Different groups of patients have different concerns and demands for less invasive surgery.  
Will I awake after the operation? How much pain will there be? When will I be able to return to work, physical and sports activities? How long will it take for my incision to heal, and what will the scar be like? Most of these concerns and demands are focused on comfort, cosmesis, and rehabilitation, which are all affected by the degree of invasiveness.  

The objective factors, affecting the degree of invasiveness of cardiac surgery are the surgical approach and cardiopulmonary bypass.  
* The surgical approach is comprised of and will determine 
* the length of the skin incision and the associated amount of visible scar tissue 
* the degree of aggression to muscle-, connective- and bone tissue, which is affected by the amount of contusion and coagulation 
* the deformation of the thoracic cavity 
* the loss of blood 
* the amount of pain and discomfort  
* the ventilatory problems 
* the amount of anesthetic or analgetic drugs needed 
* the occurrence of devastating complications, such as sternitis and mediastinitis. 
* There are several options for cardiopulmonary bypass: operate on the beating heart without extracorporeal circulation  
(1) install conventional cardiopulmonary bypass and operate on a fibrillating or arrested heart and  
(2) use the new EndoCPB(tm) System (Heartport(r), Redwood City, CA) for endocardiopulmonary bypass, arresting the heart with an endoaortic clamp.  
However, cardiopulmonary bypass has several objective problems including hemolysis, heparin-rebound phenomena, complement activation, and deterioration of the immune system. There are also subjective factors that affect the degree of invasiveness of cardiac surgery, such as poor appetite, insomnia, depression, visual, memory, or intellectual deficits, and loss of sexual ability. 

Less invasive cardiac surgery is trendy.  To be able to compare different ways to lessen the aggression of cardiac surgery in a way, to classify this new type of surgery is definitively needed.  This is a proposal to establish 4 categories: 
A. Direct Coronary Artery Surgery on the beating heart 
B. Limited or modified approaches, with ECC  for a wider array of surgical corrections 
C. MIDCAB: Minimally Invasive Direct Coronary Artery Bypass surgery: via a minimal approach a thoracoscopically harvested arterial bypass is anastomosed to LAD on the beating heart 
D. True Port-AccessTM Cardiac Surgery with ECC for all sorts of cardiac pathology. 

These methods have different degrees of invasiveness, may introduce additional risk or make the conversion to conventional surgery more or less difficult and have different learning curves. The possibility of additional risk and the length of the learning curve are affected by the changes in instrumentation, including stabilizers, special retractors, trocar ports, and smaller shafted instruments, the change in visualization to partial or complete video assistance and new ways to install Extra-Corporeal circulation. 

The Classification: 
A. Direct Coronary Artery Bypass Surgery on the beating heart without Extracorporeal Circulation: Off-Pump CABG or OPCAB 
Coronary artery bypass surgery via sternotomy without extracorporeal circulation is for the most part conventional and can only be considered less invasive because the complications of extracorporeal circulation are avoided. Because cardiopulmonary bypass is not used, stabilizers are necessary to immobilize the distal anastomotic site, although conventional forceps are needle holders are used to perform the anastomoses, and visualization is also conventional. Hence the learning curve is rather short. There is the risk of partial revascularization, but conversion to conventional surgery is not difficult. Specific indications for this type of surgery are single vessel disease, previous or current malignancy, hemodialysis, severe pulmonary insufficiency, advanced age, poor ejection fraction, calcified aortic root and arch, redo situations, recent history of cerebral hemorrhage, and a patient who is a Jehovah's Witness.  

A particular technology has been developed by several companies to “stabilize” the anastomotic site like the CTSTM or the OctopusTM stabilizer. In many centers both surgeons and anesthesiologists have elaborated technicities to work on the beating heart without compromising the hemodynamic status of the patient. Whether or not full revascularization with as many arterial grafts and as good results as with cardiopulmonary bypass can be achieved remains to be seen.  
There are no obvious reports yet that there are significant benefits for the patients undergoing OPCAB. Fig 1.  

B. Limited or modified approaches using conventional techniques and instruments 
Many alternative approaches have been described that lessen the damage to the thoracic cavity: the partial T or L sternotomy through the 3rd or 4th intercostal space, the reversed T sternotomy, the transverse sternotomy, parasternotomy with excision of two or more costal cartilages, and various types of anterolateral minithoracotomies. The surgical techniques are fairly conventional, so the learning curve is short, but conversion to conventional surgery is more difficult. Extracorporeal circulation can be either conventional or with the EndoCPB(tm) System. Visualization is conventional, but special retractors are required.  
There is an array of limited or modified approaches, including midline sternotomy, hemisternotomy, reverse T sternotomy, and J sternotomy to the left or right through the 3rd or 4th intercostal space or on a parasternal axis.  

Specific indications for these procedures include redo situations, previous sternitis and mediastinitis, severe pulmonary insufficiency, or disorder of the ventilatory muscles. These approaches reduce the aggression to the thoracic cavity and the amount of pain, and the thoracic cavity is more stable after hemisternotomy or J sternotomy, which will most certainly benefit some patients. Comfort and cosmesis may also be improved, and some patients will have a shorter rehabilitation period. However, is this truly minimally invasive cardiac surgery, or is it simply “fashionable” minimally invasive cardiac surgery? 

C. Minimally Invasive Direct Coronary Artery Bypass : MIDCAB 

* Introduction 
Minimally invasive direct coronary artery bypass (MIDCAB) is an anastomosis of a short or long pedicle of an arterial graft, most commonly the internal mammary artery (IMA) to the left anterior descending artery (LAD) (95%) or the right coronary artery on the beating heart via a parasternal or left anterior small thoracotomy.  
The value, even in the extended 18- to 20-year term, of bypass from an IMA to the LAD is well documented in the literature and, in the off-pump and minithoracotomy setting, extremely costeffective. Thus it is a valid alternative for endovascular procedures. In 2- or 3-vessel disease, it may be a part of a well-designed hybrid therapy protocol. It is most definitely minimally invasive, and epidural anesthesia can provide additional comfort to the patient. However, the learning curve is difficult, and conversion to conventional surgery can be cumbersome. Special retractors and stabilizers are required, although visualization may be conventional or video-assisted. 

* Technique 
The patient is positioned in dorsal decubitus. In the left breast groove, the skin is incised over about 7 cm, the subcutaneous layer tissue is divided, and the 5th rib is reached.  
A Bookwalter(tm)  mammary retractor is then fixed to the edge of the operating table. It has multiple articulations and can gently lift up and stabilize the upper rib by means of two hooked arms and fixate a solid aperture. On the front axillary line, a thoracic port is inserted and allows the camera eye to have a look into the left Thoracic cavity. We use a standard OTVS5 camera head with a 10-mm 0o autoclavable thorascope.. The right lung is then selectively ventilated, the left lung collapsing. One can immediately observe the left phrenic nerve and the beating heart under the pericardium. The dissection of the left internal mammary artery is started in the middle of its course with a long well-protected diathermy tip. With a curved forceps and scissors it can be continued towards the top of the pleural cavity.  
All instruments are introduced through the fixed aperture of the 5th intercostal space, while the eyes of the surgeon are focused on the screen. Cautious dissection and preservation of the left mammary artery is possible.  
Moreover, it's sometimes easier than from the angle of the median sternotomy. The images of the screen allow the LIMA to be taken away from the sternum up to the level of the left subclavian vein. In most of the cases, the aperture of the 5th intercostal space does not allow both direct view into the operating field and the introduction of the necessary instruments simultaneously.  
This technique of video-assisted harvesting of the left internal mammary allows all the side branches to be clipped off and ensures the graft to be long enough and to be far away from the sternum, which can become very important in case of redo surgery, for example. Heparin is administered, and an Endo-Bulldog attached to a thread is then applied on the LIMA to control bleeding after division distally. The pericardium is precisely incised in front of the phrenic nerve and the diseased LAD comes immediately in sight. The epicardial layer is removed from the LAD.  
Multiple polypropylene stay sutures are placed on both edges of the fatty epicardium, and the vessel is surrounded in a wide arc with 4-0 atraumatic PTFE stitches. The pulsatile blood flow in the LIMA is controlled once more, and the epicardial stay sutures are fixed to immobilize the area in which the LAD is to be grafted. The PFTE  loops brought under tension can stop the coronary flow, and the delicate anastomosis is carried out with 8-0 polypropylene in the usual manner.  
In most of the cases the ECG of the patient remained unchanged. With an 11 mm autoclavable video thoracoscope, the left thoracic cavity is checked for accurate homeostasis, and remaining bleeding vessels are coagulated. Fig 2. 

* Results 
The goals of our MIDCAB series, which began 2 years ago, were to (1) provide a valid extrapolation to the established long-term results of standard IMA grafting, (2) use a full-length IMA graft, (3) to limit the indications to those cases where complete revascularization of viable myocardium was possible, and (4) use systematic control angiography. In order to obtain a full-length IMA graft, we performed video-assisted takedown from the beginning of the series.  
There is an excellent transition that can be installed through a somewhat larger thoracotomy, where takedown of the IMA is begun in the lower portion under direct vision but continued in the upper portion with video-assisted visualization, and then after 5 or 10 learning-curve cases, takedown of the entire length of the IMA can be performed with video-assistance. Specific indications for our series (n = 53) included muscle disorder in 1 patient, calcification of the ascending aorta and arch in 1, previous malignancy in 4, noninsulin-dependent or insulin-dependent diabetes mellitus in 9, chronic obstructive pulmonary disease in 1, and 1 Jehovah's Witness. Contraindications were extreme obesity, pleural adhesions, and diffuse distal coronary artery disease. Anesthesia was administered through a double-lumen tube, and bradycardia was induced with esmolol 0.1 to 0.25 mg/kg/min.  
The heart was preconditioned with lidoflazine 1 mg/kg. No aspirin or adenosine was used. 

Intraoperatively, there were no electrocardiogram changes or rhythm disturbances, although slightly impeded regional wall motion in the interior wall was seen occasionally on transesophageal echocardiography. There were 2 cases of right ventricular bleeding that were easily treated with compression. The mean duration of the procedure was 2 hours 50 minutes, ranging from 1 hour 30 minutes to 5 hours. We had no conversions to sternotomy and used no cardiopulmonary bypass. 

Forty-eight of the first 50 patients (1 refused and 1 died) underwent systematic control angiography, which showed that 46 of the IMAs were open, for a patency rate of 95.8%.  
Two patients at the beginning of our experience were reoperated on postoperative days 8 and 2 and had a small venous interposition on a dissected portion of the IMA. After these 2 reoperations, the patency rate was 100%. Morbidity included reoperation in 2 patients, revision for bleeding in 2, pleural effusion in 6, hemothorax in 1, foot-drop in 1, supraventricular arrhythmia in 5, and wound infection in 1. Fig. 3  shows a patient breathing spontaneously 1 hour after MIDCAB. 
After 2 or 3 days, most of these patients are able to return home. 

In the future, MIDCAB may be combined with other techniques to create a 5th category of procedures known as hybrid therapy; surgery with interventional cardiology. MIDCAB may be performed using the left IMA to the LAD; used in conjunction with interventional cardiology, perhaps on the circumflex and right coronary arteries and in a hybrid strategy combined with prophylactic measures for risk factors and plaque destabilization. 

D. True Port-AccessTM Cardiac Surgery  

“Surgery is exposure“ is an adagio that I kept hearing all the way during my surgical training. Why is this? Well, two-pronged instruments and direct vision are the answers. A traditional surgeon needs lots of space! But how about bloodloss, inflammatory reaction, cracked ribs and possibly devastating complications like sternitis & mediastinitis, let alone the bad cosmetic result! 
Let ' s imagine that  
(1) we do not need the direct vision anymore and can rely -to a more or lesser- degree upon video-assistance. Fig 3. 
(2) we start to work with different instruments, “ shafted instruments “ that we can handle trough trocar-port openings -Fig 4- and that  
(3) we perform a percutaneous ECC and occlude the aorta with an Endo-Aortic Balloon. By the way, this is  the system - par excellence - to do CPB assistance in the cath-lab in case of a hemodynamic collapse because it can be installed in seconds. 
These three conditions will allow us to work trough a “ working port “ ,  which can be looked at in Figure 5. 
Another widespread adage “petite incision, petit chirurgien” - (small incision, small surgeon) - arose from the use of the classic two-pronged forceps, scissors, and suturing instruments and the direct view into the chest in conventional surgery. But why open a patient' s chest today when there is another viable option, even if new instruments and video-assisted enhanced visualization are required? 
It is up to you to decide;  the learning curve is for the surgeon. For the patient? Much less bloodloss, no cracked thoracic cavity, let alone cartilages in the dust bin and no devastating wound complications, much less pain and a sometimes astonishingly fast rehabilitation as a result. 

* Optimizing Endo-CPB 
Port-AccessTM Cardiac surgery performs surgical acts to be performed through tiny ports in the intercostal spaces. The big vessels are not easily accessible and therefore, new methods to install the CPB and to arrest the heart are necessary to allow surgery in a gold standard setting.  

The Achilles-heel of Port-AccessTM Surgery is the quite different way to install CPB. It is necessary if one wants to work through a tiny “Port” and will finally allow for “closed chest” cardiac surgery. A CPB system that doesn't call for a big access and uses “Endo-vascular “ methods can be called Endo-CPB. Not every patient is a good candidate for Endo-CPB.  
So there are pre-operative thresholds to be taken into account. Not every patient is a good candidate for Endo-CPB. Good peripheral pulses are good enough a sign to decide for Endo-CPB in most cases but, in doubt, a duplex or an IV angiography can learn a lot. During the surgery, one has to know exactly when to back off and/or convert to exclude additional risk and TEE will tell everything about the right lumen, the passage through the right vessel and the exact positioning of for example the endo-aortic balloon. 

Heartport(r)'s arterial cannula' s offer both retrograde and antegrade flow; the introduction techniques are the Seldinger or “Stab” technique. Puncturing the femoral artery is basic to have certainty about the right lumen and can avoid clamping of a diseased vessel. Gentle passage of a guidewire and advancement into the descending aorta will  give the comforting image of a free-floating guide on TEE, which is the sole measure of absolute safety. Needless to say it has to be a soft-tip guidewire. Very seldom fluoroscopy is needed to find your way through a tortuous iliac artery.  
Needless to mention your anesthesiologist has to be an expert in TEE but  -preferably- the surgeon should get himself a small monitor with the TEE image for increased comfort ! The Heartport(r) arterial cannula comes in 21 and 23 french and it is suitable for introduction over a guide wire. The only thing you need is a dilator. The Y-arm allows for safe introduction of the Endo-Aortic Clamp eventually.  
A recent Heartport(r) cannula is the Endo-directTM. It can be stabbed into the ascending aorta trough a trocar port. It' s got a Y-arm too, to bring in the Endo-aortic balloon above the sino-tubular junction. The access is shorter, it gives antegrade flow and the balloon will be less keen to migration. TEE always will guide in positioning the Endo-ClampTM. On the other hand, you 'll need a safe trip home after decannulation... 

Venous cannulation calls for the same safety measures, that is to say puncture of the lumen and Seldinger technique. Fig 6. It can be done percutaneously if it' s the sole cannulation in the groin.  
Kinetic assistance is necessary for a single or double stage femoral cannula, that comes from 21 to 28 french. Jugular cannulation is done by the anesthesiologist. DLP offers a 14 or 17 french cannula that is very suitable. The advantage is a tube-free right atrium for ASD, myxoma or tricuspid surgery. 

The pulmonary venting cannula that Heartport(r)offers is very useful in mitral and coronary artery surgery. It can prevent a lot of backbleeding in the left atrium and will prevent blood from being sequestrated in the lungs, where lysis of leucocytes can have devastating effects. 

Safe cardiac arrest is a challenge in Port-AccessTM surgery. The technology of the Heartport(r) Endo-aortic clamp allows endo-aortic balloon inflation to occlude the lumen and the delivery of antegrade cardioplegia. There is continuous improvement of the balloon and we're at the fifth generation balloons at the present time. 
Learning the technicity of safe balloon positioning asks for fluoroscopic control in the beginning but about 30 cases should suffice to rely completely on TEE. Fig 7.  
The anesthesiologist will give the exact diameter of the ascending aorta, 30mm for example, and this will usually roughly corroborate with a 30cc injected volume and 300mm mercury of balloon pressure.  
The balloon is inflated with a small amount of fluid initially and when you' ve got it floating in the blood-flow like  a kite in the wind the catheter is pulled back to be blocked to the cannula and prevent the balloon from migrating. Antegrade cardioplegia can always be completed with a dose of retrograde - if necessary - trough a coronary sinus catheter that can be introduced safely - under TEE control -  through one of the necksheats.  

The  remaining major challenges of Endo-CPB are: 
• One doesn't have the right to damage the peripheral vessel that is cannulated. Once more, pre-operative thinking, proper Seldinger technique and good monitoring are the cornerstones to avoid it.  
• We have to face the unacceptable issue of aortic dissection and there is no way this complication can be swept under the rock: in terms of technology a lot has been done yet: softer guidewires, better catheters. Thresholds and technique come into play again to avoid the problem. Wisdom should always exclude zeal. A lot is expected from the Endo-direct cannula. Larger series have to prove the high expectations. 
• So far, a small cutdown is needed to close the femoral access. No clamping is necessary as insertion of a fogarty catheter can prevent the artery from important backbleeding but we finally want to see safe percutaneous placement of endovascular cannula's. No problem for the venous cannulation but an automatic closure device of the arterial cannulation-site is to be found. 
• De-airing shouldn't be a problem with the right measures. They're all here: CO2 flushing of the operative field, PA-Vent Stop, Silicone ventricular venting and start ventilate the left lung, Trendelenburg & CC Rotation of the table, Retrograde Cardioplegia, Deflation of the Balloon and Balloon Tip & Ventricular Aspiration  
• The summary is: there is a huge task left for the industry: make CPB more bio-compatible as we'll never get rid of it completely 

* Port-AccessTM Mitral Valve Surgery 

* Introduction 
Right thoracotomy is a well known alternative for mid-sternotomy to have access to the left atrium. Port-Access(tm) approach is an invaluable option to avoid cracking of ribs and cartilages. Endo-CPB(tm) and Endo-aortic clamp allows installation of the ECC and cardiac arrest from the groin. Video-assistance and shafted instruments are the surgeon' s help to do the surgery through a five by two cm port and fulfil the main goals of minimally invasive cardiac surgery, comfort, cosmesis and fast rehabilitation. 

* Technique 
The patient is installed in dorsal decubitus with an inflatable  pillow under the right kidney and in the right inframammary groove, a 6 cm incision is made. A needle is inserted in the 4th intercostal space to fill the thoracic cavity with CO2. Heartport' s soft tissue retractor is inserted into the intercostal incision and the rib retractor will create a nicely tilted 5x 2 cm “ working port “.  
A 5 mm intercostal port is created on the front axillary line in the 3rd or the 4th IC space to allow the thoracoscope to come into the thoracic cavity. The CO2 line is attached to this port to have continuous flushing of the cardiac cavities with CO2. Another 5 mm port is created parasternally under thoracoscopic vision to avoid the internal thoracic artery. It will receive the handle of the left atrial retractor. A third 10 mm port is created on the front axillary line in the 7th or 8th IC space.  
It allows the Teflon felt reinforced stay sutures on the centrum tendineum of the diaphragm to be brought out of the thorax and fixed to bring down the diaphragmatic dome. It will serve as an introduction port for the atrial venting cannula and the thoracic drainage tube. 
See figure. 

When the extra corporeal circulation is started, the pericardium is incised and opened along the phrenic nerve and stay sutures can open it widely by bringing them out of the thoracic cavity on the middle axillary line by means of an Endo-CloseTM. The upper curtain of the pericardium is attached to the thoracic wall and the dissection of the interatrial septum is started.  
After arresting the heart by delivering antegrade cardioplegia, the zero degree 5 mm thoracoscope shows a completely flaccid heart and after both the aortic root and the pulmonary artery are vented, the left atrium is incised with specific shafted forceps and scissors. The handle of the atrial retractor system is then brought to the parasternal port, the most appropriate blade attached to it and the right atrium complete retracted. At that time the zero degree thoracoscope is pushed forward and can give a great view of the mitral valve.  
In some instances the thirty degree thoracoscope that comes in from a different angle can give better a better working space. Fig 8. 
In Mitral Valve Replacement, the posterior leaflet of the mitral valve can be preserved completely while the anterior leaflet can be resected except for its free edge close to the postero-medial commissure. Reinforced 2/0 Ticron U-stitches bring the free edge towards the annulus and they are nicely disposed on suture guides outside the patient. With a valve sizer the appropriate size can be prepared.  
The valve is pushed to the working port sometimes with the help of a shoe-horn! The thoracoscope can then nicely visualize its descend along the U-stitches into its position in the mitral annulus with the help of the valve seater. Fig 9.  
All the knots are tied extracorporeally and they are pushed into place with the Heartport(r) knot pusher. Fig 10.  
It allows the surgeon to tie a rapid succession of throws and tighten each of them firmly against the sewing ring. A silicon suction tube is placed through the valve and the patient is placed into Trendelenburg and lateral decubitus to secure proper deairing procedure. Remember that the entire operative field is continuously flooded with CO2.  
One lateral opening of this silicone tube is kept outside the closure of the atriotomy to visualize proper de-airing. The heart starts to beat slowly when the balloon is deflated and the routine procedure for weaning from the extracorporeal circulation is commenced.  

Mitral leaflets can be nicely repaired and an annuloplasty-ring perfectly placed under video-assisted visualization. The surgeon is looking at a screen while his shafted instruments are working into the patients left atrium.  
A third degree thoracoscope can give better visualization when U-stitches are in place in the mitral annulus. The “Port-Access” Cardiac Surgeon will have to get accustomed to the use of the shafted instruments and has to develop the proper eye-hand coordination for video-assisted surgery. 

Video-assisted visualization is very important to have perfect inspection when a thromboendarterectomy of the left atrium and the left atrial appendix is carried out. The visualization system has to provide proper colour, contrast, resolution, field of view and depth of field to fulfil these surgical acts properly. Three dimensional video-assisted visualization may become extremely helpful to achieve very delicate repairs of both anterior and posterior mitral valve leaflets.  
Obviously, there is no need for a wider access thanks to the video-assisted visualization, the shafted instruments and the Endo-PCB and Endo-Aortic Clamp system, but it will take the surgeon some time to get accustomed to a completely new way of working. The obvious benefits for the patient are better comfort, optimal cosmesis and a faster rehabilitation. 

