Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3614_Библиотеки_им_академика_М_И_Перельмана
.pdf
https://t.me/medicina_free
https://t.me/medicina_free
41
Optimal use ofinstruments foroff- pump
coronary artery bypassgraing
Bobby Yanagawa, Michael E. Halkos, and John D. Puskas
Introduction
O- pump coronary artery bypass graing (OPCAB) allows for
avoidance of the deleterious consequences of cardiopulmonary
bypass and can facilitate a no- or minimal- aortic manipulation
procedure for stroke reduction. However, compared to on- pump
surgical revascularization, it is more technically demanding for the
surgeon and the surgical team. In order to realize the potential benets of OPCAB, the completeness and precision of revascularization
must not be compromised.
Although OPCAB itself is more complex than on- pump CABG,
once the operative eld is optimally set up, the technical diculty of
an o- pump coronary anastomosis should be similar to one on an
arrested heart. In this chapter we will discuss the use of various specialized tools used to create a near motionless and bloodless eld to
facilitate construction of a precise o- pump coronary anastomosis.
We also discuss the use of important adjuncts aimed to reduce the
risk of sternal complications and stroke.
Harmonic®scalpel
We harvest the internal thoracic artery (ITA) in a skeletonized
fashion with the Harmonic® scalpel (Harmonic Synergy®, Ethicon,
Somerville, NJ, USA). Harvesting a skeletonized ITA gra minimizes sternal injury and preserves sternal perfusion, thus reducing
the potential for pain and sternal wound infection, particularly in
higher- risk patients such as those with poorly controlled diabetes
mellitus. It also allows for the greatest gra length and facilitates
sequential anastomoses. e Harmonic® scalpel utilizes mechanical vibrations at 55,000 cycles/ s to create ultrasonic coagulation
by protein denaturation. e resultant tissue temperature is less
than 80°C compared with greater than 300°C for electrocautery.
erefore, there is less charring and thermal damage to the ITA and
surrounding tissues with a Harmonic® scalpel. In experienced hands,
Harmonic® ITA harvest is both fast and safe, minimizing the risk of
injury to the ITA and sternum during harvest. For surgeons who
use electrocautery, it is recommended to use settings below 20 watts
(preferably 10 watts) to harvest skeletonized ITAs in order to minimize the risk of thermal injury. is alternative technique for skeletonized harvest typically requires the use of multiple small clips on
ITA side branches prior to cutting with ne scissors.
Cardiac positioningdevice
e most important cardiac positioning device is actually the operating table, which can be sharply rotated to the patient’s right to aid
exposure of the le lateral wall or placed in the steep Trendelenburg
position to facilitate exposure of the inferior and inferolateral walls
as well as to improve venous return to the heart during cardiac
displacement.
We use suction- based cardiac positioning devices and a single
‘deep pericardial stitch’ to optimize cardiac exposure and haemodynamic stability for OPCAB. e two most commonly used cardiac
positioning devices are the Starsh® Heart Positioner (Medtronic,
Minneapolis, MN, USA) and the ACROBAT- i® Positioner system
(Getinge, Sweden). ey are secured to the sternal retractor and
aid in exposure primarily of the lateral and inferior wall targets. An
important advantage of suction- based devices is that pulling rather
than pushing the heart minimizes compression of cardiac chambers
and resultant haemodynamic instability (Fig. 41.1).
e following are important tips for use of the suction- based cardiac positioning devices:
• Apply the cardiac positioning device to the anterolateral wall of
the heart ‘o- apex’ to optimize exposure of the lateral wall. e
term ‘apical suction device’ is a misnomer— this device is oen
most useful when used o- apex. Place the positioning device
on the apex for the posterior descending artery and on the acute
margin for mid- RCA exposure.
• Elevate the heart vertically to expose the posterior descending ar-
tery and many lateral wall targets.
• Position the device near the coronary target site. is improves
both exposure and stabilization.
• Optimize exposure and haemodynamic stability before occluding
the coronary target or beginning suturing.
