Sparing not only the sternum but also the pain: why port only is best

It is an exciting time in the field of minimally invasive cardiac surgery. The indications for the application of sternal-sparing approaches in a variety of cardiac surgical procedures, including treatment of valvular disease and coronary artery disease, are rapidly growing [1–4]. Cardiac surgeons should be eager to adopt these emerging techniques and innovative technologies into their practice as so many other surgical specialties have done and continue to do. With this frame of mind, we read with interest the report by Squiccimarro and colleagues in this issue of EJCTS [5] and applaud the authors for their enthusiasm towards utilizing a minimally invasive sternal-sparing surgical approach for a complex cardiac surgical problem. The authors report on their case series of 3 patients with concomitant severe mitral regurgitation and Left Anterior Descending (LAD) stenosis who underwent bilateral mini-thoracotomies for combined mitral valve repair (MVr) and minimally invasive direct coronary artery bypass—2 of the more commonly performed minimally invasive procedures (when done separately). The authors successfully combined these 2 sternal-sparing approaches for the treatment of both cardiac pathologies in 1 setting. MVr and minimally invasive direct coronary artery bypass (with Left Internal Thoracic Artery (LITA)-LAD bypass) were completed through 6 cm mini-thoracotomies—in the right and left chest, respectively. Operative time for the total procedure was reasonable, Intensive Care Unit (ICU) length of stay (LOS) was fairly short, all patients were extubated within 6 h of the procedure or less and there was no reported incidence of stroke, take-back for bleeding or early mortality. Computed Tomography (CT) angiography was performed for all 3 patients before discharge to assess LITA-LAD patency and, although not explicitly stated in the paper, presumably all grafts were patent. We congratulate Squiccimarro and colleagues on the successful application of minimally invasive surgery in concomitant valvular and coronary artery disease. Nevertheless, we believe that the authors have perhaps fallen short of what it seems they were aiming to accomplish through their chosen minimally invasive approach. First, it is well known that thoracotomies are associated with significant postoperative pain [6, 7], which can add to longer postoperative recovery times, particularly when compared to smaller (port-size), non-rib spreading incisions such as those in robotic MVr or totally endoscopic coronary bypass surgery [2–4]. In addition, the fact that these were bilateral thoracotomies only increases associated pain and undoubtedly lengthens recovery time. This is evidenced by the hospital LOS in this report—overall mean of 7 days—which is longer compared to endoscopic approaches for the same procedure [8, 9] and even for some published sternotomy series [10]. In the article, the authors describe other surgical options discussed for these 3 patients, including traditional sternotomy or a hybrid procedure with minimally invasive MVr and percutaneous coronary intervention for the LAD lesion. The authors, however, failed to mention or cite the same procedure combination published by our group in 2013 using a robotic totally endoscopic approach via right-sided ports to achieve both MVr and LITA-LAD grafting [8]. In our article, we demonstrated the feasibility, safety and efficacy of performing this combination procedure through small robotic non-rib spreading ports all on the right side. Approaching the LAD robotically from the right side requires decompressing the right heart on cardiopulmonary bypass, but this can easily be done on the beating heart prior to arresting the heart for the MVr. Admittedly this option is not available in all cases and we have performed the same combination of procedures with a totally endoscopic approach using bilateral robotic ports. In this case, the LITA-LAD anastomosis is completed first using our standard robotic off-pump totally endoscopic coronary bypass surgery approach with left chest ports, after which the patient is placed on peripheral cardiopulmonary bypass and the robot is docked to the right chest ports for the MV procedure. Although this involves a bilateral approach, these port incisions are still much smaller and are also non-rib spreading. Thus, we believe that this approach is far less painful and hastens recovery compared to a patient undergoing bilateral thoracotomies. We have recently performed a handful of these procedures with good outcomes and short hospital LOS. Once again, we applaud the authors for successfully performing this complex combination procedure and maintaining a sternal-sparing posture for their patients. However, we propose that there is still progress to be made in this regard by using the most advanced technology available. A totally endoscopic surgical approach in the treatment of multiple cardiac conditions is available using robotic technology [1], which has improved significantly since it was first introduced in the late 1990s. Our specialty unfortunately has not availed itself of this technology in the way that other specialties have, and we are therefore hampered by the retreat of industry from us, our procedures and sadly, our patients. With the introduction of new robotic systems around the corner, it is imperative upon the next generation of surgeons in our specialty to get in the game, learn how to use these systems in the execution of cardiac surgical procedures and provide the least invasive approach safely and effectively for our patients. A sternal-sparing approach in concomitant cardiac surgery is possible as demonstrated nicely by Squiccimarro and colleagues—however, let us all strive to be even less invasive by adopting the best that technology and innovation have to offer!