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Robot-Assisted Endoscopic Construction of a LITA-to-LAD Anastomosis Facilitated by the Trinity Clip (ELANA Anastomotic Connector): An Experimental Case Report
David Stecher1, Lex A. van Herwerden1, Gerard Pasterkamp1, Marc P. Buijsrogge1, Bob Kiaii2.
1University Medical Centre Utrecht, Utrecht, Netherlands, 2London Health Sciences Centre, London, ON, Canada.

OBJECTIVE: To facilitate minimal access CABG, our research group developed a potential simplified alternative for hand-sutured anastomosis, the Trinity Clip, based on the Excimer Laser Assisted Nonocclusive Anastomosis (ELANA) technique. The submitted video demonstrates the very first experience with robot-assisted endoscopic application of the experimental anastomotic technique.
METHODS: In an acute porcine OPCAB model, a LITA-to-LAD bypass was constructed with the new Trinity Clip by using the Intuitive da Vinci Si Surgical System (by an inexperienced robotic surgeon [first author]), after conventional harvesting of the LITA. The robotic arms and the laser were introduced through a median sternotomy. The implantable connector is suitable for coronaries with a minimal diameter of 1.2 mm. Nonocclusively, the graft is connected to the coronary, and a laser opens the anastomosis.
RESULTS: The anastomotic procedure was feasible, with successful application of the mounted complex (ie, graft, connector, and laser, temporarily fixated by a fixation clip) onto the LAD. Access to the diagonals or a high marginal branch was possible. After laser-punching the LAD, a failure of completely releasing the fixation clip (ie, accidentally the fixation clip caught the LITA and, subsequently, the surgeon applied uncontrolled traction onto the LITA) resulted in rupture of the anastomosis.
CONCLUSIONS: The anastomotic technique was feasible in a porcine OPCAB model in an endoscopic setting, robot-assisted, in a single case. However, the mounted and secured laser limited expediency. A more flexible laser and a simplified application of the fixation clip will further optimize the procedure, which has potential to facilitate endoscopic minimally invasive OPCAB surgery.

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