Robotic Totally Endoscopic Coronary Artery Bypass: Coronary Artery Stabilization Without the EndoWrist Stabilizer for a Second Arterial Graft

Robotic totally endoscopic coronary artery bypass (TECAB) continues to evolve as a viable alternative to traditional coronary artery bypass grafting (CABG), especially in patients at high risk for sternal wound complications. The use of multiarterial grafting, particularly bilateral internal thoracic arteries (BITA), offers clear advantages in terms of long-term graft patency and overall survival.^1,2 However, the adoption of BITA has been limited in high-risk patients due to concerns over sternal healing. TECAB, as a sternal-sparing technique, overcomes this challenge while maintaining the benefits of arterial grafting. A critical barrier to broader adoption of robotic multiarterial TECAB has been the absence of a robotic stabilizer, such as the EndoWrist Stabilizer™, which was previously available on the da Vinci Si platform but discontinued on the newer da Vinci Xi system (Intuitive, Sunnyvale, CA, USA).

This report demonstrates the feasibility of using a table-mounted epicardial stabilizer, the Octopus™ Nuvo (Medtronic, Dublin, Ireland), as a substitute for the robotic stabilizer in 2 patients undergoing robotic multiarterial TECAB (Supplemental Fig. 1). In the first case, a 68-year-old male patient with multivessel coronary artery disease underwent robotic BITA grafting, with the right ITA to the obtuse marginal branch and the left ITA (LITA) to the left anterior descending artery (LAD). The procedure used a 5-port configuration, warm humidified CO₂ insufflation, and a subcostal port for introduction of the Octopus Nuvo stabilizer. A unique seal was created by twisting the Alexis soft-tissue retractor (Applied Medical, Rancho Santa Margarita, CA, USA) around the stabilizer shaft to maintain intrathoracic insufflation. The pericardium was opened anterior to the left phrenic nerve for introducing the stabilizer, while anastomoses were performed through a posterior pericardiotomy to avoid phrenic nerve injury. Transit time flow measurements confirmed graft patency. Postoperatively, the patient experienced atrial fibrillation, managed successfully with amiodarone, and was discharged on postoperative day 3.

The second case involved a 63-year-old male patient with LAD and diagonal branch disease following a non-ST-elevation myocardial infarction. A single LITA conduit was sequentially anastomosed to the LAD and diagonal branch using the same robotic setup and stabilization approach. The Octopus Nuvo stabilizer enabled precise coronary stabilization under endoscopic visualization. A bulldog clamp was placed on the LITA and rotated 180° to expose the underside to facilitate the sequential anastomosis. The patient recovered uneventfully, was extubated the same day, and discharged on postoperative day 2 with no readmissions or complications.

These cases confirm the technical feasibility of totally endoscopic, off-pump, multiarterial coronary bypass surgery using a table-mounted stabilizer on the da Vinci Xi platform (Supplemental Video 1, Supplemental Video 2, Supplemental Video 3). Although the Octopus Nuvo lacks the surgeon-console control of the EndoWrist Stabilizer, its effective use demonstrates the potential for high-complexity robotic coronary surgery without compromising outcomes.^3–5 Success with this method depends heavily on coordination between the console surgeon and bedside assistant as well as institutional familiarity with the modified techniques. As robotic cardiac surgery matures, the need for a new console-controlled stabilization system remains critical to fully restore and enhance the versatility of TECAB.