ロボット支援下心臓手術の経験と手技の改善策

Our Experience and Technical Improvement in Robot-assisted Cardiac Surgery

da Vinciサージカルシステム（Intuitive Surgical社，Sunnyvale）によるロボット支援下心臓手術（robot-assisted cardiac surgery：RACS）は，低侵襲心臓手術（minimum invasive cardiac surgery：MICS）の一手段として注目されている．われわれは，2014年より内胸動脈（ITA）剝離を，2016年より僧帽弁および三尖弁手術，左房内血栓や粘液腫など，従来右小開胸MICSで行っていた手術を積極的にRACSで行っている．導入に先立ち複数施設で運用を調査し，実際に執刀経験を重ねるとともに当院に適合したプロクターを選択してきた．導入後は，心内操作に対して工夫を重ね［コーダライザー（住友ベークライト社，東京），COR-KNOT（LSI Solutions社，Victor），専用の長い心筋保護カニューレ，Gore-Tex糸（W.L. Gore & Associates社，Flagstaff）の多用，汎用手術台での心内脱気法］，ロボット手術が構造的に不利となる部分を除外することに努めている．本稿では，これまでの経験と失敗例から学んだ各手技の改善策を報告する．

Since 2014, we have used the da Vinci surgical system to perform internal thoracic artery harvest in minimally invasive direct coronary artery bypass （MIDCAB）, and since 2016, we have also performed robot-assisted cardiac surgery （RACS） for mitral and tricuspid valve surgery, left atrial thrombosis, and myxoma, all of which we have had performed as minimally invasive cardiac surgery （MICS） previously. Even after the introduction, different ideas （Chordalizer, COR-KNOT, special long CP cannula, de-air technique, etc.） were developed. As a result of the learning curve, more stable surgery could be performed. However, keeping in mind that RACS is only a means and not a purpose, the RACS indication should always be carefully considered. When problems, such as intracardiac manipulation or uncontrollable bleeding, occur, safe surgery must be decided to switch to normal thoracotomy as soon as possible. A further enhancement would be expected for even better results and expansion of the RACS indications.