Robotic totally endoscopic coronary artery bypass grafting: current status and future prospects

ABSTRACT

Introduction: Totally endoscopic coronary artery bypass grafting (TECAB) can only be performed in a reproducible manner using robotic technology. This operation has been developed for more than 20 years seeing three generations of surgical robots. TECAB can be carried out beating heart but also on the arrested heart. Single and multiple grafts can be placed and TECAB can be combined with percutaneous coronary intervention in hybrid procedures.

Areas covered: This review outlines indications for the procedure, the surgical technique, and the postoperative care. Intra- and postoperative results as available in the literature are reported. Further areas focus on technological development, training methods, learning curves as well as on cost. Finally, we give an outlook on the potential future of this operation.

Expert opinion: Robotic TECAB represents a complex, sophisticated but safe, and over-the-years grown procedure. Even though results seem to be in line with conventional coronary surgery worldwide adoption still has been slow probably due to procedure times, costs and learning curves. Main advantages of TECAB are minimized surgical trauma and subsequent reduction of postoperative healing time. With the current introduction of new robotic devices, a new era of procedure development is on its way.

KEYWORDS:

• Coronary artery grafting
• robotic
• endoscopic
• technique
• perspectives

Article highlights

• Robotic totally endoscopic coronary artery bypass grafting (TECAB) has been performed and developed for more than 20 years.

• Robotic technology is the only reasonable method to perform a completely endoscopic version of coronary bypass grafting. The key technologies are multi-wristed end-effectors which allow complex surgical maneuvers inside the chest as well as a robotic arm fourth arm which holds an instrument for exposure and stabilization of the coronary artery targets.

• The procedure can be performed with remote heart–lung machine perfusion and cardioplegia and also on the beating heart. Up to four grafts have been placed and hybrid approaches using combinations with percutaneous coronary interventions are very well feasible.

• Perioperative and long-term outcomes seem to meet the standards of open coronary bypass surgery. Hospital length of stay is shorter and patients return to normal activities earlier. TECAB is the version of coronary bypass surgery with the least tissue trauma and the most appealing cosmetic result.

• For successful implementation of TECAB programs simulation, mock operations, appropriate team management, and a stepwise approach are necessary.

• Current and future technological developments include 3D vision for all surgical team members, interconnected individual columns with single robotic arms, and automated collision detection. Procedure-specific exposure devices should be designed and anastomotic connectors should be integrated into robotic end-effectors. Instrument excursions are a target for procedure analysis using artificial intelligence and elements of automated surgery may be available in the intermediate term.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.