RU2723751C1 - Method of complete minimally invasive endoscopically assisted myocardial revascularization in multivascular atherosclerotic coronary bed lesion - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to cardiovascular surgery and perfusion. Method comprises sequential isolation of internal thoracic arteries of a patient by a semi-skeletal technique, using endovideososcopic instruments and superimposition of anastomoses with coronary arteries in conditions of minimal extracorporeal circulation in direct myocardial imaging through a left-sided anterolateral mini thoracotomy approach, made in IV-V intercostal space 1 cm to the left of median-clavicular line 5 cm long. At that, the thoracoports for internal thoracic arteries are separated symmetrically from the right and left sides: one in IV-v intercostal space along antero-axillary line for insufflation of carbon dioxide and two in III and V intercostal spaces along mid-clavicular line for endoscopic instrument. In III and IV intercostal space along a parasternal line on the right, thoracoports of diameter 11.2 mm and 14 mm, respectively, are installed, intended for drainage of aorta root and feed of cardioplegic solution. Larrey point is used to insert an endoscopic grasper with a fixed gauze tissue. After achieving complete cardioplegic asystole, the heart is rotated so as to provide optimal visualization and localization of a myocardial portion with a shunted coronary artery in a mini-thoracic incision. Cardioplegia is initiated each time after completion of the next coronary anastomosis, except for the last one.EFFECT: method enables reducing the risk of complications and unfavourable outcomes of complete myocardial revascularization in the patients with multivascular coronary disease by using the shunts of the patient's own internal thoracic arteries recovered by the semi-skeletal method, using endovideososcopic instruments and superimposition of anastomoses with coronary arteries in direct imaging of myocardium through anterior-lateral left-sided mini thoracotomy approach in conditions of minimal extracorporeal circulation.1 cl, 1 ex

Description

The invention relates to medicine, namely to cardiovascular surgery and perfusion, and can be used for the surgical treatment of coronary heart disease in patients with multivascular coronary lesions.

The gold standard for myocardial revascularization in atherosclerotic lesions of the coronary bed is coronary artery bypass grafting using the median sternotomy access under cardiopulmonary bypass (Subramanian V., Sani G., Benetti FJ, Calafiore AM Minimally invasive coronary bypass surgery: a multicenter report Circulation, 1995, 92 (Suppi 2): 645). This approach gives a good result and is very convenient for the surgeon, since the large size of the wound provides the possibility of extensive manipulations with the heart, and a motionless bloodless field allows you to accurately stitch. Nevertheless, the negative impact of cardiopulmonary bypass, the likelihood of developing sternal infection, the sufficiently long time required for full fusion of the sternum, and other problems make surgeons look for alternative, less invasive routes in terms of surgical and perfusion tactics of myocardial revascularization.

A known method of coronary artery bypass grafting (CABG) without cardiopulmonary bypass (Mikheev A.A., Klembovsky A.A., Travin I.O., Silaev A.A. Coronary artery operations on a working heart without the use of AIC. Thoracic and cardiovascular Surgery, 1991, 10, 23). The method includes revascularization of the myocardium on a working heart, when a coronary artery is isolated and temporarily, for 5-10 minutes, it is pinched to determine the ability of the myocardium to transfer a temporary stop of blood supply to the area fed to this artery. If the test passes without complications (rhythm disturbance, cardiac arrest, ECG changes, etc.), then aortocoronary anastomoses are applied. In the case of complications, coronary artery bypass grafting is performed under cardiopulmonary bypass. However, manipulations on a working heart can cause hemodynamic and electrical instability, cardiac arrest and sometimes massive bleeding, which can lead to emergency connection to cardiopulmonary bypass (IR) for health reasons. At the same time, patients with conversion to IR have a higher complication rate and high postoperative mortality than patients who were routinely operated on in an IR and working heart (Chowdhury R. Risk factors for conversion to cardiopulmonary bypass during off-pump coronary artery bypass surgery / R Chowdhury [et al.] // Ann Thorac Surg. - 2012 Jun. - Vol. 16, No. 3. - P. 226-30).

