Robotic Totally Endoscopic Double-Vessel Bypass Grafting: A Further Step Toward Closed-Chest Surgical Treatment of Multivessel Coronary Artery Disease


  • Johannes Bonatti
  • Thomas Schachner
  • Nikolaos Bonaros
  • Armin Öhlinger
  • Elisabeth Rützler
  • Gudrun Feuchtner
  • Christian Kolbitsch
  • Guy Friedrich
  • Thomas Bartel
  • Otmar Pachinger
  • Günther Laufer



Background. After the introduction of robotic technology into the heart surgery armamentarium the performance of totally endoscopic coronary artery bypass grafting (TECAB) has become a reality. During the first years of development, the majority of TECAB cases were restricted to single-vessel disease, and the development of multivessel procedures is desirable. We report on a preliminary series of totally endoscopic double-vessel coronary artery bypass grafting.

Methods. From 2004 to 2006, 10 patients underwent endoscopic placement of the right internal mammary artery (RIMA) to the left anterior descending artery (LAD) in combination with left internal mammary artery (LIMA) grafting to an obtuse marginal (OM) branch. Indications for the operation were isolated left main disease or left main equivalents. All procedures were performed using the daVinci telemanipulation system, remote-access perfusion, and aortic balloon endo-occlusion.

Results. Seven of the 10 interventions were completed endoscopically, and 3 patients were converted to sternotomy. RIMA takedown time was 40 minutes (range, 29-49 minutes); LIMA takedown time was 38 minutes (range, 29-48 minutes). LAD and OM anastomotic times were 23 minutes (range, 14-53 minutes) and 38 minutes (range, 29-48 minutes), respectively. Total TECAB time was 477 minutes (range, 385-545 minutes). Median ventilation time was 15 hours (range, 6-40 hours), median intensive care unit stay was 41 hours (range, 15-141 hours), and patients were discharged after a median of 7 days (range, 5-22 days). No major adverse cardiac or cerebrovascular events occurred during short-term follow-up.

Conclusion. Totally endoscopic double-vessel coronary artery bypass grafting on the arrested heart is a reproducible procedure. This intervention offers maximal preservation of patient integrity, but the long operative times need to be investigated.


Bonatti J, Schachner T, Bernecker O, et al. 2004. Robotic totally endoscopic coronary artery bypass: program development and learning curve issues. J Thorac Cardiovasc Surg 127:504-10.nBonatti J, Schachner T, Bonaros N, Laufer G. 2006. A new exposure technique for the circumflex coronary artery system in robotic totally endoscopic coronary artery bypass grafting. Interact Cardiovasc Thorac Surg 5:279-81.nChieffo A, Stankovic G, Bonizzoni E, et al. 2005. Early and midterm results of drug-eluting stent implantation in unprotected left main. Circulation 111:791-5.nD'Annibale A, Morpurgo E, Fiscon V, et al. 2004. Robotic and laparoscopic surgery for treatment of colorectal diseases. Dis Colon Rectum 47:2162-8.nDe Canniere D, Jansens JL, Goldschmidt-Clermont P, Barvais L, Decroly P, Stoupel E. 2001. Combination of minimally invasive coronary bypass and percutaneous transluminal coronary angioplasty in the treatment of double-vessel coronary disease: two-year follow-up of a new hybrid procedure compared with "on-pump" double bypass grafting. Am Heart J 142:563-70.nDogan S, Aybek T, Andressen E, et al. 2002. Totally endoscopic coronary artery bypass grafting on cardiopulmonary bypass with robotically enhanced telemanipulation: report of forty-five cases. J Thorac Cardiovasc Surg 123:1125-31.nFalk V, Moll F, Rosa D, et al. 1999. Transabdominal endoscopic computer-enhanced coronary artery bypass grafting. Ann Thorac Surg 68:1555-71.nFalk V, Diegeler A, Walther T, et al. 2000. Total endoscopic computer enhanced coronary artery bypass grafting. Eur J Cardiothorac Surg 17:38-45.nGiulianotti P, Coratti A, Angelini M, et al. 2003. Robotics in general surgery: personal experience in a large community hospital. Arch Surg 138:777-84.nKappert U, Cichon R, Schneider J, Schramm I, Schüler S. 2000. Closed chest bilateral mammary mammary artery grafting in double-vessel coronary artery disease. Ann Thorac Surg 70:1699-701.nLoulmet D, Carpentier A, d'Attellis N, et al. 1999. Endoscopic coronary artery bypass grafting with the aid of robotic assisted instruments. J Thorac Cardiovasc Surg 118:4-10.nSrivastava S, Gadasalli S, Agusala M, et al. 2006. Use of bilateral internal thoracic arteries in CABG through lateral thoracotomy with robotic assistance in 150 patients. Ann Thorac Surg 81:800-6.nStein H, Cichon R, Wimmer-Greinecker G, Ikeda M, Hutchinson D, Falk V. 2003. Totally endoscopic multivessel coronary artery bypass surgery using the da Vinci Surgical System: a feasibility study on cadaveric models. Heart Surg Forum 6:E183-190.n



How to Cite

Bonatti, J., Schachner, T., Bonaros, N., Öhlinger, A., Rützler, E., Feuchtner, G., Kolbitsch, C., Friedrich, G., Bartel, T., Pachinger, O., & Laufer, G. (2007). Robotic Totally Endoscopic Double-Vessel Bypass Grafting: A Further Step Toward Closed-Chest Surgical Treatment of Multivessel Coronary Artery Disease. The Heart Surgery Forum, 10(3), E239-E242.