Yujiro Kikuchi

Beating-heart totally endoscopic coronary artery bypass grafting: Report of a case

This case report presents beating-heart totally endoscopic coronary artery bypass grafting (TECAB) for single-vessel coronary artery disease. A 72-year-old man with isolated left anterior descending (LAD) coronary artery disease was considered eligible for TECAB. Left internal thoracic artery (LITA) mobilization and subsequent off-pump revascularization applying the LITA to the LAD in a closed chest environment was performed using the da Vinci surgical system (Intuitive Surgical, Mountain View, CA, USA). The LITA was first harvested completely in a totally skeletonized fashion through three incisions 1–2 cm long in the left thoracic wall. The LAD was immobilized with the aid of a heart stabilizer. The LITA was then anastomosed to the LAD with 10 interrupted sutures of a Nitinol self-closing S15 U-clip device (Medtronic, Minneapolis, MN, USA) on the beating heart without the use of cardiopulmonary bypass. The time acquired to perform anastomosis was 20 min, and the total operative time was 5 h 34 min. The postoperative course was uneventful and the patient was discharged 5 days after the operation. Beating-heart TECAB was successfully performed for this patient with single-vessel LAD disease. This approach may be an evolutionary step toward beating-heart multivessel TECAB.

Commissural Autologous Pericardial Patch Repair: A Novel Technique for Active Mitral Valve Endocarditis Involving the Mitral Annulus

In patients with massive destruction caused by mitral endocarditis, surgical valve repair remains a challenging issue. Although several procedures have previously been introduced, no standard method for complicated lesions has been established. We describe a technique of mitral valve repair for extensive destructive endocarditis involving both leaflets and the mitral annulus that has provided satisfactory initial results in 2 patients. This procedure is believed to be technically simple and beneficial in terms of mitral repair for active endocarditis.

Automatic aortic anastomosis with an innovative computer-controlled circular stapler for surgical treatment of aortic aneurysm

OBJECTIVE This study applied a computer-controlled mechanical stapler to vascular end-to-end anastomosis to achieve an automatic aortic anastomosis between the aorta and an artificial graft. In this experimental study, we created a mechanical end-to-end anastomotic model and assessed the strength of the anastomotic site under high pressure. METHODS We used a computer-controlled circular stapler named iDrive (Power Medical Interventions, Covidien plc, Dublin, Ireland) for the anastomosis between the porcine aorta and an artificial graft. Then the mechanically stapled group (group A) and the manually sutured group (group B) were compared 10 times, and we assessed the differences at several levels of pressure. RESULTS To use a mechanical stapler in vascular anastomosis, some special preparations of both the aorta and the artificial graft are necessary to narrow the open end before the procedures. To solve this problem, we established a specially designed purse-string suture for both and finally established end-to-end vascular anastomosis. The anastomosis speed of group A was statistically significantly faster than that of group B (P < .01). The group A anastomotic sites also showed significantly more tolerance to high pressure than those of group B. CONCLUSIONS The computer-controlled stapling device enabled reliable anastomosis of the aorta and the artificial graft. This study showed that mechanical vascular anastomosis with the iDrive was sufficiently strong and safe relative to manual suturing.

Totally endoscopic closure of an atrial septal defect using the da vinci surgical system: Report of four cases

This report presents four cases of totally endoscopic closure of an atrial septal defect using the da Vinci Surgical System (Intuitive Surgical, Mountain View, CA, USA). The patients were diagnosed with an ostium secundum atrial septal defect and elected to undergo minimally invasive surgery. A cardiopulmonary bypass was established via cannulation of the femoral vessel and jugular vein, and blood cardioplegic arrest was induced using a transthoracic cross-clamp. The mean extracorporeal circulation and cardiac arrest times were 86 ± 21 and 22 ± 8 min, respectively. No patient experienced pain after surgery, and all were fast-tracked for early discharge and released on postoperative day 3. No intraoperative or postoperative complications occurred. This procedure permitted a short hospital stay, quick return to an active lifestyle, and had an excellent cosmetic outcome. The success of this procedure therefore encourages that this procedure should be considered as day surgery.

Rerouting revascularization of the living right gastroepiploic artery graft in a patient with de novo gastric cancer

We present a case in which a redo patient in whom advanced gastric cancer was detected after coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA), and in which re-grafting to the distal RGEA using the right internal thoracic artery (RITA) was performed. To minimize the surgical invasion before gastrectomy, we performed a thoracoscopic RITA harvest and small subxyphoid incision. A month later, distal gastrectomy was carried out and no complications occurred during the operation.

Robotic Skeletonized Internal Thoracic Artery Harvesting: The Sliding Fascia Technique

Robotic skeletonizing and harvesting of the internal thoracic artery, using the da Vinci surgical system, has a number of advantages over robotic pediculed ITA harvesting. The advantages include greater blood flow, a longer conduit, and less bleeding. The technique is facilitated by use of the EndoWrist spatula cautery and fine tissue forceps (Intuitive Surgical, Inc., Sunnyvale, CA, USA). How the technique is performed is described in this report.

Endoscopic Radial Artery Harvesting: Patient Satisfaction and Complications

Endoscopic radial artery harvesting was recently introduced to reduce the morbidity associated with conventional open harvesting and improve cosmetic outcomes. From January 2004 through December 2006, 25 radial arteries were harvested endoscopically from 25 patients using the VasoView endoscopic system. Bilateral radial arteries were harvested from 6 patients by both the endoscopic and open techniques, and postoperative patient satisfaction was assessed using a visual analogue scale. Mean harvesting time was 61.9 ± 16.0 min (range, 44–105 min), and mean harvested conduit length was 16.8 ± 2.0 cm (range, 15–19 cm). Objective dorsal thenar numbness remained in 2 patients (8%); none complained of forearm numbness. All patients expressed marked satisfaction with the endoscopic technique and the small incision. Patient satisfaction was significantly higher with the endoscopic technique than with the open technique (visual analogue scale of 9 vs 5). Postoperative angiography revealed occlusion of a graft that had been anastomosed to a small diagonal branch. The overall graft patency was 96.6%. Endoscopic radial artery harvesting can be performed safely with infrequent complications. This method results in excellent patient satisfaction, particularly regarding the cosmetic outcome.

How I do it: high-quality intraoperative fluorescence imaging in off-pump coronary artery bypass grafting.

We have developed a simple technique for establishing high-quality intraoperative fluorescence imaging in off-pump coronary artery bypass grafting. The technique of transaortic injection of indocyanine green is an effective method of achieving clear fluorescence imaging and for evaluating the quality of graft anastomoses. We consider the images obtained with this technique to be equivalent to those obtained by conventional coronary angiography with selective enhancement of the graft.

How I do it: Traction of Ascending Aorta with Starfish Heart Positioner During Proximal Saphenous Vein Graft Anastomosis Using the PAS-Port System in Off-Pump Coronary Artery Bypass Grafting

The PAS-Port system allows for the rapid deployment of a clampless proximal anastomosis between a saphenous vein graft and the aorta. We have developed a simple technique of establishing traction of the ascending aorta with the Starfish heart positioner during proximal saphenous vein anastomosis using the PAS-Port system in off-pump coronary artery bypass grafting.