The port sites are marked on the patients skin (Fig. 8.3) before the incision is made. The camera port mark is on a transverse line midway between the suprasternal notch and the xiphoid process. The elevation of the camera port is located about 3 cm lateral of the midclavicular line (MCL), any place from 4 to 6 cm medial of the anterior axillary line (AAL) depending on the body habitus. This location is typically at the 4th or 5th ICS but depends on the body habitus and the length of the sternum. The location of the left instrument port is about the breadth of four fingers from the camera mark at about the same elevation, and always in the seventh ICS. The right instrument port is about the breadth of four fingers from the camera port at about the same elevation, and always in the third ICS. The three ports are in the almost same line. However, our experience is that left port should be little lower in order to prevent collisions. After deflation of the left lung, a camera port is inserted through the middle incision and carbon dioxide insufflation is initialed and maintained at an average of 6–8 mmHg, which may be increased to 12 mmHg as long as patients are able to maintain satisfactory hemodynamic status. A 30 degree-angle upward camera is inserted, and the thoracic cavity, the location and course of the LITA are examined. The left and the right instrument ports are inserted (Fig. 8.4). The surgical cart with 4 arms is brought in and docked to the camera and the instrument arm ports (Fig. 8.5).

After access to the left pleura space, a 30° upward endoscope is inserted to the camera port by the patient-side surgeon. The entire mediastinum is inspected. CO₂ is insufflated for adequate visualization and working space for hemodynamic tolerance. The required dose of CO₂ is nominally 8 mmHg (usually 8–10, 12–15 mmHg maximum for fatty mediastinum). LITA location and adhesions are carefully examined before surgery. The LITA is identified and pulsation can be observed. Both pedicle and skeletonized harvesting techniques can be applied. The skeletonized harvesting technique is similar to that used in open surgery or endoscopy.

First, the pleura parietalis, fascia and muscles covering the LITA are transected along the entire length (Fig. 8.6). This allows exposure of the vessel regardless of the amount of fat or muscle covering the mammary artery. The skeletonized LITA is dissected from the lateral edge medially using blunt dissection and short bursts of low power monopolar cautery to mobilize the anterior attachments (Fig. 8.7). Small intercostal branches are ligated with monopolar energy in a painting stroke then transected (Fig. 8.8). Large intercostal branches are clipped for hemostasis (Fig. 8.9). The entire length of LITA is dissected from the first intercostal branch to the diaphragm. Starting at about the 3rd ICS, short segments of periarterial connective tissue are left attached to help stabilize the ITA when the surgeon prepares the end for anastomosis.

The right ITA (RITA) can be harvested through the same approach for the LITA harvesting. After the instruments are inserted into the robotic ports, the anterior mediastinum is dissected and the instruments gain accesses to the right pleural space (Fig. 8.10). The RITA is identified. The pedicle or skeletonized harvesting technique is similar to that used in robotic LITA harvesting (Figs. 8.11, 8.12, 8.13, and 8.14). For RIMA to be the right coronary bypass graft, the RITA can also be robotically harvested using right chest approach, just the opposite to the left chest approach (Figs. 8.15 and 8.16).

There is an initial learning curve with the technique of robotic-assisted endoscopic ITAs harvest. From April 2007 to May 2013, 220 patients accepted totally robotic coronary bypass on beating heart (BH-TECAB, 100 cases) or robotic minimally invasive coronary bypass on beating heart (MIDCAB, 120 cases). The mean age was 58.9 ± 10.1 (33–78) years. ITA was harvested robotically in all cases successfully without damage leading to abandon, including LITAs, RITAs and double-ITAs harvesting with da Vinci S or Si system. The mean harvesting time was 30.8 ± 8.7 (16–52) min. A significant learning curve (Fig. 8.17) for harvesting time was noted: y(min) = 57.8 − 5.5 ln(x); (r ² = 0.342; P < 0.01)

The development of robotic surgical devices is a prerequisite for performing TECAB. However, TECAB is a highly complex procedure consisting of several but not routinely performed surgical steps, which requires a modular and step approach [5]. An important step of this procedure is the robotic ITA harvesting.

