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Pusca et al. Mini-invasive Surg 2021;5:51 https://dx.doi.org/10.20517/2574-1225.2021.45 Page 3 of 15

The Da Vinci robot introduced a new level of precision, visualization, and endoscopic freedom of
movement inside the body with 3-dimensional articulating instrumentation and 10x high fidelity
magnification. Thus, exposure and visualization were greatly facilitated, and more complex movements
could be made inside the chest. Furthermore, the 3-dimensional wristed instruments provided a greater
range of motion in a small space. In addition, the robotic instruments are able to filter the hand tremor;
hence this becomes a non-issue. Finally, dual consoles allow the technique to be taught much more easily,
with seamless transfer of controls between mentor and trainee.

The majority of minimally invasive CABG procedures since 2009 at Emory have been performed with
robotic assistance, thus the term robotic-assisted CABG. The procedure has been extensively described in
publications [12-16] . Briefly, patients are placed supine on the operating table, and after induction, two rolled
sheets or a bump is placed under the left should with the superior tip of the bump placed just inferior to the
scapula. The patient is positioned slightly towards the left of the table so that when the left arm is loosely
tucked, the left shoulder gently hangs off of the bed. The lowering of the left shoulder is critical to avoid
conflict with the robotic arms. The patient is then prepped and draped in the usual fashion for coronary
bypass surgery; the middle of the chest is marked between the clavicle and costal margin [Figure 1]. There is
no specific interspace, but the camera port should be generally placed in the middle of the chest or just
slightly lower at approximately the anterior axillary line.

A spinal needle is used to identify the rib and the interspace. We always use a blunt instrument similar to
tube thoracostomy prior to inserting the camera port. The camera port can then be placed gently with a
slight angle superiorly to avoid underlying cardiac injury. Immediately after this port is placed, carbon
dioxide insufflation should be initiated from 8-12 mmHg with careful attention to blood pressure while
creating a tension pneumothorax. Not infrequently, anesthesiology will need to make adjustments with
loading conditions to allow the patient to tolerate this. The insufflation can be adjusted up or down
(6-15 mmHg) as needed. The camera is then inserted, and the superior port is placed 2 interspaces above
the camera port in either the 2nd or 3rd interspace, more medial than the camera port.

The inferior port is placed 2-3 interspaces in a similar medial-lateral position as the camera port. Note, the
working arm ports should be placed with endoscopic guidance so you can see where the ports are entering
the chest and in which interspace [Figure 2]. Finally, the da Vinci system is docked [Figure 3], and the
LIMA can be harvested as a thin pedicle or skeletonized.

Our preference is to remove the overlying muscle and fascia to expose the LIMA completely and then take
the vessel as a thin pedicle with electrocautery and clips to avoid any manipulation of the artery [Figures 4
and 5]. A small pericardial window posterior to the phrenic is then made, the pericardial fat is dissected off
the anterior pericardium, and a full longitudinal pericardiotomy is then made to mirror the same
pericardiotomy that would be made via sternotomy [Figure 6].

After dividing the LIMA distally with clips, the robot is undocked, the endoscope and a spinal needle are
used to help with localization of the skin incision so that after a 3-4 cm thoracotomy incision is made, the
LAD target should lie directly underneath. No rib retractors are used, but exposure is usually more than
adequate with a soft tissue retractor without dividing or resecting any ribs or costal cartilage. The Nuvo
stabilizer (Nuvo; Medtronic, Minneapolis, MN) is used to stabilize the LAD; a vessel loop is placed around
the more proximal LAD, and tests occluded for 3 min while the LIMA is prepared.