Rationale for Endoscopic Bypass Grafting

The goals of minimally invasive or less-invasive coronary artery bypass grafting are twofold: to reduce the surgical trauma by minimizing access and to obviate the need for extracorporeal circulation. Ideally, coronary artery bypass grafting would be performed endoscopically on the beating heart. In the early 1990s, some groups developed techniques to perform coronary anastomoses on the beating heart.1,2 With the development of mechanical stabilizers that provided sufficient local immobilization of the beating heart, patency rates became comparable to conventional onpump surgery, and both the minimally invasive direct coronary artery bypass (MIDCAB) operation and offpump coronary artery bypass (OPCAB) procedures have found widespread clinical application.3–5 Stimulated by the developments in other surgical specialties, endoscopic techniques were introduced in the field of cardiac surgery in the mid-1990s. Using conventional endoscopic instruments, some groups started with endoscopic harvesting of the internal thoracic artery.6 At the same time, cardiopulmonary bypass systems, such as the Port-Access system, were introduced, which allowed for closed-chest cardiopulmonary bypass and cardiac arrest.7 Closed-chest bypass grafting was, however, still not possible, primarily because of the limitations of conventional endoscopic instruments. The introduction of computer-enhanced instrumentation systems (robotics) has prepared the ground for true endoscopic bypass grafting. These telemanipulators enhance the dexterity, allow scaling of motions, and provide tremor filtering.8 A number of groups have started to expand their minimally invasive programs with an endoscopic approach that uses the two currently available surgical telemanipulation systems. After extensive experimental trials, the first clinical studies have demonstrated the feasibility of total endoscopic coronary artery bypass (TECAB) grafting on the arrested and on the beating heart.9,10