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Pusca et al. Mini-invasive Surg 2021;5:51 https://dx.doi.org/10.20517/2574-1225.2021.45 Page 13 of 15

DEVELOPING A SUCCESSFUL HCR PROGRAM
The prerequisite for a surgeon to start a successful HCR program is to master the techniques of at least one
minimally invasive CABG approach and off-pump coronary bypass. These two goals are difficult to be
tackled simultaneously. Off-pump LIMA LAD grafting is best mastered in open sternotomy cases under the
careful supervision of a seasoned mentor. However, the pathway for training could be different for a young
surgeon just out of training vs. an experienced surgeon routinely performing the on-pump, arrested
technique. Training in a program experienced with off-pump and beating heart surgeries in its different
varieties or joining a group with extensive expertise in such techniques would be the best path forward for
the young surgeon. The surgeon will be coached to avoid serious mistakes and gain the expertise and
confidence to become a skilled surgeon. These skills can then be translated into a minimally invasive
platform.

For the seasoned surgeon with expertise in on-pump arrested CABG, a short period of observation in a busy
off-pump program, followed by the transition to performing LIMA to LAD anastomosis on a beating heart,
but in a pump assisted fashion, followed by the performance of LIMA to LAD completely off-pump in
conjunction with conventional on-pump, arrested technique for the other anastomoses, would lead to
expertise during one’s own practice.

The harvesting of the mammary artery can be learned as a second step or simultaneously. A
minithoracotomy approach harvest is probably the easiest to learn in a self-taught manner after observing
cases and watching videos. However, due to the complexities of positioning the robot, training a whole
team, and actually learning the technique, robotic cases are a much more ambitious goal and would require
either a mini-fellowship or be reserved as a later goal.

First of all, the exposure, be it mini-thoracotomy or a 2-inch, the non-rib spreading incision used for robotic
cases, offers a very different view of the heart than a surgeon is used to traditionally. This translates into
difficulties in identifying the LAD target.

From the minimally invasive view, the LAD is the furthest vessel to the right; problems can appear,
however, when the LAD is buried in epicardial fat or is intramyocardial. Therefore, it is paramount to make
sure that the vessel furthest to the right on the anterior aspect of the heart has a general direction tracking to
the apex of the heart. This can be verified by direct inspection through a minithoracotomy approach or by
camera inspection with the robot and marking the vessel with a marking pen or clip after opening the
pericardium robotically prior to performing the small access incision for the LIMA to LAD anastomosis.

CONCLUSION
In conclusion, HCR is a novel technique that can offer the next level of care for appropriately selected
patients in the hands of expert surgeons, combining the benefit of long-term results offered by sternotomy
CABG with rapid, short-term recovery and minimal morbidity. Such an approach is feasible if time and
energy are invested in the training and logistical development of a collaborative approach.

DECLARATIONS
Authors’ contributions
Conception, design and editing of the article: Pusca SV, Halkos ME