**7.7 Final surgical maneuvers**

*Latest Developments in Medical Robotics Systems*

the case, the surgeon should add additional stitches.

**7.6 Robotic-assisted, hand-sewn coronary anastomosis**

technique is also capable of doing the same procedure.

rable with the hand-sewn anastomosis [47–49].

should also be closely examined.

the hand-sewn approach.

discharged.

Surgical, Sunnyvale, Calif) using a purse-string stitch. This stitch is required to seal the insertion site of the anvil after the device is removed, since it is not part of the anastomosis. The anvil is then inserted and positioned parallelly to the coronary target. Placement of anvil inside the lumen of the vessel is crucial before moving on with the following steps of the anastomotic procedure. Then, tableside assistant activates the device and performs the anastomosis. Following the proper formation of anastomosis, the cartridge is released, the shield guard is raised, and anvil is

After the suture is tied, one should always look for potential bleeding. If that's

Occasional examination of the transit-time flow measurement (TTFM) of the graft is necessary [44–46]. In order to do this, a flexible probe through the port like Medistim (Medistim Inc., Oslo, Norway) can be used. This system provides valuable information about the procedure like mean blood flow, pulsatility index, and percentage diastolic filling. In addition, consideration of the competitive flow

If sequential grafting is needed, instead of Flex A device which is only applicable for end-to-side anastomosis, a hand-sewn technique comes into play. Thus, sequential grafting should start with the anastomotic device, then should continue with

Because of the aforementioned cases, in order to perform robotic-assisted coronary anastomosis, the anastomotic device is not mandatory since the hand-sewn

Histological studies also prove that device-driven anastomosis can be compa-

It is crucial to prepare the anastomotic sites before insertion of the suture in the thoracic cavity with the endo-wrist stabilizer. In order to perform LAD anastomosis, a 30-degree down scope provides better visualization, whereas a 30-degree up (or 0-degree) scope is preferred for left circumflex branch anastomosis. Also, observing some crucial parameters like ECG alterations, variables derived from TEE, and hemodynamic responses during the 5 to 8 minutes of myocardial ischemic preconditioning is recommended. During this period, required items like shunts and sutures can be inserted into the thoracic cavity. After clamping the ITA with a small bulldog clamp, Pott scissors are used to transcend and trim to the adequate length. It is advantageous to clip the distal side of the ITA to the encircling pericardium to deal with the conduit when conducting the anastomosis. Endo-knife (Snap-Fit; Intuitive Surgical, Sunnyvale, California, U.S.) assisted arteriotomy is performed and extended with Pott scissors after a short reperfusion

Both robotic arms are now equipped with Black Diamond forceps. A correct size shunt is now positioned (via the regular off-pump coronary artery bypass techniques) and the snare is released. A double-arm 7–0 Pronova suture is used to induce anastomosis in a continuous manner (Johnson & Johnson Medical, New Brunswick, New Jersey, United States). Suturing from the farthest side of the surgeon is introduced in the center of the arteriotomy, and should be completed on

The stitches are normally carried out on the coronary artery in an outside-in fashion, but this procedure can be altered in the opposite direction only if there is the presence of calcified plaques within the coronary target wall. The graft is then parachuted onto the target artery. It is advised to insert a shunt within the conduit

**86**

duration.

the adjacent side of the surgeon.

After the grafting procedures have been finalized with satisfactory results and adequate hemostasis, all the items used in the surgical procedure are cleared away from the thoracic cavity. Extra-pericardial fat that has been transferred to the lateral side is now sutured back to the medial border of the pericardium to cover the anterior face of the heart and the graft, and a 4–0 V-Loc suture (Medtronic, Minneapolis, Minnesota, United States) is used to conduct both of these procedures. The left lung is suctioned in and the lung is reinflated.

A 24-French Blake Drain (Ethicon Inc., Somerville, New Jersey, United States) is placed in the right thoracic cavity through the sub-costal port, and the second 24-French Blake Drain is also placed in the left thoracic cavity through the left port. The robot is undocked, and all the ports are removed.

If the surgery is performed on an arrested heart with CPB support, a 'hot shot' of cardioplegia or warmblood is administered before deflating the endoballoon. Only after the robot is undocked, all ports are removed, and ventilation is fully restored, will separation from the CPB support, protamine administration, and decannulation be carried out. To minimize the risk of bleeding on the port sides, it is strongly recommended to re-inspect the port sides with the scope after protamine is administered. For off-pump TECAB, this is extremely unlikely.

Finally, all port incisions are sealed with subcuticular stitches and in this way, the surgery is now completed.
