Editorial
The Evolution of Minimally Invasive Coronary Surgery
Federico Benetti* and Natalia Scialacomo
Department of Cardiac Surgery, Benetti Foundation Alem, Rosario Santa Fe Argentina
*Corresponding author: Federico Benetti, Cardiac Surgery, Benetti Foundation Alem, 1846, Rosario Santa Fe Argentina, Zip 2000
Published: 30 Apr, 2018
Cite this article as: Benetti F, Scialacomo N. The Evolution
of Minimally Invasive Coronary Surgery.
Clin Surg. 2018; 3: 1954.
Editorial
Despite Alexis Carrel early description of experimental CABG [1] surgeons were unable to
translate these techniques successfully to humans due to a lack of technology and tools to operate
on the unsupported beating heart. In 1952, Demikhov described the use of the LITA to directly graft
the LAD in dogs, with graft patency confirmed for up to 2-years [2] similar early success with the
use of the ITA was reported by Canadian surgeon Gordon Murray [3] William Longmire apparently
was the first surgeon in performing an OPCAB operation. He said they performed a couples of the
earliest internal mammary coronary anastomosis when they were forced into it when the coronary
artery they were endarterectomized disintegrates and in the desperation they anastomoses the left
internal mammary artery to the distal end of the right coronary artery [4] In 1960 Robert Hans Goetz
clear performed the first successful bypass operation grafting the right internal mammary to the
right coronary artery His medicals and surgical colleagues vehemently criticized him them he never
perform a CABG again in this Hospital [5] The first venous coronary bypass graft ever performed
was in April 4 1962 by Sabiston. The patient have an occlusion of the right coronary artery and
a saphenous vein was intentionally taken from the leg and anastomosed between the ascending
aorta and the right coronary artery Their cardiologists rapidly spread the news of this procedure
but unfortunately the patient later had and stroke and died [6] On the 25 February 1964, the same
year that Spencer performed the first LITA anastomosis to the LAD in the US with extracorporeal
circulation [7] Kolesov performed the first successful CABG using the suture technique. With
specially designed magnifying glasses and scissors, he grafted the LITA to the left circumflex artery
in a patient, who remained free of angina during 3-years of follow-up [8]. Garrett, Dennis, and
DeBakey also performed a successful unplanned CABG on November 23 1964, and reported 7 years
after [9] Up until the late 1950s, the main obstacle to the evolution of CABG surgery was an inability
to image the coronary tree and link symptoms with specific patterns of obstructive coronary disease.
On October 30th 1959, Mason Sones of the Cleveland Clinic inadvertently performed the world’s
first coronary angiogram. While undertaking an aortogram on a 24-year-old man with rheumatic
heart disease he accidently injected contrast into the right coronary artery [10]. This led to the
birth of coronary angiography and intense interest in coronary imaging, which generated a greater
understanding of coronary anatomy.
The ability to image the coronary arteries allowed Sones and his colleagues, including Donald
Effler and Rene Favaloro, to describe two distinct patterns of CAD, namely proximal and diffuse
obstructive disease. The Cleveland group initially advocated alternative management strategies for
these two patterns, recommending localized patch grafting for proximal disease and the Vineberg
procedure for diffuse disease Interestingly, in 1966 Favaloro reported to have performed Bilateral
Internal Thoracic Artery (BITA) grafting using the indirect Vinberg technique where the RITA
was placed in the Left Ventricle (LV) parallel to the LAD and the LITA in the lateral wall of the LV
between the branches of the circumflex and right coronary arteries with good clinical result.
Whilst the Cleveland Clinic reported reasonable results with the indirect Vineberg technique
they had a high mortality rate (11 of 14 patients) with the proximal patch graft technique. The high
mortality associated with direct coronary patching led to the use of the saphenous vein. Initially in
May 1967, the saphenous vein was used in an end-to-end fashion to replace an occluded segment of
the right coronary artery. Favaloro reported the use of the saphenous vein graft in direct coronary
surgery in 180 patients [11] and Johnson in 301 patients moro less at the same time [12] This was
an important landmark in the birth of modern coronary surgery. Although the origins of coronary
surgery began with the arterial graft, the saphenous vein, with its technical ease of harvest, its robust
handling characteristics and its versatility as an aorto-coronary graft, simplified the conduct of the
operation and allowed for widespread reproducibility. Ankeney in 1975 presented Coronary vein
graft without cardiopulmonary bypass: in a surgical motion picture [13] also Trapp and Bisarya in
1975 presented a work using coronary perfusion off pump [14].
Trying to decrease the risks of the CABG and costs, in 1978 we
repopularized the Off Pump Coronary Artery Bypass Graft (OPCAB)
and expanded the technique, addressing Lesions of the Circumflex
System (CX) and applying it to Diverse clinical scenarios [15-16].
Several surgical approaches were tested, such as full sternotomy, no
spreading sternotomy including left, anterolateral, Posterolateral
and right anterolateral thoracotomies, as well as partial sternotomy
[17]. The video-assisted techniques in the nineties allowed us, for the
first time, to dissect the Left Internal Thoracic Artery (LITA) without
opening the pleura cavity. Benetti anastomoses the LITA to the Left
Anterior Descending (LAD) through a small left anterior thoracotomy
for the first time. We did many technological developments that
allow us to trained surgeons in 45 countries of the world in Off Pump
coronary surgery [18-20].
Although the MIDCAB is a good operation full or partial lower
sternotomy carries little morbidity and allows excellent access for
LAD and right coronary artery anastomoses. With further experience,
the circumflex marginal vessels can be approached [21].
In 1997, Benetti performed for the first time an ambulatory
coronary bypass through a xiphoid lower sternotomy incision (MINI
OPCAB) using 3D technology to assist in the operation [22,23]. In
1998 Didier Loulmet performs the first endoscopic bypass using
robotic [24].
We used the right mammary as inflow from many years in
sternotomy off pump when the patient had a porcelain aorta and we
expand this technique for the MINI OPCAB operation in multiple
vessels [25]. With these and others contribution regarding to different
conduits adopted to the OPCAB; this surgery is established today
worldwide. The future requires a bypass operation more minimally
invasive; easy to reproduce and with possibilities to be done in the
entire world.
References
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