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A Novel Robotic Bilateral Internal Mammary Artery Harvest Using Double Docking Technique for Coronary Artery Bypass Grafting

Tarui, Tatsuya MD, PhD; Ishikawa, Norihiko MD, PhD; Watanabe, Go MD, PhD

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: January/February 2017 - Volume 12 - Issue 1 - p 74–76
doi: 10.1097/IMI.0000000000000331
How-To-Do-It Articles

da Vinci Surgical System (da Vinci) enabled port access for internal mammary arteries (IMA) harvesting. However, bilateral IMA (BIMA) harvesting is difficult when performed on single side. We developed a novel technique of double docking the da Vinci by transpositioning from the left side to the right and examined the feasibility. Twelve patients underwent BIMA harvesting using the double-docking technique. First, the da Vinci was set on the patient's left side for the right IMA harvesting. Afterward, the da Vinci was undocked and transpositioned from the patient's left side to the right side. The time elapsed during rotation was measured. Subsequently, the left IMA was harvested from patient's right side. Distal anastomoses were performed by a small anterolateral thoracotomy. All of the IMAs were harvested and then bypassed without damage. The mean ± SD time that elapsed during rotation was 6.5 ± 0.6 minutes. There was no conversion to sternotomy. Bilateral IMA harvesting by the bilateral docking technique was performed successfully with acceptable feasibility.

From the Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Tokyo, Japan.

Accepted for publication December 5, 2016.

A video clip is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (

Disclosure: The authors declare no conflicts of interest.

Address correspondence and reprint requests to Tatsuya Tarui, MD, PhD, Department of Cardiovascular Surgery, NewHeart Watanabe Institute, 3-19-11 Hamadayama, Suginami, Tokyo, Japan 168-0065. E-mail:

The use of da Vinci Surgical System (da Vinci; Intuitive Surgical, Sunnyvale, CA USA) has made the harvesting of the IMA through port incisions and coronary artery bypass grafting (CABG) through small thoracotomy possible, thereby decreasing surgical trauma and increasing cosmetic benefits.1–3 Although the effectiveness of bilateral IMA (BIMA) by conventional CABG has been reported,4 fewer studies of the da Vinci have been performed and its effectiveness has not been assessed. Robotic single internal mammary artery (IMA) harvesting, especially for the left IMA (LIMA), is said to be effective and feasible.5 However, BIMA harvesting from unilateral side is very difficult. As such, we believed that harvesting the right IMA (RIMA) from the patient's right side and LIMA from the left would be fast and effective.

We adopted the double-docking technique, in which we moved the da Vinci from one side to the other side of the patient. Here, we report the effectiveness and feasibility of the double-docking technique of the da Vinci for BIMA harvesting.

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Between July 2013 and August 2015, after signing informed surgical consent, 12 patients underwent BIMA harvesting by the double-docking technique by da Vinci in our institute.

The patients were anesthetized using a double-lumen endotracheal tube to enable selective single-lung ventilation. The RIMA was harvested from the patient's left side, followed by the LIMA harvesting from the patient's right side (Figs. 1A, B). For RIMA harvesting, a robotic camera port was created in the fourth intercostal space (ICS) on the anterior axillary line in the right chest, and carbon dioxide (CO2) insufflation was used to maintain a pressure of 6 to 12 mm Hg. In addition, two more instrument ports were created: one in the second ICS and another in the sixth ICS (Fig. 2). The skeletonized harvesting technique was similar to that used in open surgery (video, After the RIMA harvest, the da Vinci was undocked and moved from the patient's left side to the right side. The cables of the da Vinci remained connected throughout the rotation. After the creation of the ports in the patient's left side, LIMA harvesting was performed in the same manner as the RIMA (video,





We measured the time elapsed to move the da Vinci from the left side to the right side. The starting point was the moment that the RIMA harvesting was completed and thoracic hemostasis was confirmed, whereas the end point was the start of the LIMA harvesting.

For preparation for distal anastomosis, the RIMA was passed through the pericardium and led to the left thoracic cavity for distal anastomosis. Through the left thoracotomy in the fourth ICS, distal anastomosis was performed under direct vision (video,

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Bilateral IMA harvesting by the double-docking technique was performed in ten men and two women with a mean ± SD age of 58.3 ± 10.8 years. The mean ± SD hemoglobin A1c (National Glycohemoglobin Standardization Program) was 7.7 ± 2.2%. The mean ± SD preoperative ejection fraction was 60.0 ± 15.7%. The patients who received dual antiplatelet therapy continued the medication until the operative day.

