M. F. Khan

Totally endoscopic atrial septal repair in adults with computer-enhanced telemanipulation

OBJECTIVE Standard surgical closure of an atrial septal defect via sternotomy is a safe and effective procedure with low morbidity and mortality. Considering that young female patients are frequently operated on for atrial septal defects, a minimally invasive procedure avoiding sternotomy is convincingly desirable and led to the approach through a right anterolateral minithoracotomy. The recent clinical introduction of robotically assisted surgery further reduced skin incisions and enabled totally endoscopic procedures through ports. This article reports on a first series of atrial septal defect closures of which the first case was operated on August 24, 1999, in a totally endoscopic closed chest technique using a computer-enhanced telemanipulation system. METHODS We performed totally endoscopic atrial septal repair using the da Vinci surgical system (Intuitive Surgical, Mountain View, Calif) in 10 consecutive adult patients. Median age was 45.5 +/- 10.0 years, and preoperative New York Heart Association functional class was 1.8 +/- 0.1. Left ventricular ejection fraction was normal in all patients and mean pulmonary artery pressure amounted to 35 +/- 7 mm Hg. Shunt volume ranged from 24% to 70%. All patients displayed a fossa ovalis type of atrial septal defect; 2 of them multiperforated. RESULTS Neither intraoperative nor postoperative complications occurred. Two patients had to be converted to minithoracotomy due to endoaortic balloon clamp failure. Length of operation was 262 +/- 37 minutes, and cardiopulmonary bypass time was 161 +/- 26 minutes. Intraoperative transesophageal echocardiography certified complete closure of the atrial septal defect in all patients. The totally endoscopic computer-enhanced technique yielded excellent cosmetic results. CONCLUSION Totally endoscopic atrial septal repair is a feasible and safe procedure with good clinical results and excellent cosmetic outcomes. It may be considered as perfect adjunct to interventional treatment options. Further studies with larger cohorts and randomized trials are necessary to document potential benefits. Evolution in robotic technology and refinement of procedural flow may shorten procedural time and decrease costs.

Transarterial chemoembolization alone and in combination with other therapies: a comparative study in an animal HCC model

The purpose of this study is to compare transarterial chemoembolization (TACE) alone and in combination with other therapies in an animal model. Subcapsular implantation of a solid Morris hepatoma 3924A in the liver was carried out in 50 male ACI rats (day 0). Tumor volume (V1) was measured by MRI (day 13). After laparotomy and retrograde placement of a catheter into the gastroduodenal artery (day 14), the following protocols of the interventional procedure were applied: TACE (mitomycin C + lipiodol) + immunotherapy (group A: TNFα + IL-2, group B: OK-432 + IL-2); TACE + antiangiogenesis therapy (group C: TNP-470, group D: endostatin); TACE alone in group E (control group). Tumor volume (V2) was assessed by MRI and the mean ratio of x (V2/V1) was calculated. Data were analyzed using Dunnett’s t test (comparing therapeutic groups with the control group) and the Student-Newman-Keuls test (comparing significant therapeutic groups). Multivariate analysis showed a significant reduction in the tumor growth rate (P<0.05) in groups B (x=6.53) and C (x=4.01) compared to the mean ratio of the control group E (x=9.14). Significant results were observed in group C (P<0.05) in comparison with the other therapeutic groups. TACE combined with immunotherapy (OK-432) and antiangiogenesis therapy (TNP-470) retards tumor growth compared with TACE alone in an HCC animal model.

Awake coronary artery bypass grafting: utopia or reality?

BACKGROUND Off-pump coronary artery bypass grafting (OPCAB) was implemented to reduce trauma during surgical coronary revascularization. High thoracic epidural anesthesia further reduced intraoperative stress and postoperative pain. This technique also supports awake coronary artery bypass (ACAB), completely avoiding the drawbacks of mechanical ventilation and general anesthesia in high-risk patients. We compared our first results of the ACAB procedure with the conventional OPCAB operation. METHODS Thirty-five patients underwent ACAB (group A) with left internal mammary artery to left anterior descending coronary artery grafting using a partial lower ministernotomy (n = 25) or double bypass grafting (n = 9) and even triple vessel coronary artery revascularization (n = 1) through complete median sternotomy. Thirty-four patients (group B), matched for age, sex, and comorbidity with group A, underwent either partial lower ministernotomy (n = 24) or OPCAB by complete sternotomy (n = 10). We recorded clinical outcomes and postoperative visual analog scale pain scores. RESULTS In group A, 32 patients remained awake throughout the entire procedure. Three patients required secondary intubation because of incomplete analgesia (n = 1) or pneumothorax (n = 2). Patients in group A had a recovery room stay of 6.0 +/- 3.2 hours. In group B, mechanical ventilation was implemented for 4.8 +/- 3.1 hours and intensive care unit stay lasted 12 +/- 6.8 hours. Group A had no in-hospital deaths, compared with 1 death in the conventional OPCAB group. Each group had 1 patient with graft stenosis detected on the predischarge angiogram. Early postoperative pain was significantly less in group A than in group B (visual analog scale of 32 +/- 8 compared with 58 +/- 11, p < 0.0001). CONCLUSIONS The present data demonstrate the feasibility and safety of surgical coronary revascularization without general anesthesia. Continuation of thoracic epidural analgesia provides better pain control and faster mobilization after such procedures. Surprisingly, the ACAB procedure was well accepted by the patients.

