What is Minimally Invasive CAB Surgery ?
MIDCAB surgery offers the same same benefits as open-heart coronary artery bypass grafting (CABG) surgery with shorter hospitalization, less bleeding, and a faster recovery.
MIDCAB surgery is only ideal for patients at low risk of complications, and those who have blocked arteries towards the front of the heart which can be reached through a small opening near the ribs. Each patient's diagnosis and treatment is unique and your physician will recommend the best approach for you.
What is Minimally Invasive Heart Surgery ?
Minimally invasive heart surgery in India is performed through a small incision, often using specialized surgical instruments. The incision is about 2 to 4 inches instead of the 6- to 8-inch incision required for traditional surgery. Keyhole approaches or port-access techniques are also available for some types of surgery.
Patients with lesions in the Left Anterior Descending (LAD) coronary artery and the Right Coronary Artery (RCA) may benefit from a technique called Minimally Invasive Direct Coronary Artery Bypass (MIDCAB), or "limited access coronary artery bypass." In contrast with conventional CABG, this procedure is done through a smaller incision on the patient's chest over the heart to gain access to the coronary arteries. As the procedure is done in a confined space usually while the heart is beating and without the use of a heart-lung machine, surgeons use different methods to slow down and steady the heart.
Since it involves a smaller chest incision than conventional CABG and excludes the use the heart-lung machine, this technique results in fewer complications, less pain after surgery, and more rapid recovery. However, the technique is primarily indicated for patients with lesions on the LAD and the RCA. Whenever possible, the Internal Mammary Artery (IMA) is used to bypass the occlusions. Following the surgery, the patient is taken to the recovery area for approximately 12 to 24 hours. Total hospital stay is usually about 3 to 4 days.
How Minimally Invasive Direct CAB Surgery Is Performed ?
This procedure is done when the exact position of the affected coronary artery is known and only a single graft is required. The diagram left shows the position of the incision. No bypass machine is used. Intsruments are placed to immobilise the heart allowing the surgeon to operate. The bypass procedure is the same as the normal CABG. However, it is a more challenging procedure as the heart is still beating and there is blood present in the operating field (the heart is still pumping blood). The length of the incision means there is less room for the surgeon to work. However, the need for a large incision and splitting the chest is removed, therefore fewer complications arise and the patient will have a faster recovery time and have a shorter stay in hospital.
Benefits of Minimally Invasive Heart Surgery:
The benefits of minimally invasive heart surgery include : -
A smaller incision
A smaller scar
Other possible benefits of minimally invasive heart surgery may include : -
Reduced risk of infection
Less bleeding with minimally invasive heart surgery
Less pain and trauma
Decreased length of stay in hospital after the procedure: the average stay is 3 to 5 days after minimally invasive surgery, while the average stay after traditional heart surgery is 5 days
Decreased recovery time: the average recovery time after minimally invasive heart surgery is 2 to 4 weeks, while the average recovery time after traditional heart surgery is 6 to 8 weeks
Minimally invasive direct coronary artery bypass graft (MID CABG) surgery is an option for some patients who require a left internal mammary artery bypass graft to the left anterior descending artery. A small, 2-3 inch incision is made in the chest wall between the ribs, whereas the incision made during traditional CABG surgery is about 6 to 8 inches long and is made down the center of the sternum (breastbone).
Saphenous (leg) vein harvest may also be performed using small incisions. Several techniques for minimally invasive bypass surgery are being explored, including surgeries performed on a beating or non beating heart.
Off-pump or beating heart bypass surgery allows surgeons to perform surgery on the heart while it is still beating. A medication may be given to slow the heart during surgery, but the heart keeps beating during the procedure. This type of surgery may be an option for patients with single-vessel disease (such as disease of the left anterior descending artery or right coronary artery).
Traditionally, CABG surgery is performed with the assistance of cardiopulmonary bypass (heart-lung machine). The heart-lung machine allows the hearts beating to be stopped, so the surgeon can operate on a surface which is blood-free and still. The heart-lung machine maintains life despite the lack of a heartbeat, removing carbon dioxide from the blood and replacing it with oxygen before pumping it around the body.
