1. Computer-Assisted or Robotic Totally Endoscopic Coronary Artery Bypass Grafting 
Randall K. Wolf 
Operative Techniques in Thoracic and Cardiovascular Surgery 
Volume 6, Issue 3, Pages (August 2001)
DOI: /otct
Copyright © 2001 Elsevier Inc. Terms and Conditions

2. 1
The DaVinci console. The surgeon comfortably rests his or her forehead on the soft pad (A) and visualizes the internal view in 3D. Magnification is dependent on the distance to the target (up to 8 times closer to the target). The hands are placed in a cardiac needle holder-like instruments, and all hand and wrist motions are interpreted by the computer and translated into binary code.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

3. 10
Postoperative angiogram in a patient who underwent a totally endoscopic LITA to LAD with the DaVinci system. The LITA artery is widely patent to the LAD.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

4. 11
Dual console setup
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

5. 2
As in all endoscopic techniques, precise port placement is key. (A) Port placement is particularly important in the chest, because the ribs limit instrument mobility. The difference of one intercostal space for proper port placement can be impressive. Here I describe port placement for endoscopic robotic LITA mobilization and LITA to LAD bypass. The patient is intubated with a double-lumen endotracheal tube, if possible, and the left lung is not ventilated. The patient is positioned on the left side up 30° on a bean bag with the left arm slightly lower than the left edge of the body. The left shoulder should drop slightly toward the floor. Alternatively, the left arm can be positioned elevated superiorly with the left hand across the forehead using an Allen arm holder (B). This allows for proper right hand or superior port placement. The topical anatomy (angle of Louis and intercostal spaces) is marked and a 12-mm Ethicon (Cincinnati, OH) port is placed in the fifth intercostal space just anterior to the anterior axillary line. In a male, this port is placed slightly inferior and lateral to the left nipple. The port is placed atraumatically, using only cautery and the DaVinci trocar to dilate the opening before placement. Insufflation is instituted immediately (before camera placement) to depress the left lung and distract the ventricle posteriorally in the chest. 6- to 10-mm Hg CO2 insufflation is generally well tolerated.3 The systemic blood pressure is carefully monitored and insufflation adjusted accordingly.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

6. 3
The camera is inserted, and the internal thoracic anatomy is evaluated (A). The 30° camera is held by an assistant while 7-mm ports are placed, under direct scope vision if possible, in the third and seventh intracostal spaces. The instrument cart is then brought to the bedside and the instruments and camera attached to the instrument cart (B). The surgeon then may begin 3D work at the surgical console.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

7. 4
The third intracostal space port is more medial than the camera port, to avoid external collisions with the left shoulder. The ports should be at least 5 cm apart from one another also to avoid external collisions. The subxyphoid port is used to properly position the compression/suction stabilizer (Intuitive Surgical).
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

8. 5
Once the instruments for LITA mobilization are placed (right-hand monopolar cautery, left-hand Debakey grasper), the camera is attached to the system and the operator is seated at the console. The LITA is mobilized from the first rib (just below the left phrenic nerve) to the sixth rib. Branches are controlled by cautery and occasionally by hemoclips. Both ITAs can be mobilized from left-sided ports. In bilateral mobilization, it is best to mobilize the RITA first, otherwise the mobilized LITA may interfere with visualization of the RITA. After heparinization, the mobilized pedicled mammary is occluded with a Scanlon (St. Paul, MN) plastic vascular bulldog, hemoclipped distally, and divided.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

9. 6
The pericardial fat is dissected medially to laterally to expose the pericardium. The pericardium is opened medially and longitudinally over the LAD. It is important to dissect the pericardial fat medially to laterally so that it does not interfere with exposure after the pericardium is opened. The 30° camera is turned down for better visualization of the LAD.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

10. 7
The DaVinci endoscopic stabilizer is then placed through a subxyphoid port and positioned over the LAD. The LAD must be clearly identified. The stabilizer uses suction and is attached to the bed rail. Vessel occlusion is obtained with silastic tapes proximally and distally on the LAD. The tapes are secured to the stabilizer. After spatulization of the LITA and arteriotomy of the LAD, the anastomosis is constructed. The running suture technique is altered to facilitate the anastomosis in an endoscopic setting.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

11. 8
A specially made 7-cm double-arm 7-0 polypropoleyne suture is used. The suture is begun inside-out near the toe of the LITA and run to past the heel. The opposite needle is used to run from inside the LAD out and around to the first needle, where the suture is secured. An alternate technique is to construct the anastomosis with sutured clips (Coalescent Surgical, Sunnyvale, CA). The sutured clips offer the advantage of an interrupted technique with no knots. The bulldog is removed from the LITA, and hemostasis is verified. After the occlusive tapes are loosened, the instrument cart is removed. A chest tube is placed through the inferior port, and the left lung is inflated under scope visualization.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

12. 9
Postoperative photograph of a patient who successfully underwent totally endoscopic coronary artery bypass (LITA to LAD) using the Da Vinci system. The port sites are (1) right hand, (2) camera, (3) left hand, and (4) stabilizer.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions