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CABG or Coronary Artery Bypass Grafting surgery is performed to treat blocked coronary arteries that supply oxygen rich blood to the heart and restore normal blood flow to the heart. Also known as Heart Bypass surgery or Open heart surgery. It involves sewing a graft or substitute healthy blood vessel (artery or vein) from leg, arm or chest, around the coronary arteries in such a way so as to bypass the blockage in the coronary arteries. One end is sewn before the blockage and the other end beyond it. In other words, the blood to the heart is detoured by way of a substitute vessel or graft resulting in restoration of the normal blood flow to the heart.
Q1. How has the medical advances affected way of performing CABG surgery?
A1 Until few years ago the chest was opened wide through a 10 to 12 inches long incision or cut, in the middle of the breast bone(Sternum); heart stopped; heart lung machine used that does the function of the heart and lungs for that period and the CABG surgery used to be carried out. It was the only option for CABG surgery. However, with passing time, various medical advances have been made and the latest innovations are Minimally invasive or Robotic surgeries. No need to connect to the Heart-lung machine and the surgery can be carried out while the heart is beating. It is amazing! Isn’t it?
Q2. What does Minimally Invasive surgery mean?
A2 An advanced form of surgery that employs state of the art technology; causes minimal trauma to the tissues; and is characterized by small incision/s, referred to as key hole incisions through which thin tubes called trocars are passed; specialized tiny instruments are passed through these thin tubes and one tube (trocar)is utilized to pass endoscope (a flexible tube with an attached miniature video camera) to visualize the surgical area, the surgery and the magnified images can be seen on a video monitor.
Minimally Invasive procedures are mainly created for the comfort and better experience of the patient in terms of:
Minimal blood loss
Short hospital stay or done as an Outpatient procedure
Early resumption of normal activities in contrast to the conventional surgery.
Scars are minimal ensuring better appearance
Fewer complications and fewer post Operative infections.
Above all, it has lower or comparable cost to that of the conventional surgery and generally safer.
Minimally Invasive Heart Bypass surgery
Heart Bypass means a new route is created that bypasses the blocked heart artery in order to ensure oxygen rich blood supply to the heart. In Minimally Invasive approach patient does not need Heart lung bypass machine. The surgery can be done without stopping the heart(Beating heart surgery). Although medicines are given through vein to slow down the heart and also it is made steady with the help of mechanical devices during the procedure to enable the surgeon to carry out his work on the required area by keeping the heart as still as possible. Minmally invasive heart surgery is characterized with less trauma, small incision as compared to conventional CABG resulting in less or no need for blood transfusion, shortened hospital stay, quick recovery.
It is done in the Operation theatre under General anesthesia that puts patient to sleep and no pain is felt during the procedure. 3 to 5 inches long incision is made in between the ribs on the left side of the heart. Muscles are pushed apart and front part of the rib(Coastal cartilage) is removed, substitute healthy graft vessel i.e., Left Internal mammary artery(LIMA) is procured and prepared followed by stitching it to the coronary artery in a way so as to bypass the blocked region of the coronary artery and provide vital nutrients and oxygen to the heart muscle. Drainage tube will be placed in your chest for a day or two.
Q3 What are Coronary arteries?
A3 Coronary arteries are the blood vessels that supply blood rich in Oxygen to the heart. Coronary term is used in reference to the heart or related to heart. It is derived from a Latin word "Corona" which means a "Crown", these blood vessels encircle the heart like a crown.
Q4 What is CAD(Coronary Artery Disease)?
A4 CAD or CHD(Coronary heart disease) is one of the most common heart problem that can severely compromise the function of the heart. CAD involves the stiffening and narrowing of the blood vessels supplying oxygen rich blood to the heart due to a condition called "Atherosclerosis". As a result the blood supply to the heart is compromised thereby depriving heart its nutrition by way of blood. It can manifest as symptoms such as chest pain or even heart attacks,heart failure, disorder of heart beat rhythm(Arrhythmia) in worse cases.
Q5 What is Atherosclerosis?
A5 Atherosclerosis is a medical condition in which the walls of blood vessels(arteries) become thick, hard and stiff due to the accumulation of plaque(cholesterol,other fatty deposits,waste product of cells,calcium and blood clotting protein-Fibrin ) on their inner lining. High blood pressure, High amount of bad cholesterol,Diabetes,family history are its usual causes. Atherosclerosis is a slow progressive disease.
Q6 What does Off-pump Coronary Artery Bypass(OPCAB) Grafting Surgery mean?
A6 Off-pump Coronary Bypass Grafting Surgery is an alternative approach to conventional CABG. Patient does not need heart lung bypass machine. The heart beats during the surgery. Since heart is beating during the surgery, it is also referred to as Beating Heart Surgery(BHS). The region of the heart where the actual grafting is taking place is stabilized with the use of a mechanical device.
Q7 What is meant by MIDCAB procedure?