SECTION 7 Technical aspects ofcoronary artery bypass graft surgery310
https://t.me/medicina_free
vessels, the coronary stabilizer may be secured on the right side of
the retractor to help to elevate and expose the coronary artery to the
surgeon’s view (Fig. 41.1). Alternatively, it may be attached to the le
limb of the sternal retractor to minimize visual and mechanical obstruction of the surgeon while performing the anastomosis.
e malleable pods on the stabilizer may be manipulated by
bending them (1)up or down or into a curve, (2)together or apart,
or (3)by rotating them. Such ne adjustments are especially useful
for irregular epicardial fat, curved areas of the heart, and when
graing vessels close to each other to optimize ‘tissue capture’ and
coronary stabilization.
Silastic snares and coronaryshunts
Once the heart is in position and haemodynamic stability is
achieved, a silastic vessel loop with integral blunt needle (RetractO- Tape®, Quest Medical, Inc., Allen, TX, USA) is used to encircle
the target vessel proximally. Only very rarely do we apply a second
silastic vessel loop around the coronary artery target vessel distal to
the planned anastomotic site, preferring to avoid any risk of injury
to the distal vessel. For inferior wall coronary targets, this suture can
be displaced posteriorly and caudally by tying a posterior pericardial
suture loosely around the vessel loop to act as a pulley to further im-
Fig.41.1 Cardiac positioning device and coronary stabilizer for inferior
wall exposure including optimal use of silastic snare pulley for exposure
of inferior wall target.
Reproduced from Operative Techniques in Thoracic and Cardiovascular Surgery
(Yanagawa etal, Off- Pump Coronary Artery Bypass Grafting. Op Tech Thorac Cardiovasc
Surg. 2016;21:2– 19) with permission from Elsevier.
prove exposure (Fig. 41.1). e silastic snares are kept loose during
initial arteriotomy, which should be performed with a ‘full’ coronary
artery to prevent injury to the arterial back wall.
Some surgeons routinely use an intracoronary shunt. e advantages are maintenance of ow during the anastomosis and protection of the arterial back wall. Furthermore, they may be used to
assist in exposure of a lateral wall when gently pulled in the opposite
• For relatively small hearts with sucient anteroposterior dimension
of the chest, roll the apex of the heart under the right sternal border
without vertically liing the apex to expose the lateral wall targets
(is requires that the right pleural cavity be widely opened, the
right- sided pericardial traction sutures be released, the right limb
of the sternal retractor be elevated on rolled towels, and the cardiac
positioning device be attached to the anterolateral le ventricle.)
direction. Yet other surgeons feel that shunts are obstructive during
the anastomosis or may cause unnecessary trauma to the endothelium. We recommend the use of shunts selectively. We typically use
shunts for large right coronary arteries with moderate stenoses,
which may cause signicant ischaemia and subsequent bradycardia
with occlusion. At the rst sign that a patient is becoming electrically or haemodynamically unstable during an anastomosis, immediate restoration of coronary ow with a shunt usually reverses
Coronary stabilizationdevice
the instability quite promptly and allows safe completion of the
anastomosis.
Commercially available shunts come in sizes ranging from 1.0 to
Coronary stabilization devices provide a near- motionless eld for
coronary anastomosis. e most common coronary stabilizer devices are the Octopus® Tissue Stabilizer (Medtronic, Minneapolis,
MN, USA) and the ACROBAT- i® Stabilizer system. ey should
be centred on either side of the target coronary artery with minimal compressive pressure on the epicardium. Excessive pressure of
the stabilizer on the heart will cause a paradoxical increase in motion at the anastomosis site, making precise suturing more dicult.
Position the coronary stabilizer on either side of the target artery
with the suction applied and observe the vertical motion of the device throughout the cardiac cycle. en manually x the pods at the
3.0mm; the most commonly used are 1.25, 1.5, 1.75, and 2.0mm.
e shunt should be sized to approximately 75% of the inner diameter of the vessel. Alarger size may be dicult to insert, posing a
greater risk of endothelial injury and obstruction to suturing. Too
small a size may allow bothersome bleeding around the shunt,
making it dicult to maintain a bloodless eld. However, many surgeons have noted that the target coronary artery gradually constricts
around the intraluminal shunt, reducing bleeding and arguing for
systematic use of under- sized coronary shunts. We have found that
the 1.75 mm shunt is appropriate for most arteries that require
intracoronary shunting.
mechanical median of the vertical motion of the device while tightening the knob that renders the arm of the coronary stabilizer rigid.
With a little practice, this manoeuvre will optimize anastomotic sta-
Mistedblower
bility while preserving optimal haemodynamic stability.