* Results 
From February 1997 until November 1998, 68 patients (36 M/32 F) had either Port-Access(tm)  mitral valve repair (n=38) or replacement (n=30) for a variety of pathology: myxoid degeneration (40), rheumatic disease (19), chronic endocarditis (4), annular dilatation (2) and sclerotic disease (1). One valve was replaced due to an ingrowing myxoma. There was one closure of a paravalvular leak. 
The mean age was 60 year (33-83). Most patients had normal ejection fractions but different grades of mitral valve insufficiency and were in NYHA class II. 
One 71-year-old patient died after reoperation on POD 1 for failed repair.  
One  patient had conversion to sternotomy and conventional ECC for repair of his dissected aorta; he suffered minor cerebrovascular defects. The mean endoaortic clamp time and endoCPB time was  104 (35-160) and 147 minutes (75-215) respectively, mean ICU-stay: 2 days and mean hospital  stay:  nine days (4-36). A significant difference between the first 30 and last 38 patients in terms of length of stay  ICU and hospital was noticed. Two late mitral valve replacements for acute endocarditis after repair occurred.  

The debut of Port-Access(tm) Mitral Valve Surgery may be nerve-racking, the routine is a smooth and sure operation with maximum comfort, a very discrete scar and a fast rehabilitation as a result for the patient. There were no paravalvular leakages  nor myocardial infarctions. Cerebro-vascular accidents due to trombo-embolic phenomena, vascular lower limb or wound complications  were not seen.  
Port-Access(tm) Mitral Valve surgery is a very important investment in the future of cardiac surgery. Some “learning curve” pitfalls  were associated with the process of starting this revolutionary technique.  

* Port-AccessTM CABG 

* Introduction 
How long does it take for a young healthy individual to get rid of his catabolic state after breaking his femur: 6 weeks ! You may guess this ' ll be 3 months for a 60-year old patient with coronary artery insufficiency when his breastbone is split. However, median sternotomy has the obvious advantage that you can do direct vision  surgery with your conventional two-pronged instruments and that' s were the old quote: surgery is exposure comes from ! 
But how about cracked ribs, considerable loss of blood, impaired integrity of the thoracic cage and its consequences on ventilatory function, pain, ugly scars and the incidence of sternitis - up to 2,4 % in large series when both the MIA' s are taken down. 

* Technique 
In Port-AccessTM surgery, the “working port” is created through a 7 cm skin incision in the inframammary groove. In a female patient you have to work your way up to the level of the fourth IC space. The soft tissue retractor is of great help to organize your port.  
A TM retractor is installed to create lift between the pericardial cavity and the chest wall. Sometimes, in an obese patient, the pericardial fat  has to be removed up to the level of the phrenic nerve. Impossible to take down the IMA without cracking more ribs and cartilages - or brake your own neck -without proper video-assistance.  
A 10 mm camera head is mounted through a stabilizing device and then brought through the 11 mm port to have a look in the thoracic cavity.  
The whole decourse of the left IMA becomes visible from its take-off to the level of the diaphragm. Fig 11.  
The take-down is started in the mid-portion and continued up and down. Shafted instruments are introduced through the “working port”. No way you can see something inside without the video-assistance. Two-dimensional images perfectly allow you to do this take-down when they  provide you with proper contrast, resolution and colour.  
The RIMA can be taken down the same way and introduced from the right side in the pericardial cavity for revascularisation of LAD. Instructions can be given to residents and assistants for training purposes. I think it has become basic to train young surgeons for video-assisted surgery to be able to face upcoming challenges in MICS like closed chest CABG.  
The Heartport(r) Endo-bulldogTM is applied to the IMA through the camera port to avoid it from obstructing the working port. Fig 12. 

A proximal anastomosis can be made to the ascending aorta the usual way after withdrawal of the endo-aortic balloon to the arch and the application of a side-bite clamp. The aorta can be approximated to the working port by “traction” stay-sutures to the right sided pericardium. The video-assistance is needed as an internal light source but the suturing is done “direct vision”. 
The distal anastomoses are made on the flaccid heart that can be turned around and fixed in any position to have the anastomotic site close to the working port. Shafted instruments are needed but the suturing is done with direct vision. It is virtually impossible to do two-dimensional video-directed suturing on a 2mm vessel, because of the magnified image, that is away and above the hands and that accentuates lack of precision  and tremor, the lack of visual depth perception, the disconnected eye-hand coordination and the limited range of motion and sensory feedback.  
Computer-enhanced instruments will be needed to perform “trocar” Port-AccessTM CABG Surgery. 

* Results & Discussion 
The Results of Port-AccessTM CABG are depicted in the figures 13 -14 - 15 - 16. 

.........

* Port-AccessTM ASD & Myxoma Surgery 

* Introduction 
The best results in terms of comfort, cosmesis and fast rehabilitation can be obtained in surgery for ASD and Myxoma resection respecting the supreme quality of standard cardiac surgery. Fig 17. 

