Robotic Coronary Bypass Surgery
Patients who are diagnosed with single vessel disease in the most important coronary artery (the LAD) may be candidates for Robotic Coronary Artery Bypass (Robotic CABG). These patients can experience the long-term benefits of bypass surgery over coronary stents without the long recovery period and trauma of major open heart surgery.
Who needs this procedure?
Patients who have a tight blockage in the most important of the three coronary arteries – the LAD, requiring bypass surgery, can undergo robotic bypass surgery. This can either be done as an isolated procedure when the LAD is the only blocked artery, or can be done in conjunction with coronary stenting to any other blockages which may be present, as a Hybrid Coronary Surgery Procedure.
Bypass surgery of the LIMA to the LAD has the best long-term results of any bypass surgery and will last longer than a stent to the coronary artery. This is particularly suitable for patients who have disease that isn’t suitable for stenting because the artery is severely calcified or the diseased segment is very long. A cardiologist will discuss the applicability of stenting and if they think it is unsafe may refer a patient for single vessel minimally invasive bypass.
Coronary artery disease occurs when there are obstructions in the coronary arteries.
This is caused by numerous factors including genetics, lifestyle, diabetes, smoking, high blood pressure and high cholesterol. As the arteries become narrowed and the heart is starved of oxygen, symptoms can occur that include chest tightness, shortness of breath or even a heart attack where a portion of the heart muscle dies from lack of oxygen.
Angina is classically described as chest pain, but it is actually usually not painful. Most patients describe it as a heaviness in the chest or a tightness and there can also be pain in the left arm, the shoulder, the jaw or the abdomen.
Some people do not experience any pain or tightness with coronary artery disease and can even suffer a so-called silent heart attack. This is more common in women and diabetics.
The typical path towards surgery would often start with the general practitioner where a patient presents with chest tightness after they walk up a hill, which settles when they stop walking. The GP may arrange a stress test where the patient exercises on a treadmill while the heart is monitored either with ultrasound (echocardiography) or an ECG to look for signs of oxygen starvation (ischaemia). If the stress test is positive, and there are signs of oxygen starvation, then the patient will be referred to a cardiologist, who will perform a coronary angiogram.
The angiogram will determine the severity of the coronary disease and if the patient needs surgery or alternative medical therapies.
What is involved?
During robotic surgery a camera is placed inside the chest that provides the surgeon with a 3D view and 10x magnification. This is vastly superior to anything available in conventional surgery. A number of small instruments are then introduced into the chest that precisely mimic the actions of the surgeon. The surgeon controls these robotic instruments inside the patient from a console.
Under a general anaesthetic a 5cm incision is made in the left side of the chest and the left internal mammary artery (LIMA) is harvested from behind the breastbone. The LIMA is then attached to the LAD, the main artery of the heart, to form the bypass using ‘off pump’ techniques whereby the heart remains beating throughout the procedure. This new graft provides a completely new blood supply to the heart rather than just addressing the blocked area; this reduces the incidence of recurrence of angina or heart attacks. This is one of the key differences between bypass surgery and coronary stents – stents only open an individual blockage and don’t treat any future disease that might occur.
What is the recovery like?
The recovery after minimally invasive surgery is far more rapid than traditional open heart surgery. The operation takes 2-3 hours and you will generally wake up in intensive care later that day. Small tubes to drain any residual fluid from around the heart will be placed in your neck, as well as intravenous lines, to sample blood and administer medications. These tubes and lines will be removed after 1-2 days and then you will be transferred to the ward to continue your recovery.
Once on the ward, the goal is to monitor your blood pressure and heart rate and ensure adequate mobilisation. We work very closely with our nurses, physiotherapists and occupational therapists to work on breathing exercises and functional mobilisation. Every patient is different and the assistance is tailored to your needs. Most minimally invasive patients can go home after 4-5 days.
Once home, patients who have undergone minimally invasive surgery continue to recover a lot faster than those who have undergone open heart surgery with splitting of the breastbone. Mobilisation is far easier and there aren’t any restrictions on lifting. Patients are encouraged to take plenty of walks. Your body will let you know what it is capable of and there is no need to push it. Most patients will feel back to their usual selves after about 4 weeks following minimally invasive surgery compared with 3 months following traditional open heart surgery.
What are the benefits and risks of this procedure?
Although the operation is performed minimally invasively there are still some of the usual risks associated with major heart surgery. The main benefits are that there is no risk of sternal bone infection, and there is a reduced rate of blood transfusion. Other risks are similar to open bypass surgery including: death (1%), stroke (1%), kidney injury (2%) and blood transfusion (15%). The risk can be higher if patients have other co-morbidities including advanced age, previous heart disease or stroke, or lung disease.
Dr Bassin will explain these risks to each patient in person and how they pertain to their specific condition.