全机器人胸廓内动脉游离非体外循环冠状动脉旁路移植术

目的总结全机器人下不开胸胸廓内动脉（IMA）游离心脏不停跳冠状动脉旁路移植术的初步经验。方法使用da Vinci S全机器人系统,完成胸廓内动脉游离心脏不停跳下冠状动脉旁路移植术15例。所有患者均有心绞痛症状,其中4例患者有心肌梗死病史,冠状动脉造影显示严重的前降支病变,2例患者对角支及回旋支亦有病变。手术过程中于左侧胸壁打直径为1cm的器械臂孔3个,医生于操作台前在三维成像系统下操控机器人进行胸廓内动脉的游离,其中13例行左侧胸廓内动脉游离,1例行双侧胸廓内动脉游离,1例行对侧胸廓内动脉游离。游离结束后,沿左胸前第4肋间行长度为6cm小切口开胸,13例于心脏跳动下行胸廓内动脉和前降支的吻合,2例同时吻合对角支或回旋支。其中1例是完全机器人不停跳下冠状动脉旁路移植术。结果所有患者均成功接受胸廓内动脉游离,无胸廓内动脉损伤及术式的转变。胸廓内动脉和前降支、对角支和回旋支吻合后桥血流良好。术中平均出血量80ml,平均ICU时间20h,术后恢复好。结论全机器人不开胸胸廓内动脉游离技术精细、安全,不停跳下冠状动脉移植术效果确实、可靠,术后效果良好。

Totally robotic internal mammary artery harvest and beating heart coronary artery bypass

OBJECTIVE: To summary the first 14 cases undergoing internal mammary artery (IMA) harvest using da Vinci S system and minimally invasive direct coronary artery bypass grafting (MIDCAB) on beating heart. METHODS: The average age of patients was (60.4 +/- 10.1) years old. One case was female and 13 male. All the patients had a history of angina. The coronary arteriongraphy showed severe stenosis of anterior descending branch in all patients, of which 2 cases had diagnoal and circumflex branch stenosis. Four case had myocardial infraction history. All the patients had good lung function and had no medical history of pleurisy. Without sternotomy, the camera cannula was placed in the left, 3 cm lateral to nipple in the 4th intercostal space (ICS). Da Vinci instrument arms were inserted through two 1 cm trocar incisions. The right instrument generally was positioned 4 to 6 cm cephalad to camera cannula in the 2nd or 3rd ICS. The left instrument arm was positioned 4 to 6 cm caudal to the camera cannula in the 5th or 6th ICS. Arm trocar sites were maintained 6 cm apart at chest entry. The internal mammary artery was harvested in routine methods. Thirteen cases underwent left internal mammary artery harvest, one case underwent right internal mammary artery harvest, one case underwent double internal mammary harvest. MIDCAB was performed on beating heart in 14 cases and 1 case accepted the totally endoscopic coronary artery bypass (TECAB). RESULTS: All cases were accomplished successfully without complications. The average time of ICU was 20 hours. Robotic surgery had less draining than the conventional coronary bypass. CONCLUSIONS: Totally robotic internal mammary artery harvest and beating heart coronary artery bypass is less invasive, more precise, safe and efficient.