* Technique 
in Port-AccessTM ASD and Myxoma Surgery the introduction of a jugular cannula is very useful to have the right atrium completely free. Fig 18.  
Taping of both caval veins can be done the usual way with snares that can be brought out of the thoracic cavity with the “Endo-CloseTM”.  
After installation of Endo-CPB and Endo-ClampTM the right and/or the left atrium are opened to close the interatrial defect with or without a patch and to remove a myxoma and his attachment to the interatrial septum or the free left atrial wall. Fig 19.  

* Results & Discussion 
Since Heartport(r) obtained CE-Mark for its Endo-CPB and Endo-Aortic Clamp technology, fifteen patients with a median age of 45 years had ASD-closure and  four patients (mean age: 54 years) had a removal of a left atrial myxoma. No mortality  occurred.  
One myxoma patient needed renal dialysis postoperatively. 

Mean CPB time 
ASD 97 
Myxoma85 

Mean crossclamp time 
ASD 58 
MIXOMA 69 

Mean ICU stay 
ASD 1day 
Mixoma 1day 

Mean hospital stay 
ASD 6 days 
Mixoma 7 days 

Right thoracotomy is a well known approach for right and left atrial cardiac surgery. Port-Access(tm) surgery can avoid cracking of ribs and cartilages and limit bloodloss to an absolute minimum. The postoperative course was painless because of the absence of retraction and the effectiveness of epidural anesthesia. The mean length of the skin incision was 5 cm. Some younger patients were back to work or sports activities after two weeks.  
The main goals of minimally invasive cardiac surgery, that is to say comfort, cosmesis and fast rehabilitation can be achieved in Port-Access(tm) Cardiac surgery for ASD and Myxoma, respecting the high standards of conventional cardiac surgery. Figures 20 and 21. 

..... 

The aim of the Onze-Lieve-Vrouw Clinic Live-Teleconference was to provide attendants with valuable information about 
• which patients to select for Port-AccessTM Cardiac surgery, since it is of the outmost importance that the best opportunities are selected to start the learning curve of PA Surgery  
• the effectiveness and safety of Endo-CPB and Endo-Aortic Clamp technology  and the invaluable support of  TEE in the hands of an expert 
• tips and techniques for optimal video-assisted visualization, which is, I think vital to stick to the rules of true PA Surgery. 
•  the use of shafted instruments through a “working port” 
• and the clinical results in terms of comfort, cosmesis and rehabilitation, which obviously are the main goals of every MI technique 

The Surgery was performed at the Onze-Lieve-Vrouw Clinic while the attendants sat comfortably in an amphitheatre at a huge cinema complex in Brussels in front of two giant side-by-side screens to witness the action in the theatre, both trough the eyes of the thoracoscopes and the surgeon' s staff's eyes. 

Five Operative procedures were carried out, starting with CAB-Surgery and ASD closure the first day.  
Four patients were interviewed on the first post-operative day on ICU to assess their clinical condition. All of them had been extubated two hours after surgery and all were ready to leave intensive care for the ward. 

The second day of the teleconference concentrated on Mitral Valve surgery. A 70-year old lady had MV replacement with preservation of the entire plicated posterior leaflet and the postero-medial part of the free edge of the anterior leaflet.  In Mitral valve reconstructive Surgery, a lot of the work was done while the surgeon was completely relying on the video-screen.  
Placing of  “U” stitches in the annulus, accurate quadrangular resection and classical sliding plasty with tying of 5/0 prolene was achieved with comparable results to conventional surgery, which was demonstrated both by the preoperative and the postoperative TEE control. 

What the attendants could not witness is the fact that all patients operated on were home on the fourth or fifth post-operative day. Port-AccessTM cardiac Surgery is demanding for the cardiac surgeon, certainly in the period where he has to get accustomed to the new concepts for endo-CPB and endo-aortic clamp, quite new ways to visualize structures and perform surgery on these structures with new instruments.  
All the attendants agreed tough that Port-AccessTM cardiac Surgery could be on the verge of becoming the surgery of the twenty-first century. 

The Future: Robotic Cardiac Surgery 

The first step in Port-AccessTM is “avoiding sternotomy” and doing remote-access CPB and cardiac arrest. 
The second step: with lots of tips and techniques one can to come to true “port” surgery like the kind of approach where no ribs are cracked, no cartilages dislocated let alone removed and a retraction that is often limited to the soft tissue retractor ! Fig 22. 
The ultimate step is “trocar” port surgery: the manipulation of Endo-surgery instruments can be awkward through “trocar” ports.  
Fine suturing of distal anastomoses cannot be achieved with the sole flat image of a two-dimensional camera. The surgery becomes virtually impossible due to the followings aspects: the magnified image, that is away and above the hands and that accentuates lack of precision  and tremor, the lack of visual depth perception, the disconnected eye-hand coordination and the limited range of motion and sensory feedback. Fig 23. 

