全胸腔镜下左乳内动脉取材术在MIDCAB手术中的应用

Thoracoscopic internal mammary artery harvesting approach in MIDCAB

目的冠状动脉粥样硬化性心脏病（CAD）患者接受微创直视冠状动脉旁路移植术（MIDCAB）手术治疗时，采用两种入路进行非机器人辅助全胸腔镜下乳内动脉取材术（TIMAH），探讨该手术方式的术前准备、操作方式、主要特点、优势及不足，并观察短期疗效。方法CAD男性患者7例，年龄52～75岁，平均（63．8±8．5）岁，均行TIMAH和左乳内动脉（LIMA）到前降支（LAD）的旁路移植手术。其中LAD单纯闭塞性病变3例，钙化性重度狭窄2例，支架术后支架内血栓再狭窄1例，此6例患者均试行介入治疗，未获成功。另1例为冠状动脉旁路移植术（CABG）后，LAD静脉桥路闭塞，回旋支病变加重，进行二次CABG手术的患者。7例患者均行全麻双腔气管插管，右侧单肺通气，采用两种人路进行TIMAH，其后完成MIDCAB手术。其中4例经左腋前线第3肋间打孔置入胸腔镜，经左侧第5肋间左前外侧小切口完成LIMA取材术，其后经小切口进行冠状动脉吻合（简称2切口手术）；3例经左腋前线第2或3肋间打孔置入胸腔镜，经左侧第4肋间腋前线和第5肋间锁骨中线打胸腔镜操作孔完成LIMA取材术，其后根据前降支位置扩大第5肋间操作孔进行冠状动脉吻合（简称3切口手术）。冠状动脉血管吻合应用普通胸壁牵开器和压迫式心脏稳定装置。二次手术患者完成LIMA与LAD吻合后，以大隐静脉行LIMA到钝缘支的“Y”型桥。结果全部患者均完成MIDCABG手术，无中转正中开胸。6例LIMA取材质量良好，1例LIMA床止血过程中误伤LIMA远端，导致长度不足，加用2cm大隐静脉延长LIMA长度。6例对LAD单支手术的患者，左胸壁小切口长度（6．0±0．9）cm，TIMAH时间（112±18）min，手术时间（293±75）min，术中出血（233±52）ml，围手术期均未异体输血，术后气管插管（14．2±10．7）h，ICU停留（1．8±0．4）天，术后住院（10．1±6．7）天。患者术后恢复良好，顺利出院，短期随访，心绞痛症状消失。结论2切口和3切口手术均可完成TIMAH，手术安全可行，无需为LIMA取材向正中方向延长切口，手术切口小，术后恢复顺利，短期随访效果良好。

Objective To analysis of preoperative preparation, operation, character, advantage and deficiency of two non- robotic TIMAH approach in MIDCAB, and to observe the short-term follow up result. Methods 7 male CAD patients with classic unstable angina pectoris, the age ranged from 52 to 75 years , average （63.8±8.5 ） years, underwent TIMAH and MIDCAB, in which 6 single LAD disease patients and one patient for reoperation with saphenous vein graft （SVG） graft failure to LAD and progressive obtuse marginal（OM） coronary artery disease. These patients were intubated with a double-lumen endotracheal tube, and one-lung ventilation were used to facilitate the procedure. In the approach of two incisions TIMAH for 4 patients, the thoracoscope was placed at the third intercostals space（ICS） on the anterior axillary line, and LIMA was dissected with endo-instruments placed from the two angles of mini-thoracotomy at fifth ICS on the midclavicular line. In the approach of three incisions TIMAH for 3 patients, LIMA was dissected with endo-instruments placed from two ports at the fourth ICS on the anterior axillary line and at the fifth ICS on the midclavicular line, and the thoracoscope was placed at the second or third intercostals space （ICS） on the anterior axillary line. Anastomosis of LIMA and LAD followed through mini-thoracotomy at fifth ICS with the heart stabilizer after TIMAH. SVG graft was used from LIMA to OM in the reoperation patient. Results All patients underwent TIMAH and MIDCAB safely without transferece to stenotomy, only one LIMA was extended with 2 cm SVG for injure at the distal. In 6 single vessel disease patients the length of mini-thoracotomy incision was （6.0 ± 0.9 ） cm, TIMAH time was （112 ± 18） min, operation time was （293 ±75 ） min, bleeding volume was （233 ± 52） ml, endotracheal tube time was （ 14.2 ± 10.7 ） h, ICU time was （ 1.8 ± 0.4） d and hospital stay time was （ 10.1 ± 6.7） d. All patients were uneventful discharged and with no recurrence of cardiac symptoms in short-term follow up. Conclusion TIMAH can perform safely in both approaches for LIMA prepare to MIDCAB as described before. The minimally invasive procedure need not enlarge incision for LIMA harvesting with good short term results.