Robotic skeletonizing of the internal thoracic artery: is it safe?

Background: The advantages of internal thoracic artery skeletonization include early high blood flow, a longer conduit, and less bleeding than pedicle internal thoracic artery grafts. Longer conduits are needed for complete endoscopic arterial revascularization. Therefore this study was designed to determine the feasibility and safety of internal thoracic artery skeletonization using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA).

Methods: Nine dogs underwent bilateral robotic internal thoracic artery harvesting through three ports placed in the left chest. One internal thoracic artery was harvested as a pedicle in each dog, and the other was skeletonized. Internal thoracic artery blood flow was measured in each graft, and comparative endothelial histologic studies were performed. Data are mean +/- the standard error of the mean.

Results: All 18 internal thoracic arteries were harvested successfully. Skeletonized internal thoracic artery harvests required more time (48.0 minutes +/- 1.8) than pedicle internal thoracic artery harvests (39.0 minutes +/- 1.4; p < 0.05). Internal thoracic artery flows during the final intervals were similar (skeletonized = 30.0 mL/min +/- 2.4 vs pedicle = 31.5 mL/min +/- 1.8; p = 0.9). Free internal thoracic artery bleeding flow was similar in both groups (skeletonized = 162.0 mL/min +/- 3.0 vs pedicle = 189.0 mL/min +/- 2.4; p = 0.4). Histologically, both groups were similar with minimal endothelial damage.

Conclusions: Robotically skeletonized harvesting is safe, but it requires more time (48.0 minutes +/- 1.8) than pedicle internal thoracic artery harvesting. Despite muted tactile feedback with robotics, neither technique was associated with histologic or functional damage. These encouraging results may represent an advantage for complete arterial revascularization in robotic coronary bypass patients.