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Surgeon-Powered Robotic Arm Facilitating Left Internal Mammary Artery Harvest In Minimally Invasive Direct Coronary Artery Bypass Surgery
Robic Boris, MD, Rene Petrovic, MD, Anze Djordjevic, MD, Jernej Zeleznik, MD, Urska Intihar, MD, Peter Juric, MD, Franc Gregorcic, MD, Miha Antonic, MD, PhD.
University Medical Centre Maribor, Maribor, Slovenia.

BACKGROUND: Left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery bypass has been scientifically proven to have the best patency and long-term results in myocardial revascularization. The latest guidelines suggest minimally invasive LIMA to LAD to be the optimal therapy for isolated proximal LAD lesions. Utilizing wristed robotic arm instruments makes minimally invasive LIMA to LAD surgery accessible to most centres, allowing more surgeons to initiate the minimally invasive program.
METHODS: We started our minimally invasive direct coronary artery bypass (MIDCAB) surgery program in 2018 with the use of standard thoracoscopic long shafted instruments and LIMA to LAD off-pump anastomosis under direct vision through a 5-centimetre left anterolateral mini-thoracotomy. The introduction of wristed thoracoscopic instruments that mimic established robotic arm instruments may be of significant value for starting a minimally invasive MIDCAB program.
RESULTS: From October 2021 we have performed our first three cases of surgeon-powered robotic arm LIMA thoracoscopic harvest for MIDCAB surgery. The video showcases LIMA harvesting, which is faster, easier, and requires a lower learning curve when using the above-mentioned instruments. This combines the advantages of the established robotic harvesting techniques while allowing for a faster surgeon response time in case of an unexpected event. CONCLUSIONS: The introduction of MIDCAB program can be quite challenging. Robotic surgery demands high initial costs, while standard thoracoscopic techniques have a longer surgeon learning curve. To apply the optimal therapy according to the guidelines, more centres and surgeons should be trained to carry out this procedure in their everyday practice. In our experience, surgeon-powered robotic arm LIMA harvest combines the best of both worlds. It allows for a facilitated LIMA harvest as in robotic surgery with the comfort of the surgeon constantly standing by the patient, allowing for a faster response time in case of an emergency or the need for instrument exchange. All of this results in shorter operating times, lower costs compared to robotic surgery, and faster adoption of this technique for centres just starting MIDCAB surgery.

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