Recently, minimally invasive methods of surgical myocardial revascularization are actively being introduced into practice due to such advantages as:

1) reducing the negative effects of cardiopulmonary bypass;

2) reducing the morbidity of surgical access through the search for alternative approaches to the total median sternotomy approaches.

The prior art method for minimally invasive coronary artery bypass grafting based on mammary coronary artery bypass grafting (MSC) of the anterior descending artery (PNA) from the anterolateral minitoracotomy in the V intercostal space (Lapierre N., Minimally invasive coronary artery bypass grafting via a small thoracotomy vers a case-matched study. / Lapierre H., Chan V., Sohmer B., Mesana TG, Ruel M. // Eur J Cardiothorac Surg. 2011.- Oct; 40 (4) .- P. 804-10). This technique does not require cutting the sternum, as with standard CABG, and access to the heart is carried out through an incision from 6 to 10 cm long, made in the IV or V intercostal space on the left. This allows you to preserve the chest frame, reduce the risk of infectious complications associated with sternotomy, reduce the severity of pain, pain, facilitate deep breathing in the early postoperative period, eliminates the need to wear a corset for a long time and allows you to quickly return to normal physical activity.

However, despite the limited operational wound, the technique is traumatic, because to isolate a sufficient segment of the left internal thoracic artery (LVHA), as a rule, specialized retractors are used that not only stretch the intercostal space, but also produce aggressive chest elevation in the cranial direction, which is often accompanied by fractures of the ribs. In addition, this technique does not allow safe isolation of the internal thoracic arteries for their subsequent use as autografts for multivascular bypass surgery.

Among patients with coronary heart disease (CHD), multivascular damage to the coronary bed is more common than damage to one coronary artery. According to statistics, from 40 to 60% of endovascular interventions are performed for patients with multivascular coronary lesions.

A known method of myocardial revascularization in multivascular lesions of the coronary arteries on the working heart, including left-side anterolateral minithoracotomy and performing composite sequential shunting of the left ventricle from the left internal thoracic artery, followed by percutaneous coronary intervention in the system of the right coronary artery through the transfusion Pat. RB 19515, IPC A61B 17/00. Method of hybrid myocardial revascularization in case of multiple lesions of the coronary arteries. / Zenkov AA, Ostrovsky Yu.P. // Applicant Education Institution "Vitebsk State Order of Peoples' Friendship of the Medical University." - No. and 20120911. - declared. 12.06.12. - publ. 30.10.15). The method allows for complete myocardial revascularization in patients with coronary artery disease with multivascular lesions of the coronary arteries, reduces the frequency of perioperative complications, blood transfusions and shortens the length of the patient’s hospital stay. The application of the method increases the socio-economic efficiency of the surgical treatment of patients with coronary artery disease, which is manifested in the reduction of direct costs at the hospital stage and indirect losses after discharge from the hospital. However, hybrid revascularization also has a number of disadvantages in the form of complicating the intervention (two-stage), complicating the adoption of a tactical decision if one of the procedures fails. Shunting from mini-access is more demanding on the skills of the surgeon, less convenient conditions for the formation of anastomosis in conditions of mini-access.

At the same time, the recommendations of the American Heart Association for Thoracic and Cardiac Surgery (2011) position the choice of a hybrid method only for a limited number of high-risk patients, such as patients with coronary artery disease without significant damage to the valvular apparatus, the presence of cardiac aneurysm, with one or two vascular lesions of only pools antero-apical region of the heart, in the presence of severe concomitant diseases, in the absence of the prospect of 4KB PNA, as well as with a high risk of interventions associated with manipulations on the ascending aorta.