During off-pump or beating heart surgery, the heart-lung machine is not used. The surgeon uses advanced operating equipment to stabilize (hold) portions of the heart and bypass the blocked artery in a highly controlled operative environment. Meanwhile, the rest of the heart keeps pumping and circulating blood to the body.
Keyhole Approaches : -
For some surgical procedures, an endoscopic or "keyhole" approach may be performed. This approach may also be referred to as port access surgery or video-assisted surgery.
The port access surgery technique allows surgeons to use one to four small (5- 10 mm) incisions or "ports" in the chest wall between the ribs. An endoscope or thoracoscope (thin video instrument that has a small camera at the tip) and surgical instruments are placed through the incisions. The scope transmits a picture of the internal organs on a video monitor so the surgeon can get a closer view of the surgical area while performing the procedure.
Types of minimally invasive heart surgeries that may be performed using the innovative port-access or "keyhole" approach include : -
- CABG surgery and reoperations for select patients
- Valve surgery and reoperations for select patients
- Epicardial lead placement for cardiac resynchronization therapy
- Minimally invasive surgery for atrial fibrillation. The surgeon views the epicardial (outer) surface of the heart using an endoscope. Specialized instruments are used to create new pathways for the electrical impulses that trigger the heartbeat. Unlike traditional surgery for atrial fibrillation, there is no large chest wall incision, and the heart is not stopped during the procedure.
- Some types of thoracic procedures may use video-assisted thoracoscopy (VATS), also called thoracoscopy or pleuroscopy, such as partial lung resection, lung biopsy, lobectomy, drainage of pleural effusions, or pericardial and mediastinal biopsies.
MIDCAB vs. CABG :
Conventional CABG has been around for the past four decades, and in that time it has nearly been perfected. Although more than 1 million of these procedures take place annually with a 99% success rate, this is still a very traumatic and painful surgery for the patient.
Conventional CABG is performed through a 30 cm. vertical incision which splits the patient's sternum bone. During CABG, the heartbeat is stopped temporarily by either cardioplegic arrest or fibrillatory arrest and the blood circulation is maintained artificially by a heart-lung machine. Once the heartbeat is stopped, the surgical connection between the graft and coronary artery can be achieved with greater ease and precision than if the heart were to continue moving.
Conventional CABG is the gold standard in heart surgery for two main reasons. First, working on a non-beating heart allows for more efficient and more precise anastomosis. Second, and more importantly, CABG has been tried and tested making it widely accepted as the best heart surgery. As will all medical technologies, surgeons are reluctant to haphazardly switch from a procedure or a device with years of high success and proven reliability to a recently developed procedure or device which may look better intuitively and on paper but has not shown the same reliability and success.
Disadvantages of MIDCAB :
While MIDCAB is easier on the patient and is probably less expensive than traditional CABG, the disadvantages of MIDCAB compared with traditional CABG are substantial. First and foremost, MIDCAB is only a plausible alternative to CABG surgery involving one or two arteries, not all CABG surgeries. Secondly, minimally invasive surgeries, including MIDCAB, only comprise around 10% of total heart surgeries, so exposure is limited . Additionally, allowing the heart to continue beating during MIDCAB makes the performance of the anastomosis more difficult and significant ischemia during the procedure may lead to hemodynamic compromise of the patient, so cardiopulmonary bypass must be available . In a few cases, urgent conversion to conventional open-chest methods has also been necessary.
Recovery after minimally invasive heart surgery
Patients who had minimally invasive surgery may be able to go home 3 to 5 days after surgery. Your health care team will follow your progress and help you recover as quickly as possible.
Your health care team will provide specific instructions for your recovery and return to work, including guidelines for activity, driving, incision care and diet.
In general, you may be able to return to work (if you have a sedentary job), resume driving and participate in most non-strenuous activities within 2 to 4 weeks after minimally invasive heart surgery. You can resume heavy lifting and other more strenuous activities within 6 to 8 weeks after minimally invasive surgery.
How will I feel after minimally invasive heart surgery?
There will be some incision discomfort for the first few days after surgery. Medications can be taken to help relieve this discomfort. Ask your doctor which medication you should take for pain relief. If you begin to have discomfort in your chest that is similar to the symptoms you had before your surgery, call your doctor
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