Robotic Totally Endoscopic Multivessel Coronary Artery Bypass Grafting Procedure Development, Challenges, Results Johannes Bonatti, MD,* Jeffrey D. Lee, MD,* Nikolaos Bonaros, MD,Þ Thomas Schachner, MD,Þ and Eric J. Lehr, MDþ Abstract: Closed-chest totally endoscopic coronary artery bypass grafting (TECAB) is feasible using robotic technology. During the early phases, TECAB was restricted to single bypass grafts to the left anterior descending artery system. Because most patients referred for coronary artery bypass surgery have multivessel disease, development of endoscopic multiple bypass grafting is mandatory. Experimental work on multivessel TECAB was carried out in the early 2000s, and first clinical cases were already performed. With further technological development of operating robots, double, triple, and quadruple TECAB has become feasible both on the arrested heart and on the beating heart. To date, 161 cases of multivessel TECAB using the da Vinci telemanipulation systems are published in the literature. The main advances enabling multivessel TECAB were the availability of a robotic endostabilizer for beating heart procedures and increased surgeon skills using remote access heart-lung machine perfusion and endo-cardioplegia. Both internal mammary arteries can be harvested and both radial artery and vein graft can be used in multivessel TECAB. Y-grafting and sequential grafting are feasible. Multivessel endoscopic surgical revascularization can be combined with percu- taneous coronary interventions in advanced hybrid coronary revascu- larization. Time requirements for multivessel TECAB are significant, and conversion rates to larger thoracic incisions are higher than those observed for single-vessel TECAB. Clinical short- and long-term out- comes, however, seem to meet the standards of open coronary by- pass surgery through sternotomy. The main advantages of multivessel TECAB are a completely preserved sternum, use of double internal mammary artery even in risk groups, and a remarkably short recovery time. Key Words: Coronary artery disease, Multivessel disease, Bypass surgery, Robotic surgery, Minimally invasive surgery, Endoscopic surgery. (Innovations 2012;7:3Y8) R obotic technology has enabled performance of completely endoscopic, closed-chest coronary bypass surgery. During the initial phase, only single-vessel revascularization proce- dures were carried out, mostly left internal mammary artery (LIMA) bypass grafts to the left anterior descending artery (LAD), and the Food and Drug Administration trial on ro- botically assisted coronary bypass grafting included only sin- gle LIMA to LAD. 1 Restricting totally endoscopic coronary artery bypass grafting (TECAB) to single-vessel revasculari- zation severely limits the broader application of the procedure to patients more commonly seen by the community of heart surgeons. One way to deal with this limitation is by combining TECAB-LIMA to LAD with percutaneous intervention (PCI) in so-called hybrid procedures. 2Y4 However, only a relatively small segment of patients with multivessel coronary artery disease is suited for additional PCI. Therefore, development of multivessel TECAB (mvTECAB) is mandatory. The aim of this review was to give an overview on the history of this complex endoscopic surgery, to outline the current state of development, and to give an impression on potential future developments. HISTORY Experimental work in cadavers and animals preceded the clinical introduction of early mvTECAB. A group of pio- neers in the field carried out cadaver studies and published the results of these experiments in 2003. 5 The feasibility of mul- tivessel endoscopic coronary artery bypass grafting (CABG) was demonstrated on the unloaded and flaccid cadaver heart. Up to four distal anastomoses were performed, and proximal anas- tomoses were carried out off the ascending aorta. Y-grafts were also constructed. The authors report approaches from both the patient’s left side and the patient’s right side. Transthoracic clamping was used, and several exposure methods for the back wall of the heart were tested. An endothoracic sling seemed to be the most promising approach. Falk and coworkers 6 conducted cadaver and animal ex- periments in which both the internal mammary arteries were REVIEW ARTICLE Innovations & Volume 7, Number 1, January/February 2012 3 Accepted for publication February 13, 2012. From the *Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD USA; †University Clinic of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria; and ‡Swedish Heart and Vascular Institute, Swedish Medical Center, Seattle, WA USA. Disclosures: Eric J. Lehr, MD receives payment for lectures and develop- ment of educational presentations from Edwards Lifesciences, Irvine, CA USA. Johannes Bonatti, MD, Jeffrey D. Lee, MD, Nikolaos Bonaros, MD, Thomas Schachner, MD declare no conflict of interest. Address correspondence and reprint requests to Johannes Bonatti, MD, Divi- sion of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, 22 S Greene St, N4W94, Baltimore, MD 21201 USA. E-mail: jbonatti@smail.umaryland.edu. Copyright * 2012 by the International Society for Minimally Invasive Car- diothoracic Surgery ISSN: 1556-9845/12/0701-0003 Copyright © 2012 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.