For anterior wall targets, the ideal location to secure the stabilizer
is the caudal portion of the retractor. For the lateral and inferior wall
To perform accurate and reproducible anastomoses, the surgeon
must visualize the intima of both gra and target vessel for each
41 Optimal use ofinstruments foroff-pump coronary artery bypassgrafting 311
ANASTOMOSIS
ANASTOMOSIS
(ASSISTANT)
https://t.me/medicina_free
stitch. Good visualization is critical for a precise anastomosis and
the assistant wielding the misted blower plays a key role. During the
anastomosis, the immediate eld is kept free of blood with a warm,
humidied, pH- balanced misted CO blower. Careful and judicious
use of the blower is needed to avoid injury to the target coronary
or gra endothelium. Excessive CO ow/ pressure can cause subtle
endothelial injury or even obvious coronary dissection. e blower
should be kept at a minimum level of force (<4 L/ min ow of CO)
and held at the maximum distance that allows adequate exposure of
the anastomotic site; it should be directed towards the endothelium
only during the actual placement of stitches in the anastomosis.
or with the use of a proximal anastomotic device. Several studies
have demonstrated highest risk of stroke with total or partial aortic
cross- clamp during CABG, lower stroke risk with use of clampless
proximal anastomosis devices, and lowest stroke rate with a notouch aortic technique.– In every CABG case, prior to any aortic
manipulation, we perform epiaortic ultrasonography as a simple,
reliable, and non- invasive method for assessing the extent of atheromatous disease in the ascending aorta.
e most commonly used facilitated anastomosis devices include
Enclose® II (Vitalitec, Plymouth, MA, USA), PAS- Port® (Cardica,
Redwood City, CA, USA), and Heartstring® III (Getinge, Sweden)
(Fig. 41.3). Each device has unique advantages and disadvantages
Surgicalinstruments
(Table 41.1). PAS- Port® is a fully integrated and automated system
for a vein gra aortocoronary anastomosis. e Heartstring® III
and Enclose® II devices create a near haemostatic seal with the aorta
For construction of the anastomosis, we insist on ne microneedle
holders (Scanlan (St. Paul, MN, USA) catalogue numbers 3003- 381
that allows the creation of a hand- sewn anastomosis with a relatively
bloodless eld.
and - 391) and microforceps (Scanlan, catalogue numbers 3003- 770
and - 774) for distal anastomoses and heavier microneedle holders
(Scanlan, catalogue number 3003- 390) and microforceps (Scanlan,
catalogue number 3003- 810) for proximal anastomoses (Fig. 41.2).
Distal anastomoses are constructed with 8- 0 Prolene® (rarely 7- 0 for
thicker and bulkier vein gras) and proximal anastomoses with 6- 0
Prolene® sutures. Ethicon EP (extra penetration) needles are used to
penetrate particularly calcied coronary arteries.
Proximal anastomosisdevice
As mentioned, stroke is a major and devastating complication of surgical revascularization and aortic manipulation is a major cause of
aortic atheroembolism. Proximal anastomoses during OPCAB can
be performed with an aortic side- biting or partial- occluding clamp
DISTAL
PROXIMAL
Fig.41.2 Specialized instruments for distal anastomoses (Scanlan,
St. Paul, MN, USA; catalogue numbers 3003- 381 and 770)and
proximal anastomoses (Scanlan, St. Paul, MN, USA; catalogue
numbers 3003- 390 and 810).
Figure used with permission from Scanlan, St. Paul, MN.
Fig.41.3 The Enclose II (Vitalitec, Plymouth, MA) (top), PAS- Port
(Cardica, Redwood City, CA) (middle) and Heartstring III (Maquet)
(bottom) proximal anastomosis devices.
Figures used with permission from Vitalitec, Plymouth, MA; Cardica, Redwood City, CA;
and Maquet; Rastatt, Germany.
