA. When harvesting the LIMA from the right side, regardless of the patient body mass index, long  cm) instruments are needed with the very proximal portion of the LIMA harvest being the most challenging phase. Robotic assistance of the endoscope greatly facilitates the entire harvesting process, as camera movements are an order of precision unobtainable by human manipulation. One could argue that a surgical tele-manipulator might improve the entire process still further, but this is not a necessity. Regardless, the capability to harvest both internal mammary arteries thoracoscopically from one side, without the need for patient repositioning or three additional ports, is a small incremental step forward in the ongoing development of closed chest multi-vessel coronary artery bypass grafting.
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Footnotes
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Presented at the Annual Techno-College in association with the European Association for Cardio-thoracic Surgery, Monte Carlo, Monaco, September 21, 2002.
doi:10.1016/S1569-9293(02)00109-3
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Abstract
1. Introduction