Ann Thorac Surg 2006;81:2326-2327
© 2006 The Society of Thoracic Surgeons
How to do it
Technique of Lung Retraction During Internal Mammary Artery Harvesting
Pawan Kumar, MCh
*
,
Uday E. Jadhav, MCh,
Anil G. Tendolkar, MS
Department of Cardiovascular and Thoracic Surgery, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, India
Accepted for publication March 14, 2005.
* Address correspondence to Dr Kumar, Department of Cardiovascular and Thoracic Surgery, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, 400 022 India (Email: pawkum73{at}yahoo.com).
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Abstract
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We describe a novel technique for lung retraction during dissection of the internal mammary artery for its use in coronary artery bypass grafting. The lung is retracted using the blades of the Octopus (Medtronic Inc, Minneapolis, MN) suction stabilizer, without the suction connected. This technique can be used when the internal mammary artery is harvested by widely opening the pleura or by the extrapleural approach. This technique makes mammary artery dissection easy, and it can be used for harvesting internal mammary arteries bilaterally. The method described is simple, causes no impairment in gas exchange, and offers no additional expense, because the same stabilizer would be used later for the off-pump coronary artery bypass surgery.
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Introduction
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The major incentive for performing an off-pump coronary artery bypass is the avoidance of cardiopulmonary bypass and its associated adverse physiological effects [1]. The internal mammary arteries (left and right) have been accepted as the conduits of choice for coronary artery bypass grafting [2]. Various techniques of internal mammary artery harvesting (left and right) have been described [3–5]. The mammary artery may be harvested either by widely opening the pleura or by keeping it intact (extrapleural dissection). One problem that remains common to both the techniques is that of the inflating lungs coming in the way of dissection. We have evolved a simple and effective technique for keeping the inflating lung away from the field of mammary artery dissection.
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Technique
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The technique described is used during dissection of the internal mammary arteries both when the pleurae are widely opened as well as when the extrapleural technique is used. The blades of the Octopus IV suction stabilizer (Medtronic Inc, Minneapolis, MN) are used to retract the lungs.
After a median sternotomy, a favalaro type retractor (asymmetric sternal retractor) is positioned and the sternal margins are retracted. The pleura is widely opened, and dissection of the mammary artery is started. The inflating lungs generally do not hamper the field of vision during dissection of the distal and mid portions of the internal mammary artery. The Octopus IV (Medtronic Inc) is applied to the horizontal limb of the retractor. The required portion of the lung is retracted mechanically using the suction blades, and the stabilizer is tightened in place. There is no need to turn the suction on, because the mechanical retraction achieved is adequate. This enables a significant portion of the lung to be retracted away (Fig 1), whereas the rest of the lungs continue to expand normally. In cases where the blades of the Octopus stabilizer (Medtronic Inc) do not reach until the apex of the lung, the device may be attached to the longitudinal limb that houses the sternal edge retraction blades (Fig 2).
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Fig 1. Octopus suction stabilizer (Medtronic, Inc, Minneapolis, MN) being used for retraction of left lung during dissection of the left internal mammary artery.
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Fig 2. Octopus suction stabilizer (Medtronic, Inc, Minneapolis, MN) being used for retraction of right pleura during extrapleural dissection of the right internal mammary artery.
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A similar technique is used to retract the bulging mediastinal pleura posterolaterally when the mammary artery is dissected using an extrapleural approach (Fig 2).
So far, 42 internal mammary arteries have been harvested in 30 patients using this technique, and we found that the dissection was much easier to carry out. No change was noticed in the gas exchange as verified by continuous pulse oximetry, end tidal carbon dioxide monitoring, and regular blood gas analyses.
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Comment
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During dissection of internal mammary arteries, the inflating lungs often hamper vision. This is particularly true during dissection of proximal part of the internal mammary artery. Various techniques have been described with reference to the same problem [4, 6, 7]. The most commonly used technique is to isolate the lung using laparotomy pads [4]. Despite using laparotomy pads for isolating the lung, dissection of upper portion of the mammary artery may be hampered by the inflating lung. Not only does it cause inconvenience, but also it is never completely satisfactory. Another technique suggested for keeping the lungs away is the use of the high-frequency jet ventilation [6, 7]. This is definitely more cumbersome and expensive. The previously described problems are taken care of by using the simple technique evolved by us.
To summarize, the advantages of this new technique are:
- (1) A readily available suction stabilizer is used that will in turn be used later for the off-pump coronary bypass surgery.
- (2) Lungs are continued to be ventilated with normal tidal volume with no requirement of providing intervals of apnea.
- (3) Continuous retraction of the inflating lungs allows uninterrupted dissection of the internal mammary arteries.
- (4) The malleability of the shaft of Octopus suction stabilizer (Medtronic Inc) allows it to be retracted and not hamper the field of vision.
- (5) It is equally effective in retracting the constantly bulging mediastinal pleura posterolaterally when the extrapleural dissection of the internal mammary artery is performed.
Thus we conclude that the use of an Octopus suction stabilizer (Medtronic Inc), without the suction applied, is an easy and satisfactory method for retracting the inflating lungs and makes the dissection of the internal mammary arteries simpler.
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References
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- Gu YJ, Mariani MA, Boonstra PW, et al. Complement activation in coronary artery bypass grafting patients without cardiopulmonary bypassthe role of tissue injury by surgical incision. Chest 1999;100:312.
- Tector AJ, Kress DC, Downey FY. Complete revascularization with internal thoracic artery grafts Semin Thorac Cardiovasc Surg 1996;8:29.[Medline]
- Favaloro RG. Unilateral self-retaining retractor for use in internal mammary artery dissection J Thorac Cardiovasc Surg 1967;53:864-865.[Medline]
- Pacifico AD, Sears NJ, Bunges C. Harvesting, routing and anastomosing the left internal mammary artery graft Ann Thorac Surg 1986;42:708.[Abstract]
- Baykut D, Tsilimingas N, Leitz KH. A new sternal retraction device for the dissection of the internal mammary artery Eur J Cardiothorac Surg 1993;7:447-448.[Abstract]
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- Shine TS, Scarborough CJ, Barnhorst DA. High-frequency ventilation during dissection of the internal mammary artery Ann Thorac Surg 1988;46:256.[Medline]
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Abstract
Introduction