®
SECTION 7 Technical aspects ofcoronary artery bypass graft surgery312
https://t.me/medicina_free
Table41.1 Advantages and disadvantages ofanastomosis devices
Enclose® II PAS- Port® Heartstring® III
Ease of use + ++ +
Speed + + +
Cost + +++ +
Advantages Automatic
Disadvantages Additional puncture
site for insertion
anastomosis
Cannot use with
arterial grafts
Single
aortotomy
Not completely
haemostatic
We prefer the use of the Heartstring® III device as it is relatively
simple to use with both arterial and vein gras and necessitates
only a single aortotomy. e aortotomy can be made with a 3.8 or
4.3mm aortic punch, the sealing cup is deployed in the aorta, and
the proximal anastomosis is performed using 6- 0 polypropylene suture, preferably on a half- round vascular needle. Aer completion
of the anastomosis, the device is removed by unwinding the sealing
cup from the aorta before tying down the suture. Aer the suture is
tied down, vein gras can be de- aired with a 25- gauge needle before
being opened to the coronary bed. Arterial gras are not punctured
but are allowed to bleed backward before Heartstring® III removal.
For smaller arterial gras, smaller yet full- thickness aortic bites are
taken during proximal suturing to prevent attening of the hood
of the proximal anastomosis. Occasionally, a small arterial conduit
must be anastomosed to the ascending aorta. In this case, a very
short segment of vein may be anastomosed to the Heartstring® site
and the artery may be anastomosed directly to the hood of the vein
prior to removing the Heartstring® device. is ‘piggy- back’ technique avoids many of the challenges and risks of direct anastomosis
of small arterial conduits to the ascending aorta.
Fig.41.4 Optimal (top) and suboptimal (bottom) transit time flow
probe outputs.
Figure used with permission from Medistim, Oslo, Norway.
Flowprobe
Given the variability in individual measurements, all values should
be taken together to comprehensively evaluate conduits. Any values
outside of this range should prompt careful examination of the anasOnce bypass gras are constructed, we routinely quantitate ow using
an intraoperative transit- time ow meter (TTFM). Abnormal TTFM
measurements may alert a surgeon to an overt technical failure resulting in no ow or suboptimal ow, which can predict long- term
gra patency. Given that gra failure is oen silent in the operating
room and strongly associated with later adverse clinical events, we
feel that TTFM should be used for all surgical revascularization, particularly OPCAB. Use of TTFM is supported by the 2018 European
tomoses and gra and consideration of revision (Fig. 41.4). e
Medistim high- frequency ultrasound (HFUS) imaging probe can be
used to directly inspect the gra and/ or anastomosis with Doppler
ultrasonography to provide another measure of gra adequacy. e
surgeon should not accept suboptimal Doppler results and may
need to revise/ reconstruct either the distal or proximal anastomosis,
unless characteristics of the conduit or native coronary artery can
readily account for the Doppler and HFUS image ndings.
Society of Cardiology/ European Association for Cardio- oracic
Surgery Guidelines on myocardial revascularization (classIIa, level of
evidence B).
We use the Medistim ow probe (Oslo, Norway) in every CABG
and OPCAB case. e following are the key measurements and acceptable values:
• Mean ow:optimal value is greater than 15 mL/ min, preferably
greater than 20 mL/ min.
• Pulsatility index (PI; the resistance to gra ow):
■ PI=(maximum ow − minimum ow)/ mean ow.
■ Optimal value is less than 5, preferably less than 3.
• Diastolic fraction:optimal value is greater than 60% for le- sided
gras, greater than 50% for right- sided gras.
REFERENCES
1. Boodhwani M, Lam BK, Nathan HJ, Mesana TG, Ruel M, Zeng
W, etal. Skeletonized internal thoracic artery harvest reduces pain
and dysesthesia and improves sternal perfusion aer coronary
artery bypass surgery:a randomized, double- blind, within- patient
comparison. Circulation. 2006;114(8):766– 73.
2. Kieser TM, Rose MS, Aluthman U, Narine K. Quicker yet
safe:skeletonization of 1640 internal mammary arteries with
harmonic technology in 965 patients. Eur J Cardiothorac Surg.
2014;45(5):e142– 50.
3. Calaore AM, Di Mauro M, Teodori G, Di Giammarco G,
Cirmeni S, Contini M, et al. Impact of aortic manipulation on
41 Optimal use ofinstruments foroff-pump coronary artery bypassgrafting 313
https://t.me/medicina_free
incidence of cerebrovascular accidents aer surgical myocardial
revascularization. Ann orac Surg. 2002;73(5):1387– 93.
4. Kim KB, Kang CH, Chang WI, Lim C, Kim JH, Ham BM, etal.
Off- pump coronary artery bypass with complete avoidance of
aortic manipulation. Ann Thorac Surg. 2002;74(4):
S1377– 82.
