Background Performing fully endoscopic coronary artery bypass procedures has proven to be challenging. Therefore, we developed a new automated endoscopic connector device for distal coronary anastomoses. To evaluate its endoscopic functionality, we conducted an ex-vivo feasibility study aimed at formulating a standardized robotic-assisted procedure and assessing the closed chest maneuverability. Methods Our coronary connector employs a controlled, three-step micro-stapling procedure. First, it secures connector halves to each vessel and subsequently joins them together. Leveraging our previously established technology that generates oval-shaped side-to-side anastomoses on 1.3-3.0 mm target vessels (internal diameter), we engineered a streamlined variant suitable for introduction through 12 mm ports. To emulate real-world conditions, a closed chest environment was simulated using a dedicated box encapsulating ex-vivo porcine hearts. Employing the da Vinci Si system (intuitive Surgical, Sunnyvale, CA), internal mammary artery segments were anastomosed to various regions of the heart. First, standardization and simplification of the robotic procedure were explored. Next, the procedure’s effectivity was assessed, quantifying success rates for the accurate placement of the two connector halves and precise alignment for their subsequent fusion. Finally, the procedure’s ease-of-use, teachability , and reproducibility were evaluated by introducing additional surgeons to perform the procedure. Results The robotic-assisted procedure required four robotic instruments: two black diamond micro forceps, one large needle-driver, and a Potts’ scissors. For the anterior wall, the 30◦-up camera position was used, for the posterior wall either the up- or the down camera position proved useful. In a total of eighteen anastomotic procedures, all three procedure steps could be performed fully robotically. In two cases (5.6%), the graft connector placement required a second attempt. The construction of in-length jump grafts on both the anterior and posterior wall proved very feasible as well as Y-graft constructions. The experience of two additional surgeons supported the device’s endoscopic user-friendliness and the procedure’s easy teachability and reproducibility by first-time-right deployments. Conclusions This ex-vivo feasibility study supports the suitability of our specialized coronary artery connector device for an endoscopic, robotically assisted environment as well as the device's capability to create diverse graft geometries and accomplish anastomoses on various regions of the heart.
