Return Of The Robot: How RA-MIDCAB Further Reduces Complications Compared To OPCAB
Hannah Vaesen Bentein1, Jef Van den Eynde1, Tom Decaluwe1, Herbert De Praetere1, Mark Coosemans2, Nick Hiltrop3, Johan Bennett1, Steven Jacobs1, Wouter Oosterlinck1.
1UZ Leuven, Leuven, Belgium, 2AZ Turnhout, Turnhout, Belgium, 3AZ Groeninge, Kortrijk, Belgium.
Background: RA-MIDCAB is increasingly being introduced in hospitals around the world. To ensure safety and quality, close monitoring of surgical outcomes is essential. This study assessed the first 4 years of a single-center experience with RA-MIDCAB. Methods: Between July 2015 and October 2019, 282 RA-MIDCAB surgeries were performed at University Hospitals Leuven. Learning curves were obtained via logarithmic regression for surgical time and compared between groups based on tercile, number of anastomoses, procedure complexity, and hybrid or non-hybrid revascularization. CUSUM analysis was performed for (a) major complications including MI, stroke, repeat revascularization, and mortality, and (b) minor complications, including prolonged ventilation, pneumonia, pleura puncture, lung herniation, pericarditis, pleuritis, arrhythmia, and wound problems. Expected and unacceptable rates were set at 10% and 20%, respectively, for major complications, and at 40% and 60% for minor complications, based on historical data in OPCAB. Results: Duration of surgery varied widely, ranging from 125 to 821 minutes with a mean of 258 ± 78 minutes. Only in the first tercile a significant decrease in surgical time was observed (p=0.012). Most surgeries comprised a single anastomosis, but multiple anastomoses were gradually introduced, including 96 procedures with two anastomoses and 6 with three anastomoses. Mean surgical time for single anastomosis was 226(200-255)min, for two anastomoses 269(238-310)min (p<0.001) and for three 304(290-505)min (p<0.001). Decreases in surgical time were also significant for SIMA with 1 distal anastomosis (p=0.004) and SIMA with 2 distal anastomoses (p=0.016). CUSUM analyses for major and minor complications indicated a lower than expected complication rate. Hybrid procedures showed the earliest decline in major complication rate, although the minor complication rate of this group remained stable. Conclusions: These results suggest that integration of RA-MIDCAB in the surgical landscape can be safely achieved and complication rates can quickly be reduced below those expected in OPCAB. Collective experience plays a key role in overcoming the learning curve when a higher number of anastomoses and more complex procedures and cases are introduced. 
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