To date, the most radical from the point of view of minimally invasiveness is the method of complete myocardial revascularization in multivascular atherosclerotic lesions of the coronary bed using robotic techniques, the so-called total endoscopic coronary artery bypass grafting (TESAV) procedure. The method involves intervention on the coronary arteries using endovideoscopic instruments, without opening the chest. Incisions during robotic coronary artery bypass grafting are even smaller than those used in traditional minimally invasive surgery. The cardiac surgeon makes four or five small incisions (called “ports”) through which the camera and instruments are inserted. The internal thoracic artery is used for the shunt. During the robotic bypass, 3 shunts can be installed, and coronary artery stenting can also be performed. During The surgeon controls the instruments that are mounted on robotic manipulators connected to a computer console (Deppe A, Oliver J. Liakopoulos E, Kuhn W, Slottosch I, Schemer. M Minimally invasive direct coronary bypass grafting versus percutaneous coronary intervention for single-vessel disease: a meta-analysis of 2885 patients. European Journal of Cardio-Thoracic Surgery, Volume 47, Issue 3, 1 March 2015, Pages 397-406; Wittwer T, Sabashnikov A, Rahmanian PB, Choi YH, Zeriouh M, Mehler TO et al Less invasive coronary artery revascularization with a minimized extracorporeal circulation system: preliminary results of a comparative study with off-pump-procedures. J Cardiothorac Surg 2013; 8:75; Bonaros N, Schachner T, Lehr E, Kofler M, Wiedemann D, Hong P et al. Five hundred cases of robotic totally endoscopic coronary artery bypass grafting: predictors of success and safety. Ann Thorac Surg 2013; 95: 803-12). The technology implies the possibility of minimized cardiopulmonary bypass and, as a rule, the main stage of the operation in conditions of cardioplegia. At present, quite a lot of experience has been gained in using TESAV technology and in a number of clinics it exceeds 1000 operations. This technique is very effective from a clinical and cosmetic point of view, however, the complexity and high cost do not allow to introduce it into the widespread practice of coronary bypass surgery.

The use of endoscopic technologies in coronary surgery simplifies the use of arterial conduits and expands indications for minimally invasive myocardial revascularization in patients not only with a single coronary artery lesion, but also with multivascular lesions.

Closest to the claimed solution is a method of minimally invasive coronary artery bypass grafting in patients with multivascular myocardial damage - Endo-CABG (Endoscopically Coronary Artery Bypass Grafting) (found on the Internet: http://www.cardiothoracicsurgery.be/professionals/endoscopic-coronary-artery- bypass-grafting .; Direct myocardial revascularization operations on a working heart without cardiopulmonary bypass - minimally invasive coronary surgery: [Electronic resource] // StudFiles students file archive. https://studfiles.net/ (Date of access: 02.15.2019). The method includes endoscopic mobilization of both internal thoracic arteries with separate intubation of the bronchi by means of a double-lumen tube and one-lung ventilation.The patient is placed on the right side with an inclination of 30 ° and with the left hand lifted upward.Arterial conduits are isolated endoscopically through three thoracoports installed in the left pleural cavity. located to the right of endoscopic instruments in the III intercostal space in the anterior axillary line. The second port is introduced into the IV-V intercostal space along the mid-axillary line and the third port - into the VI-VII intercostal space along the anterior axillary line. The location of the ports in relation to the intercostal spaces in each case can be individual and depend on the constitutional features of the patients. The left internal thoracic artery (LVHA) is isolated along with clipping and intersection of the lateral branches. The use of an endoscopic technique in the mobilization of the HAV allows multivascular myocardial revascularization using the right internal thoracic artery (PVGA). At the same time, both conduits are allocated through left-side access without changing the location of the ports. After careful endoscopic monitoring of hemostasis, access to the coronary arteries (CA) is made through a left-side anterior minithoracotomy 4-5 cm long. Turnstiles are placed on the site of the coronary artery at the site of the suspected anastomosis, and after the test with compression of the CA, the anastomosis is applied with a continuous upholstery suture with 7/0 proline .

The disadvantages of the Endo-CABG technique are the lack of full and adequate myocardial protection. Limited ability to bypass coronary arteries. When forming an unstable stabilization of the myocardium, the quality of the formed anastomosis suffers.