Operative techniques in awake coronary artery bypass grafting.

BACKGROUND Off-pump coronary artery bypass grafting was implemented to reduce trauma of surgical coronary revascularization by avoiding extracorporeal circulation. High thoracic epidural anesthesia further reduces intraoperative stress and postoperative pain. In addition, this technique even allows awake coronary artery bypass grafting, avoiding the drawbacks of mechanical ventilation and general anesthesia in high-risk patients. METHODS Thirty-four patients underwent awake coronary artery bypass grafting with left internal thoracic artery to left anterior descending coronary artery by partial lower ministernotomy (n = 20), H-graft technique (n = 2), or rib cage-lifting technique (n = 2). In 9 cases we performed double bypass grafting, and in 1 case we performed triple-vessel coronary artery revascularization through complete median sternotomy. In addition to clinical outcomes, visual analog scale pain scores were recorded on days 1, 2, and 3 after surgery. RESULTS Thirty-one patients remained awake throughout the whole procedure. Three patients required secondary intubation because of incomplete analgesia (n = 1) or pneumothorax (n = 2). Procedure time was 90 +/- 31 minutes, and recovery room stay was 4.2 +/- 0.6 hours. There were no in-hospital deaths or serious postoperative complications. In 1 case a graft occlusion was documented on predischarge angiography. Early postoperative pain was low (visual analog scale score of 30 +/- 6). CONCLUSION These data demonstrate the feasibility and safety of various surgical coronary revascularization techniques without general anesthesia. Continuation of thoracic epidural analgesia provides good pain control and fast mobilization postoperatively. Surprisingly, the awake coronary artery bypass grafting procedure was well accepted by the patients.

Totally endoscopic coronary artery bypass graft: initial experience with an additional instrument arm and an advanced camera system

Background:Robotically enhanced telemanipulation for totally endoscopic coronary artery bypass does not provide adequate tactile feedback, traction, or countertraction. The exposition of coronary target sites is difficult, the visual field is limited, and the epicardial stabilization may be troublesome. A fourth robotic arm for endothoracic instrumentation has been added to the da Vinci surgical system to facilitate totally endoscopic operations. The stereoendoscope was upgraded with a wide-angle feature.Methods:The procedure was performed in five patients. Four of these patients had left internal thoracic artery (LITA) to left anterior descending artery (LAD) grafting on the beating heart and the fifth had sequential bypass grafting (LITA to diagonal branch and LAD) on an arrested heart. The additional effector arm of the da Vinci surgical system was brought into the operative field beneath the operating table and used as a second right arm. The wide-angle view was activated by either the console or the patient side surgeon.Results:The mean operative, port placement, and anastomotic times for a beating-heart totally endoscopic coronary artery bypass were 195 ± 58, 25 ± 10, and 18 ± 5 min, respectively. All procedures were free of morbidity and mortality, with satisfactory angiographic control. The sequential arterial bypass grafting procedure was fully completed in totally endoscopic technique.Conclusions:The additional instrumentation arm and wide-angle visualization are useful technical improvements of the da Vinci surgical system, solving the problem of traction, countertraction, and facilitated exposition of target sites as well as visualization of the surgical field. They provide potential for wider acceptance of totally endoscopic coronary artery bypass grafting in a larger surgical community.

How safe is the port access technique in minimally invasive coronary artery bypass grafting

BACKGROUND This study compares conventional coronary artery bypass grafting (CABG) with port access CABG via a left anterior small thoracotomy in patients requiring surgical multivessel revascularization. Clinical, neuropsychological, and angiographic outcomes were studied, as well as parameters of myocardial and cerebral protection. Pathogenicity of cardiopulmonary bypass (CPB) was further evaluated by measuring parameters of peripheral limb ischemia and inflammatory whole-body response. METHODS In a prospective randomized study, 40 patients who required multivessel CABG were assigned to either conventional CABG via complete median sternotomy (group A) or port access CABG via minithoracotomy (group B). Control angiograms were performed in group B only. In addition, patients underwent neuropsychological testing after the operation. CK, CK-MB, and Troponin T levels were documented. S-100B protein and neuron-specific enolase (NSE) served to quantify cerebral injury. The terminal complement complex (C5b-9) and myeloperoxidase concentrations were determined to analyze inflammatory whole-body response after CPB. RESULTS There was no mortality. One patient suffered a retrograde aortic dissection immediately after onset of CPB, but had an uneventful postoperative course after surgical repair. Troponin T and CK-MB showed no difference between groups. CK and myoglobin were significantly higher in the minimally invasive cohort. Changes in complement activation (C5b-9) and myeloperoxidase during CPB markers of the whole-body inflammatory response were similar in both groups. S-100B concentrations in the port access group were significantly higher, whereas NSE levels were similar in both groups. Both groups did not display any significant difference in neuropsychological testing. CONCLUSIONS Minimally invasive multivessel CABG via minithoracotomy using port access technology is feasible and safe. Though prolonged operating and CPB times with significantly higher S-100B concentrations were observed in group B, equivalent myocardial and cerebral protection and similar whole-body inflammatory response were documented.