Intuitive Surgical provides the surgeon with an eight times magnifying, six chip three-dimensional image and shafted, remote-controlled endo-wrist instruments manipulators on a huge cart, next to the patient.  
The surgeon is sitting at a console, away from the patient, where both his left and right eye have a separate monitor and his hands are manipulating joy-sticks that look like the jaws of a gastroviejo and electronically translate every single move from the surgeon in a customized scale difference to extremely precise acts inside the patient' s chest. 
The stunning fact about the “playstation” is the amazingly short learning curve. The system can take surgical precision and technique beyond the limits of the human hand. 

We had the opportunity to clinically testdrive the intuitive system in December 1998. For time-saving and safety purposes we elected to make one 2,5 cm working port and two trocar ports. At the OLV-Clinic two patients had “closed” chest cardiac  Surgery.  
In a 38yr old lady, three separate holes in the interatrial septum were closed. A 57yr old lady had a single LIMA to LAD bypass. Both interventions were finished in less then four hours and both patients went home on the third postoperative day.  

The combined application of the Heartport (r) technology and the Intuitive surgical system allow the surgeon to perform very precise surgical acts on the heart through “trocar” ports. Going for the ultimate goals of Minimally Invasive Cardiac Surgery without compromising surgical safety and precision has become possible.  
One thing is for sure: it is heavy, massive equipment and it is a huge investment but they allow the endo-surgeon to work very instinctively. The future will tell us where the benefit of these computer-enhanced instruments exactly is and much more experience is needed to overview the array of possibilities to these rapidly evolving technologies but they can give mini-access surgery a huge leap forwards. 

Discussion 

I actually do not like the term Minimally Invasive cardiac Surgery, the least invasive cardiac intervention obviously being PTCA: no pain, no scar & immediate rehabilitation.  
Some surgeons who confine their sternotomy to two thirds of the sternum think they' re doing Minimally Invasive Cardiac Interventions.  
Well the name of the game is fashion: everybody wants to be in this trendy game, apples are compared with oranges and there is a lot of confusion going on, so we definitely have to adopt a common way to classify different forms of MICS and we should at least try to determine those that, we think will stand the test of time, differentiate the  truly revolutionary ones from the ones that are mere fashion. 

A couple of thoughts,  
* Big-Size tennis rackets were just fashionable in the early seventies but we don't see a single small wooden racket anymore these days.  
* Laparoscopic cholecystectomy looked like hell to some surgeons in the early nineties, but nobody would dare propose a laparotomy for cholecystectomy at the present time. 
* You have to crack the thoracic cavity to a big extend to have an exposure that allows  you to work with the same direct vision and the tools Alexis Carrel worked with in 1903. 
* It takes a young healthy individual 6 weeks  to get rid of his catabolic state after braking his femur ! So you bet this 'll be 3 months for a 60-year old when his breastbone is split and the cavity cracked 
* Sternotomies have identical effects, all over the world, but all CPB systems are different: closed or open, various tubings, aspirations and primings, crushing rollerpumps or softer biomedicus pumps 
* Remains the fact that Blood-Air interface & pulmonary sequestration of leucocytes are very bad aspects of ECC, the worst being melted fat and bone wax dripping in the suckers! 
* The best way to predict the future is to invent it ! The challenge is much more a mental one than a technical ! Figure 24. 

But there is more: nobody ever stated what MICS should be.  
What are the rules of the game?  
* We know the paradigms but these goals are achieved to a different extend in different categories of MICS and  
* we need to prove the quality of the procedure is the same.  
* Cost-efficiency remains arguable, but -by the way- ABS brake systems were extremely expensive in the early eighties but part of the standard equipment of a small car today because nobody' s still arguing about their efficacy! Robotic Cardiac Surgery has a long way to go before it ' ll be able to prove cost-efficiency.  
Fortunately, at the end of this century, we can already have a glimpse of next century' s surgery with this machine that allows tool changes and can provide you with complete three-dimensional video-play-station.  
* The fourth criterium, namely the surgical aspects will have to be simple, predictable and ensure absolute safety one day, which is not the case yet today. Problems for surgical training ? No ! the joy-stick generation is born already and waiting to play with these tools !  
 
Hugo Vanermen, MD 
Chief, Department of Cardiovascular  
and Thoracic Surgery, 
Onze-Lieve-Vrouw Clinic, Aalst, Belgium