机器人辅助双侧乳内动脉获取微创小切口五支冠状动脉旁路移植一例

Robot-assisted bilateral internal mammary arteries harvesting for off-pump coronary artery bypass grafting with 5 grafts by minimally invasive small incision: A case report

目的介绍机器人辅助双侧乳内动脉获取经左前外侧小切口行心脏不停跳冠状动脉5支搭桥手术的方法及初步经验。方法采用达芬奇机器人手术系统获取双侧乳内动脉,经右侧第2肋间打孔将原位右乳内动脉拉出胸腔外。经左胸外侧小切口,截取右乳内动脉远端部分与左乳内动脉构建Y型桥,将大隐静脉与原位右乳内动脉端端吻合构建复合桥并回纳入胸腔内。非体外循环下使用心表稳定器,分别将左乳内动脉Y型桥与前降支及对角支行端侧吻合,将右乳内动脉-大隐静脉复合桥与钝圆支、左室后支及后降支行序贯吻合完成手术。结果手术过程顺利,未出现血流动力学不稳定需主动脉内球囊反搏(IABP)或体外循环辅助。左乳内动脉Y型复合桥血流量24 mL/min,右乳内动脉-大隐静脉复合桥血流量30 mL/min。呼吸机辅助时间35 h,住ICU时间62 h,围术期心肌酶一过性增高。术后冠状动脉造影(CTA)显示桥血管均通畅,心脏超声提示心功能正常,术后7 d患者痊愈出院。结论机器人辅助获取双侧乳内动脉行微创小切口非体外循环5支冠状动脉旁路移植术可行,可实现完全血运重建。

Objective To introduce the method and preliminary experience of robot-assisted bilateral internal mammary arteries(BIMA)harvesting for off-pump coronary artery bypass grafting(OPCAB)with 5 grafts via left anterolateral minithoracotomy.Methods BIMA were harvested using the da Vinci robotic surgical system,and the right internal mammary artery(RIMA)was pulled out of the thoracic cavity through right second intercostal space.Intercepting the distal part of the RIMA for the BIMA composite Lima-Rima Y graft and anastomosing the great saphenous vein with remaining RIMA end to end.The Y graft anastomosed with left anterior descending(LAD)branch and diagonal branches(DIAG),artery-vein graft sequentially anastomosed with blunt round branch,left ventricular posterior branch and posterior descending branch.Results The operation succeeded without hemodynamic instability and intra aortic balloon pump(IABP)implantation or cardiopulmonary bypass.The blood flow of Y graft was24 mL/min,and the blood flow of artery-vein graft was 30 mL/min.Ventilator assistance time was 35 hours,ICU staying time was 62 hours,and postoperative myocardial enzymes increased temporarily.Postoperative coronary CTA showed that all the grafts were patency,and cardiac ultrasound indicated that the heart function was normal.The patient cured and discharged from hospital 7 days after operation.Conclusion Robot-assisted bilateral internal mammary artery harvesting for OPCAB with 5 grafts via left anterolateral minithoracotomy is feasible,which can achieve complete revascularization.