What are the operative steps for a patient undergoing robot-assisted Coronary Artery Bypass Grafting (CABG)?

Robot-Assisted CABG Operative Steps

Robot-assisted coronary artery bypass grafting involves port-based endoscopic access, robotic internal mammary artery harvesting, and anastomosis construction on the beating heart, typically targeting the left anterior descending artery with the left internal mammary artery graft. 1

Preoperative Preparation

Patient Selection and Multidisciplinary Planning

• Carefully select patients through multidisciplinary team evaluation including cardiologist, cardiac surgeon, and anesthesiologist 2
• Ideal candidates include those with left anterior descending disease requiring revascularization, particularly when minimizing surgical trauma is prioritized 1, 3
• Consider patients with severe comorbidities, heavily calcified ascending aorta, or lack of suitable graft conduits where traditional sternotomy poses higher risk 1

Antiplatelet Management

• Continue aspirin (100-325 mg daily) preoperatively 1
• Discontinue clopidogrel and ticagrelor at least 5 days before elective surgery, or at least 24 hours before urgent surgery 1
• Discontinue prasugrel at least 7 days before elective surgery 1

Anesthetic Approach

Induction and Maintenance

• Use volatile anesthetic-based regimens with opioid supplementation to facilitate early extubation 1
• Employ nondepolarizing neuromuscular-blocking agents with intermediate duration (avoid pancuronium due to higher heart rates and residual depression) 1
• Consider intrathecal, paravertebral local anesthesia, and patient-controlled analgesia techniques for ultrafast-track protocols 2

Monitoring

• Establish central venous access and comprehensive cardiovascular monitoring 1
• Use intraoperative transesophageal echocardiography for monitoring hemodynamic status, ventricular function, regional wall motion, and valvular function 1
• TEE is particularly valuable for detecting acute hemodynamic disturbances and confirming adequate graft placement 1

Surgical Access and Setup

Port Placement

• Create three port incisions for robotic instrument access rather than full sternotomy 1, 4
• The most minimally invasive approach uses totally endoscopic technique with robotic technology 1
• Some centers perform mini-thoracotomy or partial sternotomy as alternative approaches 3

Robotic System Preparation

• Position the robotic surgical system and dock the robotic arms through the ports 4
• The surgeon operates from the console using the robotically assisted microsurgical system 5, 4

Internal Mammary Artery Harvesting

Robotic Dissection

• Harvest the left internal mammary artery (LIMA) robotically through the port-based approach 4, 6
• The LIMA should be used to bypass the left anterior descending artery when possible, as this provides superior long-term patency 1
• In total arterial revascularization approaches, bilateral internal mammary arteries may be harvested 6

Conduit Preparation

• Prepare the harvested arterial conduit while maintaining adequate length 1
• Arterial conduits are prone to spasm and should be handled carefully 1

Target Vessel Preparation

Beating Heart Technique

• Most robot-assisted CABG is performed on the beating heart without cardiopulmonary bypass 2, 3
• Apply stabilizer devices to the epicardium to immobilize the target coronary artery 1
• Monitor for hemodynamic alterations during heart manipulation, including changes in heart rate, cardiac output, and systemic vascular resistance 1

Coronary Arteriotomy

• Create the arteriotomy on the target vessel (typically the left anterior descending artery) 4
• Ensure the target vessel has severe stenosis (≥70%) for optimal graft patency with arterial conduits 1

Anastomosis Construction

Robotic Suturing Technique

• Perform the distal anastomosis (LIMA to LAD) using hand-sewn suture techniques through robotic instruments 1, 4
• Use continuous polypropylene suture for the anastomosis, though interrupted techniques are also acceptable 1
• The robotic system enables precise microsurgical technique despite the endoscopic approach 4

Graft Assessment

• Measure blood flow through the LIMA graft intraoperatively using handheld Doppler probes 1
• Perform intraoperative angiography after graft construction to confirm Fitzgibbon class A graft patency 2
• If flow is inadequate, revise the anastomosis immediately 4

Additional Grafts (If Required)

Hybrid Approach Consideration

• For multivessel disease, robot-assisted LIMA-to-LAD may be combined with percutaneous coronary intervention of non-LAD vessels (hybrid revascularization) 1
• Additional grafts beyond the LIMA-to-LAD may be performed using conventional hand-sewn techniques if needed 4
• Total arterial revascularization using multiple internal mammary artery grafts can be achieved robotically in experienced centers 6

Hemostasis and Closure

Final Assessment

• Use TEE to evaluate ventricular function, regional wall motion, and confirm absence of new wall motion abnormalities suggesting ischemia 1
• Assess for any bleeding requiring intervention 2

Port Closure

• Close port incisions with minimal trauma 1
• The cosmetic benefit and reduced surgical trauma are key advantages of the robotic approach 1, 3

Immediate Postoperative Management

Ultrafast-Track Protocol

• Extubate in the operating room for carefully selected low-to-medium risk patients 1, 2
• Transfer directly to postanesthesia care unit (PACU) for 4-hour recovery, bypassing cardiac surgical intensive care unit 2
• Transition to oral analgesics using multimodal pain management 2

Standard Recovery Protocol

• For patients not meeting ultrafast-track criteria, use early extubation strategies with accelerated recovery protocols 1
• Monitor for postoperative complications including bleeding (revision rate approximately 2.5%), wound infection (1.2%), and renal failure (0.9%) 3

Graft Verification

Six-Week Angiography

• Perform selective coronary angiography of the LIMA graft at 6 weeks postoperatively to confirm long-term patency 4
• Studies report 100% graft patency at 6 weeks and excellent intermediate-term outcomes 4

Common Pitfalls and How to Avoid Them

Technical Challenges

• Steep learning curve: Requires experienced surgeon and dedicated heart team; outcomes improve significantly with experience 5, 6
• Lack of haptic feedback: Compensate with visual cues and experience; conversion to larger incisions occurs in approximately 2.6% of cases 5, 6
• Inadequate graft flow: Immediately revise anastomosis if intraoperative flow measurements are suboptimal 4

Patient Selection Errors

• Inappropriate candidates: Avoid in patients with heavily diseased right coronary or circumflex arteries requiring multiple grafts unless experienced in total arterial robotic revascularization 6
• Emergency cases: Reserve for elective or urgent cases; emergency CABG typically requires conventional sternotomy 1

Perioperative Management

• Premature extubation: Do not use early extubation strategies in facilities with limited backup for airway emergencies 1
• Inadequate monitoring: Always use TEE for hemodynamic monitoring and graft assessment 1