Robotic Skeletonized Internal Thoracic Artery Harvesting: The Sliding Fascia Technique

Robotic skeletonizing and harvesting of the internal thoracic artery, using the da Vinci surgical system, has a number of advantages over robotic pediculed ITA harvesting. The advantages include greater blood flow, a longer conduit, and less bleeding. The technique is facilitated by use of the EndoWrist spatula cautery and fine tissue forceps (Intuitive Surgical, Inc., Sunnyvale, CA, USA). How the technique is performed is described in this report.     

Passing the Right Internal Thoracic Artery Through the Transverse Sinus

We describe a simple reliable method to pass the right internal thoracic artery safely through the transverse sinus. At first, a 4-mm-wide vascular tape is passed through the transverse sinus. The cut end of the right internal thoracic artery is then attached to the right end of the tape with a hemoclip. Pulling the left end of the tape leftwards can ensure the passage of the right internal thoracic artery without any risk of twisting.     

Cystic Medial Necrosis of the Internal Thoracic Artery: Case Report

In an internal thoracic artery intended as a graft in coronary angioplasty, multiple intramural haematomas impeded blood flow and consequently precluded use of the artery as a free graft. The cause was found to be cystic medical necrosis of the internal thoracic artery. A good result was obtained with three single aorto-coronary venous bypass grafts.     

乳内动脉skeleton取材法在冠状动脉旁路移植术中的应用

目的 评价乳内动脉skeleton取材法在冠状动脉旁路移植术（CABG）中的应用及其效果。方法 277例接受CABG的患者（其中合并糖尿病33例）在术中分离乳内动脉的过程中，仅使用剪刀和钛夹来分离乳内动脉，即不附带任何周围组织的skeleton取材法游离一侧或两侧乳内动脉，其中21例糖尿病患者取用双侧乳内动脉；并观察患者术中、术后的临床结果。采用非体外循环CABG5例，体外循环CABG272例。结果 体外循环时间60～217min，平均90．1min；主动脉阻断时间30～160min，平均53．3min。手术死亡率2．2％（6／277）。手术中见乳内动脉桥质量良好，动脉桥血流量满意；术后移植血管通畅，心绞痛症状消失。取用双侧乳内动脉和糖尿病患者亦未出现更高的胸骨感染率。手术后冠状动脉造影显示乳内动脉血管桥通畅。结论 乳内动脉skeleton取材法有良好的血管桥通畅率，对患者胸骨创伤较小，对糖尿病患者取用双侧乳内动脉不再是禁忌证。     

The Clinical Significance of Performing Preoperative Angiography of the Internal Thoracic Artery in Coronary Artery Bypass Surgery

(Received for publication on Nov. 25, 1996; accepted on July 8, 1997)     

The Internal Thoracic Artery and Its Branches After Coronary Artery Anastomoses in Pediatric Patients

The internal thoracic artery has been favored because of its superior early and late patency for coronary artery bypass grafting (CABG) in pediatric patients. We have studied the angiographic changes of the internal thoracic artery and its side branches before and after CABG with internal thoracic artery to the left anterior descending artery. The internal thoracic artery with remaining thymic or pericardial branches was patent but showed enlargement of the branches in the early period after the operation, and a postoperative exercise test suggested a remaining ischemic lesion in the bypass. Angiogram taken 1 year after CABG demonstrated the grown internal thoracic artery with disappearance of most of the side branches, which had been enlarged 1 month after the operation. Our findings suggest the importance of ligation of the whole proximal internal thoracic artery branches to maintain good early and late patency.     

Feasibility of an endoscopic approach to the axillary nerve and the nerve to the long head of the triceps brachii with the help of the Da Vinci Robot

Surgery to transfer the axillary nerve and the nerve of the long head of the triceps presents two obstacles: 1) the access portals are not standardized and 2) the nerves are for their larger part approached through large incisions. The goal of this study was to explore the feasibility of an endoscopic microsurgical approach. The posterior aspect of a cadaver shoulder was approached through three communicating mini-incisions. The Da Vinci robot camera was installed on a central trocart, and the instrument arms on the adjacent trocarts. A gas insufflation distended the soft tissues up to the lateral axillary space. The branches of the axillary nerve and the nerve to the long head of the triceps brachii muscle were identified. The dissection of the axillary nerve trunk and its branches was easy. The posterior humeral circumflex veins and artery were dissected as well without any difficulty. Finding the nerve to the long head of the triceps brachii was found to be more challenging because of its deeper location. Robots properties allow performing conventional microsurgery: elimination of the physiologic tremor and multiplication of the movements. They also facilitate the endoscopic approach of the peripheral nerves, as seen in our results on the terminal branches of the axillary nerve and the nerve to the long head of the triceps brachii.     

