Successful Redo-robot Assisted Minimally Access Bypass Graft In A Complex Congenital Patient
Maria Cannoletta, richard Trimlett, Anthony De Souza.
Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
BACKGROUND:Endoscopic atraumatic coronary artery bypass grafting has been introduced in our institution more than 20 years ago. 932 procedures have been performed, with excellent results. Through the years it has been proven to be a safe procedure even in high risk and complex patients. We successfully performed an Endo ACAB on a congenital patient undergone arterial switch operation and coarctation repair as a baby, recently found to have a disconnected left main.
METHODS:A 26 years old woman recently started complaining of atypical chest pain on exertion radiating to her left arm. As a baby she was born with transposition of the great arteries and underwent balloon atrial septostomy followed by arterial switch with re-routing of coronary arteries to neo-aorta re-implanted via pericardial patch and finally coarctation repair though left thoracotomy. Investigations showed reversible ischemia at a low workload. Coronary angiogram showed a disconnected LMS with back filling from right coronary artery. CT scan showed close proximity of sternum with RV. Surgical revascularization was proposed through redo sternotomy. Femoral cannulation was planned but both femoral arteries were found to be extremely small therefore this original plan was abandoned. Central cannulation was excluded because of proximity of RV to sternum. The left chest was then explored thoracoscopically to potentially perform an off pump EndoACAB despite concerns in terms of possible adhesions (previous left thoracotomy for coarctation repair). Endotracheal tube was changed to a double lumen tube to allow single lung ventilation, a 3D camera was inserted through 10 mm port at the 4th intercostal space. Fortunately there were few adhesions and with the aid of a robotic arm (AESOP: Automated Endoscopic System for Optimal Positioning) and an harmonic scalpel, these were divided and LIMA harvested. Though left anterior minithoracotomy the LAD was identified using ultrasound scan. The LIMA was anastomosed to the LAD with 7/0 prolene suture. On completion a chest drain was inserted.RESULTS:The patient made an excellent recovery despite reduced sensation in her right leg following right groin exploration which gradually improved. CONCLUSIONS:We demonstrate that robotic assisted EndoACAB can be performed safely in complex redo-cases with excellent results. 
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