The objective of the invention is to develop methods for the complete direct myocardial revascularization in patients with multivascular atherosclerotic myocardial damage by endoscopically assisted coronary artery bypass grafting, observing the principles of minimally invasive surgical access and minimized extracorporeal circulation from peripheral access using the MESS system.

The technical result of the invention is to reduce the risk of complications and adverse outcomes of complete myocardial revascularization in patients with multivascular lesions of the coronary channel, due to the use of patient’s own internal thoracic arteries isolated by semi-skeletonized technique using endovideoscopic instruments and the application of anastamoses with coronary arteries with direct visualization of the myocardium through the anterolateral left-side minithoracotomy access, in conditions of minimal extracorporeal circulation.

The selection of patients with coronary heart disease for minimally invasive endoscopically assisted coronary artery bypass grafting surgery was carried out in accordance with relevant recommendations of international and Russian expert communities (ECS, EFTA, VOK, ROSSX) at a multidisciplinary consultation of cardiospecialists: a cardiologist, cardiac surgeon, and X-ray endovascular surgeon as the preferred method revascularization recommended coronary artery bypass grafting.

The method is as follows: Before the start of the surgical intervention, the patient undergoes standard premedication and antibacterial preoperative prophylaxis. General anesthesia is performed according to a standard technique. Intubation of the main bronchi is performed separately under endoscopic control. To analyze the state of the heart cavities, intracardiac hemodynamics, as well as the features of the main vessels of the mediastinum, transesophageal echocardiography (PE-ECHO-KG) is performed.

Then proceed to the sequential allocation of the internal (right and left) thoracic arteries. With the standard procedure, the right internal thoracic artery is initially isolated, however, depending on the preferences of the surgeon, manipulations to allocate autoshunts can be started on the left side. The first stage involves the installation of three telescopic ports on the right side: one in the IV-V intercostal space along the anterior axillary line for insufflation of carbon dioxide and two in the III and V intercostal spaces along the midclavicular line for an endovideoscopic instrument with a working diameter of 5 mm with a valve and an insufflation channel.

They start selective artificial ventilation of the right lung and insufflation of warm carbon dioxide into the pleural cavity until the target gas pressure in the pleural cavity of 6 mm is reached. Hg. Art. This indicator value is labile and depending on the quality of myocardial imaging and the patient’s hemodynamic response to mediastinal displacement, the indicator value can be more or less. Then, using the electrocoagulator and the hemostatic clips applicator, the right internal thoracic artery is isolated by the semi-skeletal technique.

After that, similar manipulations on the installation of ports and the allocation of the left thoracic artery are performed symmetrically on the left side. The technique for isolating LVHA is not different from that in mobilizing PVHA.

After completion of the allocation of the right and left internal thoracic arteries, the common femoral artery and femoral vein are isolated in the inguinal fold and purse-string sutures with turnstiles are applied. A calculated dose of heparin is introduced to achieve the target level of activated blood coagulation time (ACT) of more than 400 s. The internal thoracic arteries are cut off distally, and taking into account their pronounced tendency to spasm, 1 ml of a 0.2% papaverine solution is injected into the lumen of the artery , which allows for adequate antegrade blood flow.

The next step is to perform a left-side anterolateral minithoracotomy in the IV-V intercostal space 1 cm to the left of the midclavicular line and no longer than 5 cm. A cylindrical silicone soft tissue retractor is installed in the incision, if its retraction effect is insufficient, an additional thoracic retractor with narrow branches (no more than 3 cm). Through the minithoracotomy wound, previously isolated internal thoracic arteries are brought out, and they are thoroughly inspected, as well as additional skeletonization if it is necessary to increase their length. An additional 0.2% papaverine solution is additionally introduced into the lumen of the HAV using a microcatheter.

Using an endovideo camera inserted into previously installed thoracoports, control of the HAV flaps is carried out all the way to the mouths in order to exclude the possibility of torsion. Pericadiotomy is performed, a preliminary revision of the coronary arteries is performed and the features of the topography of the heart are clarified, the final revascularization strategy is determined (if necessary, the internal thoracic arteries remain in situ, or composite anastomoses are formed).

