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Ann Thorac Surg 1996;61:1271-1272
© 1996 The Society of Thoracic Surgeons

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How To Do It

Mini-Sternotomy for Coronary Artery Bypass Grafting

Minneapolis Heart Institute, Minneapolis, Minnesota

Accepted for publication November 8, 1995.

	Abstract

Top Footnotes Abstract Introduction Technique Reference

 
This communication details the approach to the left anterior descending artery, right coronary artery, or both via a single limited incision of the chest. The mini-sternotomy incision is 10 to 12 cm long. The distal anastomosis can be accomplished, with a beating heart, through this small incision, with or without cardiopulmonary bypass.

	Introduction

Top Footnotes Abstract Introduction Technique Reference

 
The adaptation of laparoscopic and thoracoscopic techniques to the treatment of intraabdominal and intrathoracic pathology has allowed a minimally invasive approach to be used in the treatment of disease that, in the past, was amenable only to open surgical intervention. The potential for decreased patient morbidity, shorter hospital stay, and lower cost of care has created a broad interest in this rapidly developing specialty. Although closed, less invasive techniques are now becoming commonplace in the specialty fields of obstetrics and gynecology, general surgery, and thoracic surgery, the application in the field of cardiac surgery has been limited [1]. This communication will briefly detail the approach for single or double coronary artery bypass grafting to the left anterior descending coronary artery, the right coronary artery, or both via a single limited incision on the chest.

	Technique

Top Footnotes Abstract Introduction Technique Reference

 
The patient is placed in the supine position, and a skin incision is made from a spot approximately 5 cm cephalad to the tip of the xiphoid cartilage and ending at the area adjacent to the third intercostal space. Sternotomy is begun at the angle on the left aspect of the sternum where the last costal cartilage is attached to the breast bone. The sternotomy is carried out just to the left of midline and ``T'd'' off to the left second intercostal space. The complete midline sternotomy could also be accomplished from this skin incision in case both the right and left anterior descending arteries need to be bypassed. A Chevalier retractor (Delacroix-Chevalier, Paris, France) is used during the procedure and is essential for the exposure of the left anterior descending artery (Fig 1). The entire length of the internal mammary artery is taken down in the usual fashion using direct vision. A pursestring suture is applied in the usual manner right at the tip of the right atrial appendage. Another pursestring suture is applied to the right lateral wall of the ascending aorta, adjacent to the right atrial appendage, both visible through this limited approach.

View larger version (34K): [in this window] [in a new window]   Fig 1. . Mini-sternotomy incision with Chevalier retractor in place. With two 4 x 4 sponges behind the heart, the entire length of the left anterior descending coronary artery can be exposed, as shown.

This approach has the following advantages: (1) There is only one incision (about half the sternal length, 10 to 12 cm long). (2) No groin incision for femorofemoral bypass is needed, thus eliminating groin complications. (3) There is no lateral chest incision, no rib removal, and no postoperative chest pain from intercostal nerve damage, if it occurs. (4) The patient is ready for cardiopulmonary bypass with a pursestring suture already placed in the right atrial appendage and the adjacent lateral aspect of the ascending aorta, without the need to expose the distal ascending aorta. (5) Exposure of the right coronary artery and the left anterior descending coronary artery can be obtained through the same incision. (6) Exposure of the entire length of the left anterior descending artery is easy with one or two 4 x 4 sponges placed underneath the left ventricle. (7) Takedown of the entire left internal mammary artery can be accomplished.

This technique has been used in 16 cases at our institutions. Because it remains in the learning curve, 10 of the 16 cases necessitated a brief period on cardiopulmonary bypass because of either arrhythmia or hypotension. Otherwise, the entire procedure was carried out while the heart was beating. All patients have had excellent recovery, were able to sit up the same afternoon, were transferred from the intensive care unit within 24 hours, and had a shortened hospital stay.

Although continued investigation and comparison with more conventional techniques are called for, this approach has nonetheless arrived, appears very promising, and has several benefits for the patient. Defining the value of techniques of minimally invasive coronary artery bypass surgery requires continued study.

	Footnotes

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Address reprint requests to Dr Arom, Minneapolis Heart Institute, 920 East 28th St, Suite 420, Minneapolis, MN 55407.

	Reference

Top Footnotes Abstract Introduction Technique Reference

 

1. Robinson MC, Gross DR, Zeman W. Development of a new closed-chest technique for coronary revascularization, using the pig as a model. J Cardiac Surg 1995;10:529–36.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kit V. Arom Robert W. Emery Demetre M. Nicoloff Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Arom, K. V. Articles by Nicoloff, D. M. Search for Related Content PubMed PubMed Citation Articles by Arom, K. V. Articles by Nicoloff, D. M.