5. Kapetanakis EI, Stamou SC, Dullum MK, Hill PC, Haile
E, Boyce SW, etal. e impact of aortic manipulation on
neurologic outcomes aer coronary artery bypass surgery:a
risk- adjusted study. Ann orac Surg. 2004;78(5):1564– 71.
6. Rosenberger P, Shernan SK, Löer M, Shekar PS, Fox JA,
Tuli JK, etal. e inuence of epiaortic ultrasonography on
intraoperative surgical management in 6051 cardiac surgical
patients. Ann orac Surg. 2008;85(2):548– 53.
7. Puskas JD, Halkos ME, Balkhy H, Caskey M, Connolly M,
Crouch J, etal. Evaluation of the PAS- Port Proximal Anastomosis
System in coronary artery bypass surgery (the EPIC trial). J
orac Cardiovasc Surg. 2009;138(1):125– 32.
8. Yanagawa B, Orozco- Sevilla V, Pawale A, Puskas JD. Piggyback
technique facilitates o- pump coronary artery bypass gra by
using a proximal anastomotic device with arterial conduits. J
orac Cardiovasc Surg. 2015;150(3):725– 7.
9. Quin J, Lucke J, Hattler B, Gupta S, Baltz J, Bishawi M, etal. Surgeon
judgment and utility of transit time ow probes in coronary artery
bypass graing surgery. JAMA Surg. 2014;149(11):1182– 7.
10. Neumann F- J, Sousa- Uva M, Ahlsson A, Alfonso F, Banning
AP, Benedetto U, etal. ESC/ EACTS Guidelines on myocardial
revascularization. Eur Heart J. 2019;40(2):87– 165.
https://t.me/medicina_free
https://t.me/medicina_free
42
Incisions forcoronaryrevascularization
Valavunar A. Subramanian and Nirav C. Patel
Introduction
Coronary artery bypass graing (CABG) surgery is most oen performed through a median sternotomy. To lower the risk of deep
sternal wound infections, the technique of sternotomy has been improved over recent decades. In addition, to reduce the invasiveness
of surgery, other approaches have been developed. In this chapter,
the surgical technique for dierent incisions is explained, including
median sternotomy, anterior minimally invasive direct coronary artery graing (MIDCAB), lower mini- sternotomy, lateral MIDCAB,
transabdominal MIDCAB, and right anterior mini- thoracotomy.
Mediansternotomy
Using a scalpel, a skin incision is made that begins one nger’s
breadth above the manubriosternal angle and is extended down to
the xiphoid process. Progression down through the subcutaneous
tissues is carried out by sharp dissection utilizing the scalpel, reserving the use of cautery only for points that are signicantly
bleeding, thereby attempting to minimize any unnecessary thermal
injury to the surrounding so tissues. Cautery is used to elaborate
the space above the suprasternal notch; any crossing jugular veins
in this area are mobilized and divided under direct vision. Cautery
is used to divide all so tissue above the manubrium, and it is important to be sure that the suprasternal ligament is itself transected.
e index nger of the surgeon is oen used to gently sweep beneath
the manubrium to ensure that no so tissue remains that would
otherwise impede progress of the sternal saw. e midline of the
sternum is identied by palpating the intercostal spaces at multiple
levels and a line can then be marked on the sternum (using cautery)
from the centre of the suprasternal notch down to the middle of the
xiphoid process. e lungs are deated at this point. e sternum
is divided using a reciprocating saw, and the lungs are reinated.
Cautery is utilized to secure any bleeding points on the periosteal
surfaces of each sternal table. Arm paste of vancomycin is vigorously applied to the cancellous bone on either side to stem bleeding
from the bone marrow and act as prophylaxis against sternal wound
infection. Paran bone wax is known to promote sternal infection
and is contraindicated for routine use.