Then, in the III and IV intercostal space along the parasternal line on the right, additional thoracoports with a diameter of 11.2 mm and 14 mm, respectively, are installed (without valves). And at the Lorrey point (the vertex of the angle formed by the costal arch and the xiphoid process), a port is set up for the introduction of the endoscopic grasper.

Through a purse string suture in the femoral vein according to the Seldinger technique, a conductor string of at least 150 cm in length is inserted into the inferior vena cava system. Under the control of PE-ECHO-KG, the conductor string is positioned so that its distal end is located strictly in the superior vena cava. A puncture hole in the common femoral vein is ventured and a multistage cannula is inserted into the conduit to the mouth of the superior vena cava for drainage; the position of the distal part of the cannula is strictly controlled in the superior vena cava by PE-ECHO-KG. Through a purse string suture in the common femoral artery according to the Seldinger technique, a conductor string of at least 50 cm in length is inserted into the descending aorta. Under the supervision of PE-ECHO-KG, the conductor is located in the descending part of the thoracic aorta. The puncture hole in the common femoral artery smoothly bougues, then an arterial cannula is inserted through the conductor. Through thoracoports 11.2 and 14 mm, purse string sutures with turnstiles are placed on the ascending aorta and a 14Fr cannula is installed, which is used to supply a cardioplegic solution and drainage of the aortic root.

Then, cardiopulmonary bypass using the system of minimum volume of extracorporeal circulation (MESS-system). The use of the MESS system minimizes the process of hemodilution and trauma of shaped elements, helps to reduce the severity of the systemic inflammatory response and, as a result, leads to a significant reduction in the effect of extracorporeal circulation on patients inherent in standard IR, which leads to a significant improvement in the quality of treatment as a whole.

Upon reaching stable operation parameters of the centrifuge pump and satisfactory venous return, the ascending aorta is pinched with a Chitwood clamp. Drainage of the aortic root is performed until the left ventricle is deserted and the passage of blood hyperkalemia normothermic cardioplegia begins until persistent ventricular asystole is obtained. The flow of the cardioplegic solution, the closure of the valves of the aortic valve are controlled by PE-ECHO-KG.

An endoscopic grasper with a fixed gauze napkin is inserted through an additional thoracoport at the Larrey point and the heart is rotated in such a way as to provide optimal visualization and localization of the myocardial site with a shunted coronary artery in a mini-thoracotomy incision.

Consistently form the required number of mammarocoronary anastomoses until complete revascularization is achieved. Moreover, cardioplegia is initiated after the completion of each coronary anastomosis, except the last, but no later than 15 minutes after the completion of the previous passage of cardioplegia.

The quality of the anastomoses and the patency of mammary coronary bypass grafts are monitored visually with a short-term loosening of the “bulldog” clamps on the mouths of the internal mammary arteries.

After completion of the formation of anastomoses in order to prevent unwanted bends and torsions, the HAV flap is fixed to the epicardium with fibrin-thrombin glue, or with a few seams.

Electrodes are fixed to the myocardium of the right ventricle, for temporary pacemaking, the pericardial cavity is sutured with several interrupted sutures.

After prophylaxis of air embolism, the clamp is removed from the aorta. According to PE-ECHO-KG, the restoration of cardiac activity is monitored: the contractile function of the ventricles, the degree of filling of the chambers of the heart, the presence of gas bubbles in the chambers of the heart, the function of the mitral valve are evaluated.

To check the functioning of coronary bypasses, their sequential ultrasound flowmetry is performed: linear and volumetric blood flow velocities are estimated, and the pulsatory index is calculated. Based on these parameters, a decision is made on the adequacy of revascularization.

When recovery is sufficient to maintain hemodynamics, the kinetics of the heart gradually reduce the performance of the centrifuge pump until the IR stops completely.

