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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3753_Библиотеки_им_академика_М_И_Перельмана
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226 A. Yilmaz et al.
Fig. 9 Left sided mini-thoracotomy with a soft tissue retractor and with a low profile rib spreader
Multi-vessel Endoscopic Coronary Artery Bypass Grafting 227
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Fig. 10 Marking the correct side of the pedicle with a prolene 6–0
Fig. 11 An endoscopic grasping forceps and an endoscopic needle holder
228 A. Yilmaz et al.
Fig. 12 The transthoracic aortic clamp is placed fully over the distal ascending aorta, and the cardioplegia catheter is
inserted in the aorta
RCA can be realized through a right minithoracotomy as far as the crux of the RCA.
For multi-vessel coronary artery disease, the
in situ mammary artery usage is applied as much
as possible. For example, in case of a left main
(LM) stem disease or a proximal LAD and Cx
coronary artery disease, the in situ LIMA is used
to the OM branch and the in situ RIMA to the
LAD (Fig. 20). If only the proximal LAD and the
proximal RCA is significantly calcified, then the
in situ LIMA is used for the LAD through a left
mini-thoracotomy and the in situ RIMA for the
RCA via a right mini-thoracotomy (Fig. 21). In
case a diagonal branch of the LAD is needed to
be bypassed together with the LAD and the OM
branch, then the in situ LIMA is used as a jump
graft to the diagonal and LAD and the in situ
RIMA is brought to the OM branch via the
transverse pericardial sinus (Fig. 22). This last
aspect is done as the operator is standing on the
left side of the patient. The RIMA is clipped and
transected after its distal bifurcation and hold in
the left hand with an endoscopic grasping forceps. Next, the right hand holds another endoscopic grasping forceps, and this instrument and
the endoscope enter the transverse pericardial
sinus on the left side and exit the sinus on the
right side. The in situ RIMA is cautiously handed
over from the left hand to the right hand endoscopic grasping forceps. The endoscope is pulled
back, and the right hand endoscopic forceps is
also pulled back gently with the in situ RIMA in
it. The in situ RIMA is fixed to the edge of the
pericardium with a clip to prevent torsion.
When the patient has three vessel disease, a
Y-graft construction is needed as described
above. If the postero-lateral branch of the Cx
(PLCx) or the RCA (PLR) needs to be bypassed,
then a Y-graft construction is also necessary.
In conclusion, with the in situ LIMA, the
anterior wall and the OM region can be reached.
With the in situ RIMA, the RCA as far as the
Multi-vessel Endoscopic Coronary Artery Bypass Grafting 229
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Fig. 13 A subxyphoid introduced endoscopic clamp holding a peanut gauze and a clamp with a peanut used through
the mini-thoracotomy
230 A. Yilmaz et al.
Fig. 14 An instrument holder attached to the operating table
Multi-vessel Endoscopic Coronary Artery Bypass Grafting 231
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crux of the RCA and the OM region, via the
transverse pericardial sinus, can be achieved. In
all other situations a Y-graft construction is
required (Video 1).
Video 1 A step-by-step video of totally endoscopic coronary artery bypass grafting (▶ https://doi.org/10.1007/000-a8b)
Fig. 15 A normal Castroviejo needle-holder and forceps is used for anastomoses
232 A. Yilmaz et al.
Fig. 16 A Y-graft construction with on top the free RIMA
Fig. 17 The aortic clamp is released, the cardioplegia catheter removed, and its suture tied down with an automated
knotting device
Multi-vessel Endoscopic Coronary Artery Bypass Grafting 233
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Fig. 18 Pain catheter insertion
Fig. 19 Final view on surgical wounds
234 A. Yilmaz et al.
Fig. 20 LIMA-MO and
RIMA-LAD anastomoses
Fig. 21 LIMA-LAD and
RIMA-RCA anastomoses
Multi-vessel Endoscopic Coronary Artery Bypass Grafting 235
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Fig. 22 LIMA-D-LAD and
RIMA-MO anastomoses
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