Technology has brought heart surgery a long way, but most coronary artery bypass surgeries are still performed by splitting the sternum (breastbone) to reach the heart, stopping the heart, then rerouting the patient's blood hrough a heart-lung machine to supply oxygen while the surgeon stitches in the bypass grafts.

This type of surgery is called coronary artery bypass grafting (CABG). Having a CABG means a long and painful recovery for the patient, as it can take the breastbone several months to completely heal. It can also mean the patient, who may have had a heart attack, could have various complications from being on the heart-lung machine.

But today, technology allows doctors to perform the same function for heart disease patients — bypassing a blocked artery by grafting a new blood vessel around it — without a huge incision and a broken breastbone. Though minimally invasive coronary artery bypass surgery has been around for over a decade, it's still not as common as traditional bypass surgery — and the results are still being studied.

MIDCAB, Robotically Assisted Surgery, and PortCAB

There are several types of minimally invasive coronary artery bypass surgery. They include:

  • MIDCAB. Minimally invasive direct coronary artery bypass (MIDCAB) has several benefits as compared to the traditional CABG:
    • Instead of splitting the breastbone, a smaller incision — typically about three to five inches in length — is made horizontally in the muscles between two ribs on the left side of the chest. This area is pulled apart during the surgery so that the surgeon can look at the heart underneath, and directly see the blocked coronary artery.
    • In a MIDCAB procedure, an instrument called a heart stabilizer keeps just the section of the heart that is being repaired very still, so that the surgeon can accurately place the tiny stitches to hold the new bypass graft. Unlike in a traditional CABG, the heart does not have to be completely stopped, and the patient's blood does not have to be circulated through a heart-lung machine during the procedure. (This is called off-pump bypass surgery.)

    As in other types of procedures, a section of the patient's own blood vessel, taken from the chest, arm, or leg, is connected to the heart to reroute the flow of blood around the blocked artery. The procedure itself is done through the small incision in the chest while the surgeon looks at the procedure on a monitor, to see more through this incision.

    • Robotically assisted surgery. Robotically assisted surgery is very similar to MIDCAB, but is done through an even smaller incision, often only two inches wide. Instead of manually placing the bypass grafts, in this procedure, the surgeon uses robotic arms and an internal video camera inserted through the incision to precisely guide the graft placement.
    • PortCAB. Port-access coronary artery bypass, referred to as PortCAB or PCAB, is similar to MIDCAB in that it avoids the long incision in the breast bone, but different in that it involves several small incisions over multiple areas of the left side of the chest. These incisions are known as ports, and surgical instruments are passed through these ports to complete the bypass grafting. PortCAB requires that the heart be stopped, so the patient must be placed on a heart-lung machine for the duration of the procedure.

    Benefits of Minimally Invasive Coronary Artery Bypass Surgery

    There are some definite benefits to minimally invasive coronary artery bypass surgery. They are:

    • Reduced pain following bypass surgery
    • Less time in the hospital recovering
    • Usually no need for a blood transfusion
    • Reduced risk of complications
    • Fewer infections
    • Quicker recovery

    For minimally invasive procedures done without putting the patient on a heart-lung machine, there are additional potential benefits, since being on this machine may increase the risk of kidney problems, difficulties with memory, and the need for transfusion.

    Experts are still studying the outcomes of people who have undergone minimally invasive bypass surgery to determine whether it is more effective — or even as effective — or offers fewer risks and complications than traditional bypass surgery.

    But some initial studies do indicate that minimally invasive bypass surgery is safe, effective, and offers more benefits to the patient when compared to traditional bypass surgery. One study found that fewer than 9 percent of patients who had this "mini" surgery experienced complications, and most had shorter hospital stays.

    Other research indicates that the procedure’s safety and effectiveness depend upon the surgeon performing it and his specific experience with the surgery; the more times he performed the surgery, the better the outcomes.

    In addition, it's important to understand that minimally invasive bypass surgery may not be appropriate for everyone.

    Who Should Consider Minimally Invasive Surgery?

    Minimally invasive bypass surgery is only performed on people who need a single or double bypass, meaning only one or two arteries need bypassing. For those who need three or four arteries bypassed, minimally invasive bypass surgery is generally not an option.

    Before deciding on minimally invasive bypass surgery, the doctor and patient must consider additional factors — including how damaged the coronary arteries are, the patient’s body weight, and other factors which might affect healing, such as having diabetes. The location of the arteries to be bypassed is also a consideration, as minimally invasive bypass surgery is generally only performed on arteries near the front of the heart.

    Learn more in the Everyday Health Heart Health Center.