A7 MIDCAB stands for Minimally Invasive Direct Coronary Artery Bypass Grafting. As the name implies, it is a minimally invasive procedure. Heart Lung Bypass machine is not required. Breast bone or sternum is not cut open in this procedure as in Off pump Coronary artery bypass grafting surgery,instead, small incision/s are made between the ribs on the left side of patient's chest, in order to gain access to the heart, straight to the artery that needs to be bypassed. MIDCAB is indicated when one or two coronary arteries need to be bypassed. The length of the incision is around 3 inches in contrast to 6 to 8 inches long incision made during conventional CABG surgery or during OPCAB(Off Pump) surgery. The most common artery used for the graft is "Left Internal mammary artery(LIMA)."
MIDCAB surgery is suitable for select few. It is employed especially for those patients who need to bypass the coronary arteries in front of the heart especially the main artery to the heart(LAD-Left Anterior Descending Artery). Not indicated for multivessel disease, where more than two coronary arteries require bypass.
Q8 What does Robotic Coronary Artery Bypass (RACAB)surgery entail?
A8 Coronary Artery Bypass Grafting is a revascularization surgery for treating blocked arteries that supply oxygen rich blood to the heart. The surgery involves grafting a substitute healthy vessel in a way so as to bypass the clogged artery and restores normal blood supply to the heart.
RACAB, Robot Assisted Coronary Artery Bypass, is a more advanced form of MIDCAB that uses a robotic system, the Da Vinci Surgical System. It is a minimally invasive approach to carry out Coronary Artery Bypass Grafting. Robot Assisted Coronary Artery Bypass surgery offers several advantages over conventional CABG or Open heart surgery. Conventional CABG needs 10-12 inches long cut through the chest and the breast bone (Median Sternotomy)in order to access the heart whereas in Robotic surgery few tiny incisions are made in between the ribs to perform the surgery. A big advantage in robotic surgery is that, here the sternum or the breast bone is kept intact. Robot Assisted Minimally Invasive approach results in
Also, there is more precision in the surgery in contrast to conventional CABG, due to better visualization of the surgical area provided by Da Vinci Surgical System's 3-D High definition camera.
Robot Assisted Coronary Artery Bypass Surgery can be carried out using two techniques:
MIDCAB(Minimally Invasive Direct Coronary Artery Bypass) Grafting surgery wherein 3 small sized incisions are made in the chest to cut and procure the mammary artery graft, subsequently followed by stitching the mammary artery graft to the heart vessel through a 2 inch long incision in between the ribs on the left side of the chest. Hear lung Bypass machine is not required, if only LAD(Left Anterior descending) artery needs to be bypassed. It is the main artery of the heart. This approach is often referred to as Off Pump MIDCAB procedure. Its a Beating Heart Surgery.
TECAB(Totally Endoscopic Coronary Artery Bypass Surgery)- Only 3 openings or ports are sufficient to carry out the whole surgery. No additional incisions are needed.
It is purely your surgeon's discretion to select the type of procedure or Robotic surgery in the first place, after taking several factors into account such as number of blocked vessels, their location, your medical condition and so on. Your wellbeing is the first and the foremost priority for the specialist and will decide the best treatment protocol for you.
Q9 What does Hybrid Robotic CABG/Angioplasty surgery mean?
A9 Hybrid literally means anything that is made after combining two different elements. In Hybrid CABG/Angioplasty surgery Robotic Cardiac Surgeon works in tandem with the Interventional cardiologist to combine and utilize CABG and Angioplasty together to treat the patient. Its a revolutionary advancement in heart surgery that involves Minimally Invasive Robotic Bypass surgery for blocked LAD(Left Anterior Descending artery, Heart's main artery) along with Non Invasive Angioplasty with stent placement for one or more of other coronary arteries. Hybrid surgery is indicated when the patient has blocked coronary arteries requiring Angioplasty and also a remarkably blocked LAD(Main artery of the heart) which can no longer be treated with Angioplasty.
Q10 What is the difference between MIDCAB and Conventional CABG surgery?
A10 The differences between MIDCAB and conventional CABG can be summarized as follows:
Most affordable cost coupled with quality.
World class hospitals with state of the art infrastructure.
No waiting period.
Globally trained Cardiologists with decades of experience in carrying out the procedure with competence and ease.
Compassionate staff to look after
Hospitals accredited with international organizations such as JCI(Joint commission International) for quality standards.
Language no barrier. English speaking people and if required, translators are available for your convenience
Most economical accommodation available at a walking distance from the hospital. Wide range of options starting from guest house, service apartments to five star hotels, best suited to your budget and choice.
Good flight connectivity
India has a diverse and rich cultural heritage. You can witness its beauty and uniqueness. It offers most conducive environment for recuperation.
Dr Naresh Trehan
MBBS, Diplomat(American Board of Cardiac Surgery),Diplomat(ABS)
Chairman and Managing Director,Heart Institute, Division of Cardiothoracic and Vascular Surgery)
Medanta,The Medicity,Gurgaon, Delhi-NCR
Saket, New Delhi
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