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Non-Rib Spreading Minimmaly Invasive Coronary Artery Bypass Grafting using 3D Endoscope
Takahiro Takemura, Yujirou Kawai, Hirokazu Niitsu, Yasuyuki Toyota, Yasutoshi Tsuda.
Saku Central Hospital Advanced Care Center, Saku, Japan.

OBJECTIVE: Minimally invasive coronary bypass grafting (MICS CABG) thorough a left minithoracotomy may be associated with earlier recovery, better cosmetics, fewer transfusion and fewer infections. We performed 3D endoscopic harvesting of left internal thoracic artery (ITA) for this procedure since 2012. However we used hard retractor during harvesting left ITA and anastomosis of coronary arteries in early cases. Fully endoscopic harvesting of bilateral mammary arteries under closing chest using CO2 insufflation has nowadays been established.
METHODS: 5 patients (3 Female and 22 Male, average age 66 years) underwent MICS CABG using the 3D endoscope between February 2013 and December 2015. The 3D endoscope is inserted 5th or 6th intercostal space at the anterior axillary line. Another 2 or 3 additional 5mm port was used for harvesting ITA. ITA harvesting underwent using Harmonic Scarpel under fully endoscopic vison with closing chest. Right ITA harvesting underwent using same manner in 3 cases and using bilateral endoscope insertion in 1 case. We performed off pump anastomosis of left ITA to the left anterior descending coronary artery through 5cm left thoracotomy using soft tissue retractor without rib-spreading. Right ITA was used on the diagonal branch in 2 cases and the obtuse marginal artery in 2 case through 7cm skin incision.
RESULTS: The endoscopic procedures were successfully in 24 cases. Conversion to full sternotomy occurred in 1 case due to failure of harvesting left ITA. All patients underwent off-pump CABG. There was no operative mortality. Staged hybrid percutaneous coronary intervention underwent in 3 cases. Postoperative pain was less compared with MICS CABG procedure before using 3D endoscope.
CONCLUSIONS: MICS CABG using 3D endoscopic harvesting and non-rib spreading anastomosis is less invasive and painless procedure compared with conventional MICS CABG under direct vision using hard retractor. The experience of harvesting bilateral ITA is a little and early stage of learning curve. However this procedure might have potential to develop MICS CABG for the patients with multi vessels coronary artery disease with or without hybrid revascularization.

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