The ultimate goal of Minimally Invasive Multivessel Coronary Surgery (MICS) is treating multivessel coronary artery diseases in an endoscopic manner. There is sufficient progress made in minimally invasive surgery where the burden of the patient is minimized to a lower amount. Rodriguez & Ruel, (2016) in their observation notes that in coronary artery bypass grafting (CABG), minimally invasive surgery is used for assistance in minimally invasive direct coronary artery bypass grafting (MICS-CABG) as well as robot-assisted CABG. In MICS-CABG, the surgeon positions small incision than under conventional surgery and conducts the operation on a beating heart.
Almost 2.8 vessels are anastomosed to the heart in coronary artery bypass grafting. On the other hand, in robot-assisted CABG, one vessel is anastomosed. However, in multi-vessel CABG, coronary stones can exist on the heart’s dorsal aspect; the position of the heart should be altered and exposed. Such an operation is considered to bring upon the heart a burden. For this reason, instruments and techniques for multi-vessel CABG that do not require changing the heart’s posture are necessary.
Progress due to this, has constantly been made in the development of surgery assisting robots as well as forceps manipulators to provide solutions for these issues as well as providing further improvement to minimally invasive multivessel coronary surgery. These manipulators provide the required manipulation. Importantly, the approach to a dorsal aspect of organs is an essential challenge in minimally invasive multivessel coronary surgery. As an example, Rodriguez & Ruel provides an image of a section of the chest. This figure shows the expires for distal anastomosis with the help of a small thoracotomy. It proves that it is possible to undertake MICS with or without Cardiopulmonary Bypass (CPB) assistance.
In their literature, Deo et al. (2014) addressed that minimally invasive cardiac surgery focused on ameliorating two potentially invasive surgical intervention components. They included CPB and the sternotomy incision. Even though multivessel revascularization can be achieved through bilateral LITA takedown as well as particular endoscopic cardiac position instrument, most patients who undergo EACAB receive isolated revascularization of the LAD and the diagonal branches.
The common situation where EACAB is employed for isolated LAD revascularization includes isolated LAD disease, a multivessel disease where EACAB is used as part of revascularization, isolated proximal left main disease and multivessel disease where EACAB is used as part of the revascularization. Specific attention has to be paid on angiogram in order to choose patients in whom ease of anastomosis will be maximized. Also, the careful review should be based on diffused diseased distal LAD targets. Similarly, addition attention has to possibly intramyocardial LAD segment is essential since the situations can create technical challenges when conducted through minimally invasive processes.
Even though randomized evaluation of conventional CABG and MICS-CABG for the multivessel coronary disease has not been conducted, strengths and weaknesses to revascularization can be mentioned. The strengths include proved survival benefit, complete revascularization, perfect angina relief, few subsequent procedures, and the possibility of long-term survival benefit of CABG. On the contrary, the potential weaknesses include increased magnitude of surgery as well as the long period of hospital recovery, utilization of CPB and the attendant issues and questionable risks of the periprocedural Q-wave myocardial infarction. Even so, the primary potential benefit of MICS-CABG involves avoiding CPB and reduced magnitude of surgery which results in reduced postoperative pain and early return to work. Despite this fact, several questions still remain unanswered in terms of minimally invasive approaches to surgical revascularization.
References
Rodriguez, M., & Ruel, M. (2016). Minimally Invasive Multivessel Coronary Surgery and Hybrid Coronary Revascularization: Can We Routinely Achieve Less Invasive Coronary Surgery?. Methodist DeBakey cardiovascular journal, 12(1), 14.
Deo, S. V., Sharma, V., Shah, I. K., Erwin, P. J., Joyce, L. D., & Park, S. J. (2014). Minimally invasive direct coronary artery bypass graft surgery or percutaneous coronary intervention for proximal left anterior descending artery stenosis: a meta-analysis. The Annals of thoracic surgery, 97(6), 2056-2065.