Totalarterielle Bypassoperationen über komplette Sternotomie am wachen Patienten

Backround In minimally invasive coronary artery bypass surgery beating heart procedures and operations via limited incisions became more popular and are routinely performed in many centers. An additinal approach to minimize general trauma is avoidance of general anesthesia endotracheal intubation. Patients and methods Between March and June 2001, 14 spontaneously breathing patients underwent coronary artery bypass grafting on the beating heart without general anesthesia. Intra- and postoperative analgesia management was performed using continuous epidural infusion of local anesthetics at level Th2–Th3. Single (n=8) as well as double (n=5) and triple (n=1) bypass grafting was performed with the off pump technique. Surgical access to the chest cavity was created via partial (n=8) or complete sternotomy (n=6). Results Twelve patients remained awake throughout the procedure; 2 patients required secondary intubation due to incomplete sensory block and pneumothorax. Operating time was 94±18 minutes. Intermediate care monitoring time amounted to 4.8±0.6 hours. No surgery-related complications or myocardial infarction occured. Postoperative angiography reviewed good graft function in all patients. Conclusion Our preliminary experience shows that complete surgical revascularization is safe and feasible without endotracheal intubation and general anesthesia. Thus, invasiveness in cardiac surgery is further reduced with less need for intensive care unit monitoring enabling faster mobilization and recovery. Hintergrund Im Zuge der Entwicklung minimalinvasiver Operationstechniken in der Herzchirurgie gehören Koronarbypassoperationen am schlagenden Herzen und Operationen über limitierte Zugänge („Schlüssellochoperationen”) inzwischen in vielen Zentren zur Routine. Eine weitere Möglichkeit der Minimierung des Operationstraumas besteht darin Patienten ohne Vollnarkose in Regionalanästhesie zu operieren. Methode Seit März 2001 wurde bei insgesamt 14 Patienten eine koronare Bypassoperation am schlagenden Herzen ohne Vollnarkose bei Spontanatmung durchgeführt. Hierzu wurde ein Periduralkatheter in Höhe von Th2–Th3 präoperativ eingelegt. Die Revaskularisation erfolgte total arteriell, wobei 8einfach, 5 zweifach und 1 dreifach Bypassgraft angelegt wurden. Die Zugänge verteilten sich auf sowohl komplette als auch partielle Sternotomien. Ergebnisse Zwölf Patienten blieben während der gesamten Operation wach. Zwei Patienten benötigten aufgrund einer unvollständigen Analgesie bzw. eines Pneumothorax eine sekundäre Intubation. Die mittlere Operationszeit betrug 94±18 Minuten. Der mittlere Aufenthalt auf der Überwachungsstation betrug 4,8±0,6 Stunden. Es traten keine postoperativen Komplikationen auf. Postoperativ zeigten alle Bypasses angiographisch eine gute Funktion. Schlussfolgerung Unsere bisherigen Erfahrungen zeigen, dass eine vollständige und sichere Revaskularisation auch am wachen Patienten möglich ist. Die Methode ermöglicht kürzere Operationszeiten, und beschleunigt die postoperative Rekonvaleszenz.

Totally endoscopic coronary artery bypass graft

BackgroundRobotically enhanced telemanipulation for totally endoscopic coronary artery bypass does not provide adequate tactile feedback, traction, or counter-traction. The exposition of coronary target sites is difficult, the visual field is limited, and the epicardial stabilization may be troublesome. A fourth robotic arm for endothoracic instrumentation has been added to the da Vinci surgical system to facilitate totally endoscopic operations. The stereoendoscope was upgraded with a wide-angle feature.MethodsThe procedure was performed in five patients. Four of these patients had left internal thoracic artery (LITA) to left anterior descending artery (LAD) grafting on the beating heart and the fifth had sequential bypass grafting (LITA to diagnonal branch and LAD) on an arrested heart. The additional effector arm of the da Vinci surgical system was brought into the operative field beneath the operating table and used as a second right arm. The wide-angle view was activated by either the console or the patient side surgeon.ResultsThe mean operative, port placement, and anastomotic times for a beating-heart totally endoscopic coronary artery bypass were 195±58, 25±10, and 18±5 min, respectively. All procedures were free of morbidity and mortality, with satisfactory angiographic control. The sequential arterial bypass grafting procedure was fully completed in totally endoscopic technique.ConclusionsThe additional instrumentation arm and wide-angle visualization are useful technical improvements of the da Vinci surgical system, solving the problem of traction, countertraction, and facilitated exposition of target sites as well as visualization of the surgical field. They provide potential for wider acceptance of totally endoscopic coronary artery bypass grafting in a larger surgical community.