Decanulation is carried out and protamination is started at a dosage adequate to the dosage administered before heparin was administered. After the introduction of the calculated amount of protamine sulfate, an express study is conducted on the content of heparin residual activity. In accordance with the results of rapid analysis, additional administration of protamine sulfate may be required.

Previously installed endoscopic ports are removed. Through the holes in which these ports were previously installed, the right and left pleural cavities are separately drained.

A microcatheter is inserted through the lateral angle of the minithoracotomy wound parallel to the intercostal nerve, to which a pump with a local anesthetic solution (for example, procaine solution) is connected.

Layer-by-layer suturing of the wound in the groin and of the mini-thoracotomy wound is performed (suture fixation of the ribs is not required). The holes remaining on the skin from the endoscopic ports are sutured with single interrupted sutures, or are reduced with skin strip strips.

The inventive method on the basis of the cardiac surgery department of the FSBI "Institute of Surgery A. Vishnevsky" 21 patients underwent minimally invasive endoscopically assisted coronary artery bypass grafting under conditions of cardiopulmonary bypass with minimized perfusion circuit and cardioplegia. All patients showed no clinically significant intraoperative, hospital and long-term complications within 6 months. Operational, hospital and long-term mortality among patients was not recorded. Angiographic monitoring performed on the eve of patient discharge confirmed coronary bypass grafts.

The following is an example implementation of the proposed method.

Example 1. Patient K., aged 57, was admitted to the A.V. Vishnevsky Surgical Research Center for Surgery of the Ministry of Health of the Russian Federation with complaints of burning pains behind the sternum that occur while walking for 100-200 meters, which are at rest. For the first time, mild pain in the left half of the chest appeared in October 2016. Subsequently, the gradual progression of the intensity and frequency of anginal attacks.

Upon receipt, the condition is satisfactory. On the ECG, sinus bradycardia, blockade of the anterior branch of the left leg of the bundle of His. CDS of the bracheocephalic vessels: stenosis of the mouths of the internal carotid arteries 25% on both sides. VDS of the vessels of the lower extremities: stenosis of the right and left common femoral artery 35%. With echocardiography, the heart cavities are not enlarged, there is no valvular pathology. Diastolic function of type 1 is impaired. The systolic function of the left ventricle is normal. General clinical analyzes within reference values. According to coronary angiography: Chronic occlusion of the middle third of PNA, proximal third stenosis of PCA 70%, distal third stenosis of VTK 60%.

Diagnosis. Ischemic heart disease. Multifocal atherosclerosis. Angina pectoris 3 functional class. CHF I, III functional class. Stenosis of the right and left internal carotid arteries 25%. Stenosis of the right and left common femoral artery 35%.

Given the severity of atherosclerotic multivascular coronary lesions, in order to reduce the risk of adverse outcomes and postoperative complications of coronary artery bypass grafting, it was decided to perform complete myocardial revascularization using the minimally invasive endoscopically assisted coronary artery bypass grafting.

Operation: Endotracheal anesthesia with separate intubation of the bronchi. A state-of-the-art ECHO-KG sensor has been started. The left common femoral artery (OBA) and the left common femoral vein (OBV), vessels of a satisfactory diameter, are suitable for peripheral cannulation. The vessels were taken to the holders, two purse-string sutures with the thread "Prolene" 4/0 were put on the BOTH, one purse-string suture with the thread "Prolene" 4/0 was put on the OBV.

In the IV intercostal space, an optical thoracoscopic port 5 mm equipped with a CO ₂ valve for insufflation is installed on the right along the anterior axillary line. Carbon dioxide insufflation has begun in the pleural cavity under a pressure of 6 mm. Hg. Art. Next, two short thoracoscopic ports were installed in the III and V intercostal spaces, along the midclavicular line. With the help of video-assisted thoracoscopic support by monopolar coagulation in “spray” mode using the scapula and hook, the right inner thoracic artery (PVGA) was remotely isolated by the semi-skeletonization technique along the entire length (from the mouth to the bifurcation), the first intercostal artery of large diameter was double-clipped and cut off. HAV is clipped distally.