Bilateral IMA harvesting was successful in all patients. There were no injuries to the BIMA during harvesting, and no dissection was observed in any of the grafts. Total grafts per patient ranged from 2 to 4 (mean ± SD, 2.7 ± 0.5). The graft distribution is listed in Table 1. The median ± SD operation time was 248.8 ± 115.8 minutes. The mean ± SD time required for rotation from the right to left side was 6.5 ± 0.6 minutes. Transposition of the da Vinci was successful in all cases with no mechanical problems. There were no cases of operative death, myocardial infarction, cerebrovascular accident, or renal failure.



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Bilateral IMA harvesting from one side of the patient is very difficult and requires an advanced technique. Feasibility of this technique depends heavily on the patient's anatomy because the far side of the IMA must cross the mediastinum. Surgical vision is limited, and sufficient ITA length cannot be harvested. Harvesting is especially difficult in patients who are obese or small or have a funnel chest. In our new approach of the double-docking technique using the da Vinci, BIMA can be harvested easily with acceptable length, and RIMA grafts was used for left anterior descending artery as an in situ graft. As reported previously, using this method, bypass to the target vessel was achieved in every patient. RIMA harvesting from the patient's right side is technically easy because the heart does not project as far into the right thoracic cavity as it does into the left thoracic cavity and surgical vision is not restricted by the heart during the harvest.

Furthermore, during the ITA harvest, insufflation to the thoracic cavity by CO2 is performed. In BIMA harvesting using a unilateral approach, the bilateral lungs are suppressed for oxygenation by pneumothorax. This can lead to high airway pressure, which can cause severe pulmonary complications such as barotrauma. Using the double-docking technique, the CO2 insufflation is performed on one side at a time and the lungs are not simultaneously suppressed. Thus, we noted no respiratory system complications reported in other studies.

Skeletonized IMA harvesting reportedly has better patency for CABG.1 With the use of a high-resolution three-dimensional monitoring system, robotic IMA harvesting can be performed with less damage. The side branch of the IMA was detected clearly, and the IMA was dissected quickly and with little damage. In our study, no postoperative re-exploration was required because the side branch was adequately dissected.

For patients with severe diabetes mellitus, the risk of infection to the mediastinitis by a median sternotomy in harvesting both IMA is considered high. This approach avoids the need for median sternotomy and seems to reduce the risk of mediastinitis. Avoiding a sternotomy also reduced the blood loss. In our study, more than half of the patients were administered two antiplatelet drugs (also known as hybrid therapy), but the procedure was performed safely regardless.

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The double-docking technique of the da Vinci is now in the developing stage. Technical advancements are needed to decrease the operation time. The time for rotating the da Vinci will shorten with an acceptable learning curve. In the near future, the transposition time will decrease with the learning curve, and the results will continuously improve. This approach may be an evolutionary step toward total endoscopic coronary bypass surgery.

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1. Srivastava S, Gadasalli S, Agusala M, et al. Use of bilateral internal thoracic arteries in CABG through lateral thoracotomy with robotic assistance in 150 patients. Ann Thorac Surg. 2006;81:800–806.
2. Ishikawa N, Watanabe G, Tomita S, Yamaguchi S, Nishida Y, Iino K. Robot-assisted minimally invasive direct coronary artery bypass grafting. ThoraCAB. Circ J. 2014;78:399–402.
3. Bonatti J, Schachner T, Bonaros N, et al. Effectiveness and safety of total endoscopic left internal mammary artery bypass graft to the left anterior descending artery. Am J Cardiol. 2009;104:1684–1688.
4. Locker C, Schaff HV, Dearani JA, et al. Multiple arterial grafts improve late survival of patients undergoing coronary artery bypass graft surgery: analysis of 8622 patients with multivessel disease. Circulation. 2012;126:1023–1030.
5. Halkos ME, Liberman HA, Devireddy C, et al. Early clinical and angiographic outcomes after robotic-assisted coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2014;147:179–185.

Double-docking technique; Bilateral internal thoracic artery harvesting; Minimally invasive coronary artery bypass grafting; da Vinci surgical system; Robotically-assisted surgery

©2017 by the International Society for Minimally Invasive Cardiothoracic Surgery