Importance of Preoperative Marking for Minithoracotomy and for Internal Thoracic Artery Harvesting in Minimally Invasive Direct Coronary Artery Bypass Grafting

(Received for publication on Apr. 21, 1999; accepted on Nov. 11, 1999)     

达芬奇外科系统在胆道疾病手术中的应用体会

目的:总结达芬奇外科系统在胆道疾病手术中的经验,并探讨其优越性。方法:2010年2月至2011年10月应用达芬奇外科系统为24例胆道疾病患者施术。分析总结分别以肝十二指肠韧带、肝脏为视野的两组患者手术过程及术后康复情况。结果:24例患者中1例中转开腹,无一例死亡。以肝十二指肠韧带为术野的17例患者手术时间平均(342.4±37.4)min,术中出血量平均(168.8±39.5)ml,术后平均住院(11.6±1.5)天。以肝脏为术野的7例患者手术时间平均(438.5±33.9)min,术中出血量平均(292.9±67.6)ml,术后平均住院(10.1±1.2)天。结论:达芬奇外科系统不仅可独立完成胆道疾病手术,使患者受益,而且受到外科医师的青睐,将会推动腹腔镜外科的进程。     

Robotic surgery update

Background Minimally invasive surgical techniques have revolutionized the field of surgery. Telesurgical manipulators (robots) and new information technologies strive to improve upon currently available minimally invasive techniques and create new possibilities.Methods A retrospective review of all robotic cases at a single academic medical center from August 2000 until November 2002 was conducted. A comprehensive literature evaluation on robotic surgical technology was also performed.Results Robotic technology is safely and effectively being applied at our institution. Robotic and information technologies have improved upon minimally invasive surgical techniques and created new opportunities not attainable in open surgery.Conclusions Robotic technology offers many benefits over traditional minimal access techniques and has been proven safe and effective. Further research is needed to better define the optimal application of this technology. Credentialing and educational requirements also need to be delineated.     

应用钩-钉内固定框架治疗特发性胸椎侧弯

目的 :分析钩 椎弓根钉内固定框架在治疗特发性胸椎侧弯中的治疗效果。方法 :自 1998年 12月～ 2 0 0 0年 12月 ,3 2例特发性胸椎侧弯的患者接受手术治疗 ,患者均采用钩 钉配置的固定矫正方法 ,即上胸椎采用多钩固定 ,胸腰段采用椎弓根钉固定系统。术前、术后测量侧弯角、顶椎旋转度、最低固定椎体 (LIV)的倾斜角、以及矢状位T5～T12 、L1～L5的屈曲角 ,随访时间为 2 2月 (10～ 2 8月 )。结果 :术前侧弯角平均为 68°(3 8°～ 10 5°) ,术后 8d胸椎矫正侧弯角平均为 3 2° ,平均矫正率为 5 8% ,术后随访最终平均矫正为 3 3° ,显示 1.7%的丢失。术前站立位的LIV倾斜角平均为 2 1° ,术后为 8°。术前、术后胸椎前曲角 (T4～T12 )为 + 18°/2 6°(8°) ,腰段 (T12 ～L2 )为— 3 6°/— 41°(5°)。顶椎的旋转度术前为2 0° ,术后为 15° ,显示 2 6%的矫正率。每例患者均未出现伤口感染和脊髓神经损伤 ,以及由椎弓根钉引起的神经根或硬膜囊损伤 ,随访未发现有内固定物脱落、断裂以及假关节形成的现象。结论 :使用钩—钉配置的固定方法在矫正特发性胸椎侧弯上简单有效 ,安全牢固 ,有利于未融合腰椎节段恢复正常的生理状态和功能 ,且不增加并发症的发生。     

Robotic phrenic nerve harvest: A feasibility study in a pig model

The aim of this study was to report on the feasibility of robotic phrenic nerve harvest in a pig model. A surgical robot (Da Vinci S™ system, Intuitive Surgical^®, Sunnyvale, CA) was installed with three ports on the pig's left chest. The phrenic nerve was transected distally where it enters the diaphragm. The phrenic nerve harvest was successfully performed in 45 minutes without major complications. The advantages of robotic microsurgery for phrenic nerve harvest are the motion scaling up to 5 times, elimination of physiological tremor, and free movement of joint-equipped robotic arms. Robot-assisted neurolysis may be clinically useful for harvesting the phrenic nerve for brachial plexus reconstruction.     

Reducing the Risk of Intraoperative Neurological Complications during Carotid Endarterectomy with Early Distal Control of the Internal Carotid Artery

AIM OF THE STUDY: To assess the feasibility and effectiveness of a modified surgical technique with early clamping of the distal internal carotid artery (ICA) during carotid endarterectomy in a single centre experience. STUDY DESIGN: Retrospective study, teaching hospital. MATERIAL AND METHODS: Between 1996 and 2002, 2235 CEAs were performed. Until April 1999, the intra-operative strategy consisted of standard isolation and dissection of the carotid bifurcation preliminary to ICA clamping (group 1; 1090 interventions). Starting from May 1999, we performed early isolation and clamping of the distal ICA, followed by dissection of the carotid bifurcation and clamping of the external and common carotid artery (group 2; 1145 interventions). RESULTS: The modified technique was feasible in all the patients of group 2. In group 2 there was a significantly lower incidence of neurological deficit on waking than in group 1 (0.4% and 1.8%, respectively; p=0.02). CONCLUSIONS: Early distal control of the internal carotid artery during CEA is feasible and could contribute to reducing intra-operative neurological events.