Then, the thoracoscopic ports are installed at similar points on the left, the left HAV is taken out along the entire length, the first intercostal artery is clipped and cut off. The left HAV is also clipped distal to the bifurcation and cut off.

An anterolateral minithoracotomy of 5 cm long was formed 1 cm to the left of the midclavicular line in the V intercostal space. A cylindrical silicone soft tissue retractor 50 mm in diameter was installed. Pericardium visualized. HAV revision - suitable for shunting. 1 ml of 0.2% papaverine solution was added to the HAV. A port with a diameter of 14 mm is installed along the parasternal line to the right in the III intercostal space and thoracoscopic ports with a diameter of 11 mm are installed in the IV intercostal space. An ascending aorta was isolated, a purse string suture was applied, and a U-shaped cardioplegic cannula was inserted through the 11 mm port. Further peripheral cannulation of the forehead and forehead without features. After an emergency echocardiography control of the position of the cannulas, an IR was started using the MESS system. An ascending aorta is pinched through a 14 mm port with a Chitwood clamp. Normothermic blood cardioplegia. Through an additional 12 mm port under the left costal arch along the midclavicular line, endoscopic tweezers with a fixed napkin and a stabilization system are inserted. The lateral wall is positioned, an anastomosis of the left HAV (in situ) is formed - PKA. Repeated passage of normothermic blood cardioplegia. Formed anastomosis of the right HAV (in situ) - GENA. After the prevention of air embolism, the clamp was removed from the aorta. EX electrodes are hemmed to the myocardium of the right ventricle. Self-restoration of cardiac activity. Reduce the performance of the centrifuge pump, stable hemodynamic parameters, heart kinetics is satisfactory. Stop IR. Dekanulation of the forehead and forehead. The left and right pleural cavities are drained.

In the V intercostal space parallel to the course of the intercostal nerve, a catheter with a pump is installed for continuous infusion of a local anesthetic. The minithoracotomy wound and the wound under the left inguinal fold are sutured in layers. Accesses from thoracoscopic ports are sutured with interrupted sutures.

The postoperative period without features, hemodynamics is stable, indicators of systemic inflammation are not fixed. The patient is vertical on the 2nd day after surgery, without features. Postoperative wound healing by primary intention. During control coronary angiography, functioning anastamoses of MKSh-PMZHV (from the right HAV), MKSh-ZBV PKA (from the left HAV).

The proposed technique for endoscopically assisted coronary artery bypass grafting, rationally combines the advantages and eliminates the disadvantages of known techniques from the prior art. It allows you to achieve complete direct myocardial revascularization in accordance with the principles of minimally invasive perfusion and minimally invasive surgical access, while fully complying with more than ever the relevant concept of resource saving in healthcare.

Claims (1)

A method for complete minimally invasive endoscopically assisted myocardial revascularization in case of multivascular atherosclerotic lesion of the coronary bed, including sequential isolation of the patient’s internal thoracic arteries using a semi-skeletal technique, using endovideoscopic instruments and the application of anastomoses with coronary arteries in the presence of minimal extracorporeal myocardium access made in the IV-V intercostal space 1 cm to the left of the midclavicular line 5 cm long, while the installation of thoracoports for the isolation of the internal thoracic arteries is carried out symmetrically from the right and left side: one in the IV-V intercostal space along the anterior axillary lines for carbon dioxide insufflation and two in the III and V intercostal spaces along the midclavicular line for the endoscopic instrument, and in III and IV intercostal space along the parasternal line with thoracoports with a diameter of 11.2 mm and 14 mm, respectively, intended for drainage of the aortic root and supply of a cardioplegic solution are established, and at the Lorrai point a port is set up for the introduction of endoscopic grasper with a fixed gauze napkin, after reaching a complete cardioplegic asystole, the heart is rotated in this way in order to ensure optimal visualization and localization of the myocardial site with the shunted coronary artery in the minithoracotomy section, and cardioplegia is initiated every time after the completion of the next coronary anastomosis, except the last.