For the patients undergoing robotic harvesting, the preoperative three-dimensional computer tomography images are needed to be taken to evaluate the quality of the target ITA. The robotic-enhanced IMA takedown is a prerequisite for TECAB or MIDCAB operations and can be safely implemented. With a noted learning curve, the surgeon will harvest the target ITA in an acceptably shorter time. In this study the harvesting time stayed stable after about 30 cases and decreased as case number increased. The harvesting time was reduced to an acceptable duration between 25 and 30 min. Long preparation time at the beginning may be explained by the complexity of this new system and the lack of clinical experience of the operation team [6].

Bolotin and associates [7] reported robotic LITA harvesting speed in a range of 39–48 min when using the dog model. Learning curves and long preparation time at the beginning of implementation had also been described by Falk and associates [8] and Reuthebuch and coworkers [9]. The Falk group presented a LITA takedown time of about 40 min after 50 cases. The Reuthebuch study noted that after the learning curve, a target LITA harvesting speed in the 35 min range could be achieved.

In conclusion, robotic-enhanced IMA takedown can be safely implemented, and is prerequisite for TECAB operations. After overcoming learning curve, IMA takedown can be performed in an acceptable time. Demographics and chest size do not seem to influence ITA harvesting time. The rate of LITA injuries is comparable with the rate reported for conventional thoracoscopic harvesting [6].

After LITA is completely mobilized, the pericardium is incised robotically, anterior to the left phrenic nerve and the small pericardial branches are carefully cauterized (Fig. 8.18). This helps in clearing the operative field and also proper placing of ITA. Then the left anterior descending artery (LAD) or the target vessels are identified (Fig. 8.19) and the corresponding anterior intercostal space is identified to confirm the proper placement of the small left anterior thoracotomy incision, usually 4 cm long in the 4th ICS. After systemic heparinization, with an activated clotting time (ACT) goal of 350 s, the LITA is dissected distally. The distal end of the artery is parked on the pericardium using a hemoclip (Fig. 8.20). If RITA is to be used for anastomosis, it is harvested prior to LITA harvest. RITA is harvested in its full length as a skeletonized conduit as described above in Fig. 8.16. If a free RITA is to be used for composite grafting, it is dissected at its origin, and the free RITA is parked on the pericardium. The small left anterior thoracotomy incision (about 4 cm) may be made in the fourth or fifth intercostal space (Fig. 8.21). And the left pleural cavity is entered and a retractor is placed in the incision (Fig. 8.22). The distal end of the artery is then prepared for anastomosis. LAD is stabilized with a cardiac stabilizer and LITA is anastomosed to LAD manually in the end to side fashion, using a continuous 7-0 Prolene suture (Fig. 8.23). The in situ LITA is always used as grafting to the LAD (Fig. 8.24), or sequentially to diagonal branch (Fig. 8.25). The LAD along with composite RITA can be used to the lateral wall grafts. In some instances, in situ RITA can be anastomosed to the LAD, and in situ LITA to the lateral wall vessels. All composite grafts are anastomosed prior to the coronary grafting.

Conventional coronary artery bypass grafting provides complete revascularization with excellent long-term results for various clear-cut indications with a major favorable impact on the patient outcome and recurrence of adverse cardiac events. The success of catheter-based techniques for treating ischemic coronary syndromes, combined with the shift toward less invasive approaches, has renewed interest in minimally invasive approach. The current tendency is to perform operations through smaller and smaller incisions to reduce hospital stay and to hasten postoperative recovery. After the introduction of robotic telemanipulators, TECAB became feasible in the late 1990s. Didier Loulmet [1] performed the first TECAB procedure on arrested heart in 1999, and subsequently several investigators reported TECAB on beating heart [10, 11]. However, only a limited number of cases have been performed worldwide.