AnteriorMIDCAB
e patient is placed in an anterolateral decubitus position, with a
20– 30° tilt to the right, utilizing a so roll positioned underneath
the le scapula. Using a scalpel, a sub- mammary incision is made,
typically at the level of the fourth intercostal space. Two- thirds
of the incision tends to be lateral to the nipple, and one- third of
the incision lies medial to it. e length and exact position of the
incision depends on the site of the distal target, as guided by the
preoperative coronary angiogram. e preoperative plain chest
radiograph also gives some idea as to the relative position of the
apex of the heart in the craniocaudal axis. Once the skin incision
is made and the subcutaneous tissues are divided, entrance into
the pleural cavity is typically through either the fourth or h
intercostal space, depending upon how distal the anastomosis
will need to be on the le anterior descending coronary artery
(LAD). e le lung is selectively deated, and the pleural space
is opened sharply. e parietal pleural dissection can be extended
medially and laterally beyond the connes of the skin incision in
order to improve exposure. Aso tissue wound retraction device
is placed within the wound to further aid exposure; we typically
use the Alexis® wound protector (Applied Medical, Rancho Santa
Margarita, CA, USA), but any similar device would be suitable for
this purpose.
Various chest retractors can be used for exposure in anterior
MIDCAB, but our preference is the Genzyme (Cambridge, MA,
USA) retractor. is retractor is low prole and is adaptable for
mounting of various rigid and exible stabilization systems.
Alternatively, one can use the Medtronic (Minneapolis, MN, USA)
oraTrak® retractor or the Estech (San Ramon, CA, USA) retractor
with various sizes of blades. Either retractor system provides adequate exposure to permit le internal thoracic artery harvest under
direct vision via the anterior MIDCAB incision.
When robotic assistance is used to harvest the internal thoracic
artery, the pericardium should be opened robotically to identify the
site of anastomosis on the LAD. Atargeted small incision can then
be made aer determining the intercostal space suitable for LAD
target location. e incision should be placed more laterally as the
mediastinum shis laterally aer carbon dioxide pressure is released
from the chest following removal of robotic cannulae.
SECTION 7 Technical aspects ofcoronary artery bypass graft surgery316
https://t.me/medicina_free
Lower mini- sternotomy
is incision is used to perform a distal bypass to the LAD. Alower
midline incision is made and an inferior partial sternotomy is performed with lateral extension into the fourth intercostal space.
Limited spreading of the lower half of the sternum can be performed
with any small chest retractor. Caution must be used when placing
the thoracic artery harvesting retractor as excessive spreading of
the le lower sternum can lead to stretching of internal thoracic
arteries. e internal thoracic artery should be separated from the
endothoracic fascia and chest wall, superiorly rst, before spreading
the retractor. Alimited dissection of the internal thoracic artery is
performed and opening of the pleural space can usually be avoided.
Alinear pericardiotomy can then be performed to access the LAD.
muscles are marsupialized by several retraction sutures anchored to
the skin, thus exposing the deeper tissues. Bilateral costal attachments of the diaphragm are sequentially released with cautery, to
further facilitate exposure and to increase the working angle. e
cartilaginous xiphoid process of the sternum is usually excised in its
entirety. e inferior margin of the sternum itself, and the costal arch,
is lied with table- mounted retractor hooks; these retractors are typically those oen utilized to harvest the internal thoracic artery. e
sternopericardial ligaments and associated brous adhesions are
divided with cautery to allow the mediastinum to drop down. e
pericardium can either be opened above or through the diaphragm,
depending upon the target vessel to be revascularized. e LAD is
approached through an inverted T- shaped pericardiotomy above
the diaphragm, with dislocation of the anterior surface of the le
ventricle to the midline facilitated by deep le lateral pericardial stay
sutures, with retraction of these towards the right side. e mid-
LateralMIDCAB
e patient is positioned in the right lateral decubitus position, as for
a standard le posterolateral thoracotomy. A7.5– 10cm (3– 4inch)
skin incision is made below the tip of the scapula; two- thirds of the
incision lies anterior to the tip of the scapula, one- third of the incision should be posterior to it. It is important to ensure that this
incision is situated more anteriorly than would otherwise be the case
right coronary artery can also be approached from above the diaphragm by utilizing deep diaphragmatic stay sutures that are pulled
downwards and to the right so as to dislocate the inferior surface
of the heart. e posterior descending and posterolateral coronary
arteries are typically approached through an incision in the central
tendon of the diaphragm. Division of the le triangular ligament
and subsequent retraction of the le lobe of the liver downwards and
towards the right usually provides adequate working space.
