title: Totally endoscopic multivessel coronary artery bypass surgery using the da Vinci surgical system: a feasibility study on cadaveric models.
abstract: BACKGROUND
  The aim of the study was to develop a totally endoscopic coronary artery bypass procedure for the treatment of multivessel disease (MVTECAB).
  
  
  METHODS
  Procedure development was conducted on 6 human cadavers with the da Vinci Surgical System. For aortic clamping, a transthoracic aortic clamp was applied. The proximal anastomoses of vein grafts were created transthoracically with the Corlink automated anastomosis device. The target vessels on the heart were exposed with a modified endoscopically applicable Starfish vacuum device. In 1 cadaver, the endo-sling and endoscopic fan retractors were studied for exposure support.
  
  
  RESULTS
  Harvesting of bilateral internal thoracic arteries was easily accomplished. Aortic clamping was easier from the right side. In the left-side approach, the proximal anastomoses were completed without leakage in all 3 cadavers. One incorrect deployment occurred, and the deployment needed to be redone. In the right-si d e approach, 1 proximal anastomosis was performed without leakage, and another needed to be repaired for incorrect deployment. The fan retractors either covered too much of the targeted area of the heart surface or did not provide good manipulation capabilities. The endo-sling enabled atraumatic exposure of the target vessels. The modified Starfish performed sufficiently for exposing target vessels. Problems were found with epicardial fat clogging the Starfish suction chamber and with bending of the suction tube neck, both of which resulted in a loss of tissue contact. Two of the cadavers approached from the left side were completely revascularized with 3 grafts, and 4 anastomoses were performed on the third cadaver. Triple-vessel revascularization was performed in the cadavers approached from the right side.
  
  
  CONCLUSIONS
  This study demonstrates the feasibility of performing an MVTECAB on the arrested heart with the da Vinci Surgical System. Further procedure development is necessary to optimize the synergistic effects of the technologies used and to introduce this operation into clinical practice.
authors.affiliation: Department of Clinical Development Engineering, Intuitive Surgical Inc, Sunnyvale, California, USA. hubert.stein@intusurg.com
authors.forename: Hubert
authors.initials: H
authors.lastname: Stein
authors.forename: Romuald
authors.initials: R
authors.lastname: Cichon
authors.forename: Gerhard
authors.initials: G
authors.lastname: Wimmer-Greinecker
authors.forename: Michael
authors.initials: M
authors.lastname: Ikeda
authors.forename: Douglas
authors.initials: D
authors.lastname: Hutchison
authors.forename: Volkmar
authors.initials: V
authors.lastname: Falk
mesh_terms: D002102:Cadaver; D001026:Coronary Artery Bypass / Q000379:methods*; D003327:Coronary Disease / Q000473:pathology / Q000601:surgery*; D005240:Feasibility Studies; D006801:Humans; D007091:Image Processing, Computer-Assisted; D012371:Robotics / Q000379:methods*; D013536:Suture Techniques