Nonrobotic Totally Endoscopic Harvesting of Bilateral Internal Thoracic Arteries Via Pressure Bag–Assisted Positioning and Symmetric Port Access

We describe a nonrobotic, totally endoscopic technique for bilateral internal thoracic artery (ITA) harvesting using pressure bag positioning and symmetric port placement (Supplemental Video). This approach provides clear visualization without robotic assistance, avoids robotic cost, and may facilitate wider adoption of minimally invasive coronary surgery. ¹

Patients were evaluated preoperatively using computed tomography to exclude severe pulmonary disease or subclavian artery stenosis and to assess chest wall anatomy, which could complicate endoscopic harvesting. Pulmonary function tests and echocardiography were performed to confirm tolerance for one-lung ventilation and CO₂ insufflation.

The exclusion criteria were emergency surgery, hemodynamic instability, redo sternotomy, or subclavian stenosis/occlusion. Severe obesity, chest wall deformity, poor ventricular function, or cardiomegaly were relative contraindications, similar to those for robotic ITA harvesting. ²

After induction of general anesthesia, both arms were wrapped in sterile sheets and positioned alongside the torso. Pressure bags were placed beneath both scapulae (Supplemental Fig. 1). For left ITA harvesting, the left bag was inflated and the table tilted to rotate the torso about 45° leftward; for right ITA (RITA) harvesting, the right bag was inflated, the left bag deflated, and the torso rotated rightward. This positioning eliminated external retractors or robotic platforms. A similar dual pressure bag method was reported by Sakai et al. for other minimally invasive cardiac procedures. ³

During the transition from right-sided to left-sided one-lung ventilation, we resumed bilateral ventilation for approximately 5 min, applied FiO₂ 1.0, and performed a gradual shift while monitoring oxygen saturation and end-tidal CO₂, minimizing hypoxemia risk.

Three 12 mm ports were placed on each side: the right-hand port at the third intercostal space (posterior to the midclavicular line), the left-hand port at the fifth intercostal space (posterior to the midclavicular line), and the camera port with a 30° three-dimensional (3D) endoscope at the fifth intercostal space (the anterior axillary line), mirrored contralaterally (Supplemental Fig. 2). CO₂ was insufflated (7 to 10 mm Hg) into the thorax.

The pericardium was opened to expose the left anterior descending artery, minimizing the risk of conduit injury. Each ITA was skeletonized under 3D endoscopic vision from near the phrenic nerve proximally to the bifurcation of the musculophrenic and superior epigastric arteries distally (Supplemental Fig. 3). Side branches were divided using clips or electrocautery. In patients with abundant perivascular fat, particularly proximally, a Harmonic Scalpel 1100 (Ethicon, Cincinnati, OH, USA) was used. Venous bleeding was managed using a suction ball coagulator (AMCO Inc., Tokyo, Japan). Should ITA trunk injury or complete branch avulsion occur, preparation to open the planned thoracotomy for direct suture repair under vision is necessary.

This bilateral approach enables complete proximal RITA dissection and avoids the limited reach and visualization issues seen with RITA harvesting via a left-sided mediastinal approach. We have not experienced oxygenation deterioration during switching of lung dependency. Although 6 ports are required, the technique is reproducible, safe, and independent of robotic platforms. This technique may support the adoption of minimally invasive coronary bypass in programs without robotic systems.