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Two-port robotic cardiac surgery for atrial septal defect using cross-arm technique
Ishikawa Norihiko, Go Watanabe, Tatsuya Tarui, Ryuta Kiuchi, Hiroshi Ohtake, Shigeyuki Tomita, Kenji Kawachi.
NewHeart Watanabe Institute, Tokyo, Japan.

OBJECTIVE: We successfully performed totally endoscopic atrial septal defect (ASD) repair via 2 ports using the da Vinci surgical system (Intuitive Surgical, Inc., Sunnyvale, CA), and we named this procedure TROCS (Two-port robotic cardiac surgery).
METHODS: Anesthesia was induced using a double-lumen endotracheal tube. The patients were placed in a left hemi-lateral decubitus position. After systemic heparinization, an outflow cannulas inserted transcutaneously into the right internal jugular vein, and an Inflow cannula and an outflow cannula was inserted into the right femoral artery and vein respectively. Two ports were placed on the right side of the chest, and one of the ports was for robotic endoscope. Two robotic instruments were inserted through another port and crossed while preventing them from colliding with each other. At the same time, the master-instrument association at the surgeon console was set to the reverse of default settings so that the right master would control the left instrument and the left master would control the right instrument. Cardiopulmonary bypass (CPB) was initiated, and the superior vena cava was occluded with a small clamp. We performed ASD repair with the 0 degree robotic endoscope and 5mm robotic instruments using cross-arm technique. Ventricle fibrillation (VF) is induced using combined methods of electrical fibrillator, injection of potassium and hypothermia without aortic cross-clamp. The ASDs were directly closed with 4-0 Gore-Tex in running suture. After defibrillation, the patient was weaned from CPB. The integrity of the ASD repair was confirmed by transesophageal echocardiography.
RESULTS: Seven patients with secundum ASD were performed robot-assisted ASD repair under ventricle fibrillation without aortic cross-clamp. The operation time was 133+-29 min.; CPB time was 69+-26 min.; VF time was 10+-6 min.; and no patient needed blood transfusion.
CONCLUSIONS: TROCS ASD repair using cross-arm technique was achieved safely with good clinical results and excellent cosmetic results.


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