in a conventional posterolateral thoracotomy, as this will facilitate
better identication of the target coronary vessels, improve cardiac
stabilization, and improve visualization (more perpendicular to the
eld, as opposed to a more oblique angle that would result from a
more posterior incision). e latissimus dorsi muscle is divided
using cautery, but the serratus anterior muscle is spared in its entirety. e le lung is deated. e pleural space is typically entered
through the h intercostal space. Aso tissue wound retraction
device is placed within the wound to further aid exposure, such as
the Alexis® wound protector. e inferior pulmonary ligament is
divided sharply to allow superior displacement of the lung. Warm,
Right anterior mini- thoracotomy
is incision is used to perform in situ right internal thoracic artery
bypass to the mid- right coronary artery. e right internal thoracic artery can be harvested under direct vision or preferably endoscopically.
e incision needs to be more medial, almost on the costal cartilage,
and may need to be extended inferiorly or superiorly depending on
the location of the target vessel. is incision is always in the h
intercostal space to get best access to the right coronary artery.
moist laparotomy gauze pads are used to pack the lungs superiorly
to enhance exposure. e pericardium is incised parallel and posterior to the phrenic nerve. Four pericardial sutures are placed, two
on either side of the pericardial incision to present the target vessel.
In a reoperative surgery, the target is identied by following the prior
gras. Only limited incision in the pericardium is performed over
the coronary target. We prefer to use the standard Getinge o- pump
retractor for lateral MIDCAB cases. Asuction stabilizer is introduced through the incision itself or a shaed compression stabilizer
can be introduced through a separate stab wound anteriorly.
TransabdominalMIDCAB
Using a scalpel, a 5– 7.5cm (2– 3inch) convex curvilinear incision is
made in the epigastrium, just under the xiphoid process, following
the contours of each costal margin. Both rectus abdominis muscles,
together with their anterior and posterior sheaths, are divided, using
cauter y. e neurovascular bundles, which tend to run along the
lateral margins of the rectus muscles, are preserved, if possible, in
an eort to reduce postoperative pain. e cut edges of the rectus
REFERENCES
1. Kieser TM, Rose MS, Aluthman U, Montgomery M, Louie T,
Belenkie I. Toward zero:deep sternal wound infection aer 1001
consecutive coronary artery bypass procedures using arterial
gras:implications for diabetic patients. J Cardiovasc orac Surg.
2014;148(5):1887– 95.
2. Lazar HL, Salm TV, Engelman R, Orgill D, Gordon S. Prevention
and management of sternal wound infections. J orac Cardiovasc
Surg. 2016;152(4):962– 72.
3. Gorki H, Patel NC, Balacumaraswami L, Jennings J, Goksedef D,
Subramanian A. Long- term survival aer minimal invasive direct
coronary artery bypass (MIDCAB) surgery in patients with low
ejection fraction. Innov Technol Tech Cardiothorac Vasc Surg.
2010;5(6):401– 6.
4. Subramanian VA, Loulmet DF, Patel NC. Minimally invasive
coronary artery bypass graing. Semin orac Cardiovasc Surg.
2007;19(4):281– 8.
5. Subramanian VA, McCabe JC, Geller CM. Minimally invasive
direct coronary artery bypass graing:two- year clinical
experience. Ann orac Surg. 1997;64(6):1648– 53.
42 Incisions forcoronaryrevascularization 317
https://t.me/medicina_free
6. Balacumaraswami L, Patel NC, Gorki H, Jennings J, Plestis KA,
Subramanian VA. Minimally invasive direct coronary artery bypass
as a primary strategy for reoperative myocardial revascularization.
Innov Technol Tech Cardiothorac Vasc Surg. 2010;5(1):22– 7.
7. Subramanian VA, Patel NU. Transabdominal minimally invasive
direct coronary artery bypass graing (MIDCAB). Eur J
Cardiothorac Surg. 2000;17(4):485– 7.
8. Subramanian VA, Patel NU, Patel NC, Loulmet DF. Robotic
assisted multivessel minimally invasive direct coronary
artery bypass with port- access stabilization and cardiac
positioning:paving the way for outpatient coronary surgery?
Ann orac Surg. 2005;79(5):1590– 6.
9. Subramanian VA, Patel NU. Current status of MIDCAB procedure.
Curr Opin Cardiol. 2001;16(5):268– 70.
Соседние файлы в папке Библиотека им академика М.И. Перельмана