Patients undergoing heart bypass surgery traditionally have the sternum, or breast bone, cracked open to expose the heart for surgery.  This standard surgical technique results in months of recuperation as the bone knits together again.  But a robotic technology is offering a way to do the lifesaving bypass surgery using just four small incisions in the chest, no sternum break, and returning patients to normal activities within a week.

Coronary Artery Disease
Coronary artery disease is a condition in which plaque builds up along the walls of the arteries that provide blood flow to the heart muscle. Over time, the plaque can accumulate and impede the flow of blood through the affected areas of the vessels. In addition, a piece of plaque can break loose, travel through the blood stream and become trapped in a small or narrow artery. When blood flow through a coronary artery is blocked, the heart muscle beyond the point of blockage is deprived of oxygen and can die. This is called a myocardial infarction, or heart attack.

The American Heart Association estimates about 16 million Americans have coronary artery disease. Each year, more than 900,000 heart attacks occur in the U.S. In 2004, 196,000 Americans died from a heart attack. Those who survive have up to 15 times a higher rate of death than those in the general population.

Bypass Surgery
One of the treatments for blocked coronary arteries is coronary artery bypass surgery (CABG, often referred to as bypass surgery or a heart bypass). In 2005, 261,000 Americans had bypass surgery. The goal of the treatment is to re-route blood around the blockage and restore flow to the heart muscle. In one method, surgeons use an artery in the chest, called the internal mammary artery. The artery is cut and the free end is sewn onto the heart’s blood vessel at a point just below the blockage. Internal mammary arteries are ideal bypass conduits because they are resistant to plaque build-up and are less likely to develop blockages.

The second method of heart bypass surgery uses a section of leg vein. A long section of vein is removed (harvested) and may be cut into smaller sections to create multiple bypass conduits. One end of the vein section is sewn onto the target vessel at a point near the blockage. The other end of the vein is sewn onto the vessel below the blockage. Blood flow is then diverted through the vein, around the blockage. Vein grafts can be very useful for patients who have multiple blockages. However, they are more prone to plaque accumulation. Ten years after bypass surgery, only 38 to 45 percent of vein grafts remain open. If the vessels become blocked, further surgery is needed to restore blood flow to the heart.

Heart-lung bypass has been used to treat heart blockages for more than 40 years. But there are some drawbacks to the procedure. The surgeon needs to make a long incision into the chest. Then the breastbone is cut and split open to access the heart. These steps increase the risk for bleeding and infection and, after surgery, contribute to a significant amount of pain and a prolonged recovery. In addition, during surgery, the heart must be stopped, so the patient needs to be placed on a heart-lung bypass machine to temporarily provide oxygen to the rest of the body.

TECAB
Some doctors are using a less invasive technique, called totally endoscopic coronary artery bypass surgery, or TECAB. Instead of a long chest incision, the surgery is performed through four or five tiny cuts made between the ribs. The surgeon sits at a console and, with special equipment, guides the arms of a surgical robot. A camera inserted through one incision provides magnified, 3-D images of the interior of the chest. Tiny surgical instruments are placed through the incisions. The robot’s arms pivot with a greater range of movement and flexibility than human hands, allowing for better navigation within the confined space. In addition, the robot’s arm corrects the slightest tremor of the surgeon’s hands. The robotic technique is so precise the surgery can be done without the need for a heart-lung bypass. In many cases, the surgeon uses the internal mammary artery. So there is no need to cut into the leg to harvest a vein and the bypass will last much longer.

Valluvan Jeevanandam, M.D., Cardiothoracic Surgeon with the University of Chicago Medical Center, says TECAB is a lot easier for patients than the standard bypass procedure. With smaller incisions, surgeons can avoid the long chest incision and splitting the breast bone. There is significantly less pain after surgery and a lower risk of infection and bleeding. The incisions are typically covered with a few bandages. Patients are usually out of the hospital within one to three days. Jeevanandam says most patients are able to control post-operative pain with regular over-the-counter pain medicines. Recovery time is also much faster, usually about one to two weeks compared to 4 to 8 weeks after traditional heart bypass surgery.

Cardiac Surgeon, Sudhir Srivastava, M.D., pioneered the TECAB procedure. He says TECAB is not recommended for patients who are extremely obese, have scar tissue from previous chest surgery that causes the lung to be stuck to the chest wall and patients who are medical unstable (like those who are in shock or having a heart attack or stroke). So far, surgeons at the University of Chicago Medical Center have used TECAB to perform up to four bypasses in a single surgery.

AUDIENCE INQUIRY
For general information on heart disease:
American Heart Association, http://www.americanheart.org, or contact your local chapter
National Heart, Lung and Blood Institute, http://www.nhlbi.nih.gov