Two-Port Robotic Cardiac Surgery (TROCS) for Atrial Septal Defect (ASD) Using Cross-Arm Technique　– TROCS ASD Repair –

Abstract

Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp position. After systemic heparinization, a 16Fr outflow cannula was inserted transcutaneously into the right internal jugular vein, and a 18Fr Inflow cannula and a 25Fr outflow cannula were inserted into the right femoral artery and vein, respectively. The first 20-mm port for the robotic arms was made in the 4th intercostal spaces at the right anterior axillary line. The second 10-mm port for the robotic endoscope was inserted through the 4th intercostal space at the right midclavicular line.Next, the da Vinci S surgical system was introduced from the left side of the patient. Both robotic instruments were inserted through the first port and crossed while preventing them from colliding with each other (Figure 1A). At the same time, the master-instrument association at the surgeon's console was set to the reverse of the default settings so that the right master would control the left instrument and the left master would control the right instrument.Cardiopulmonary bypass (CPB) was initiated, and the superior vena cava were occluded with a small clamp. We performed the ASD repair with the 0 degree robotic endoscope and 5 mm robotic instruments using a cross-arm technique. Ventricle fibrillation (VF) was induced using a combined method of electrical fibrillator, injection of potassium and hypothermia without aortic cross-clamping. The ASD was directly closed with 4-0 Gore-Tex and a running suture ( Figure 1B). After defibrillation, the patient was weaned from or treatment of atrial septal defect (ASD), various minimally invasive surgical procedures have been developed to minimize the surgical incisions and cosmetic results, such as transthoracic approach transcatheter approach. 1,2 Recently, a robotic surgical system has been developed to enhance the surgeon's ability not only in the field of laparoscopic surgery but also cardiac surgery, 3 and the first total endoscopic closed-chest ASD repair using the da Vinci surgical system (Intuitive Surgical, Inc, Sunnyvale, CA, USA) was reported in 2001. 4 The present study describes a case of total endoscopic cardiac surgery for ASD via 2 ports using a cross-arm technique, which we named two-port robotic cardiac surgery (TROCS).A 51-year-old woman was diagnosed with secundum ASD. Preoperative 2D echocardiography revealed a pulmonary blood flow (Qp)-to-systemic blood flow (Qs) ratio of 1.9, and a diagnosis of secundum ASD (maximal diameter, 16.5 mm) with enough tissue surrounding the defect to enable transcatheter ASD repair. However, the patient preferred to undergo surgery, and we planned a minimally invasive robotassisted ASD repair after consulting the institutional review board. Informed consent for this novel technique and the payment was obtained from the patient and her family before the operation.Anesthesia was induced using a double-lumen endotracheal tube. The patient was placed in a left hemi-lateral decubitus Ryuta Kiuchi, MD, PhD; Hiroshi Ohtake, MD, PhD; Shigeyu...

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