Ann Thorac Surg 2008;85:e30-e31. doi:10.1016/j.athoracsur.2008.02.025
© 2008 The Society of Thoracic Surgeons
How To Do It
Facile Stabilization and Exposure Techniques in Off-Pump Coronary Bypass Surgery
Murat Kurtoglu, MD,
Sanser Ates, MD,
Tuba Demirozü, MD,
brahim Duvan, MD,
Haldun Y. Karagoz, MD,
Tayfun Aybek, MD, PhD*
Güven Hospital, Department of Cardiovascular Surgery, Ankara, Turkey
Accepted for publication February 4, 2008.
* Address correspondence to Dr Aybek, Güven Hospital, Department of Cardiovascular Surgery, Ankara, 06450 Turkey (Email: ta{at}tayfunaybek.com).
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Abstract
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Off-pump coronary artery bypass grafting can not be performed without adequate stabilization and exposure techniques. Although most of the commercially available systems provide effective stabilization and exposure, their use were generally deemed time consuming and cumbersome. Achieving the same and even better results with simple traction sutures has led to the abandonment of commercially available systems. Although not a primary concern, the radial suture traction technique is also extremely cost efficient.
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Introduction
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Although most of the commercially available systems provide effective stabilization and exposure, their use were generally deemed time consuming and cumbersome. Achieving the same and even better results with simple traction sutures has led to the abandonment of commercially available systems. Although not a primary concern, radial suture traction technique is also extremely cost efficient.
Off-pump coronary artery bypass grafting can not be performed without adequate stabilization and exposure techniques [1]. Such techniques should be reproducibly and effectively stabilized and expose the target area without compromising the ease and quality of the operation, and they should not cause hemodynamic instability.
Off-pump coronary artery bypass grafting surgery has been performed since 1993 at our institution. During this period of time, more than 14,000 patients underwent off-pump coronary artery bypass grafting and significant experience had accumulated regarding various aspects of this surgical strategy. This report describes the current methodology of off-pump coronary artery bypass grafting surgery focusing only on the exposure and stabilization techniques.
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Technique
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The techniques described as follows are for a conventional median sternotomy.
Left Anterior Descending Coronary Artery Territory
Exposure for the left anterior descending coronary artery territory is fairly simple and conventional. Simple traction sutures on the pericardium on the left side often provide adequate exposure for this territory. Occasionally a gauze pad placed lateral to the lateral wall of the left ventricle may be necessary to bring the diagonal artery into sight.
Stabilization of the target area is achieved through four radial traction sutures (Fig 1). The 2-0 silk sutures are placed at the four corners of the target area. These are myocardial sutures and they do not pass under the target artery. The sutures are placed 5 mm lateral to the target artery, and they are pulled up radially as well as fixed at both sides of the sternal retractor. The target area is thus pulled upwards and immobilized very effectively.
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Fig 1. Stabilization of the left anterior descending coronary artery (LAD). Intraoperative situs during stabilization of the LAD. (1 = epicardial stabilization sutures.)
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Lateral Wall of the Left Ventricle
For exposing the lateral wall of the left ventricle without hemodynamic compromise, the patient is placed into the Trendelenburg position. The heart is rotated toward the right hemithorax and herniated into the right chest. For this purpose, right pleural cavity is opened freely and the diaphragmatic edge is incised completely toward the inferior vena cava. Any excessive fat pad is removed to slide the heart easily into the right chest. Deep or superficial pericardial traction sutures are not used, as they lift and compress the heart in the right chest wall or on the right side of the sternal retractor (Fig 2).
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Fig 2. Exposure and stabilization of the circumflex coronary artery territory. Suture technique during stabilization of the ramus circumflexus artery. (1 = epicardial stabilization sutures; 2 = transmural exposition sutures.)
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While holding the heart in place with gauze, a 2-0 myocardial silk suture is placed at the distal cephalad edge of the target area, and it is fixed cephalad to the right side of the sternal retractor. A second symmetrical suture is placed on the opposite side of the target artery and fixed at the caudal part of the right chest wall. A second set of symmetrical sutures are placed at the proximal corners of the target area and fixed at the left side of the sternal retractor, respectively. None of the sutures are passed underneath the target artery, but rather they radially track and immobilize the target area.
Right Coronary Artery Territory
For exposing the right coronary artery territory, a wide "U" suture, buttressed with a piece of gauze, is placed under the acute margin of the heart and tracked and fixed toward the left shoulder of the patient; thus exposing the inferior surface of the heart (Fig 3). Stabilization of the target area is achieved with four 2-0 silk sutures placed at the four corners of the target area providing radial traction.
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Fig 3. Exposure and stabilization of the right coronary artery territory. Intraoperative situs for exposition and stabilization of the right coronary artery. (1 = epicardial stabilization sutures; 2 = transmural exposition sutures.)
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Comment
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Through our extensive surgical experience of off-pump coronary artery bypass grafting, various methodologies have been used regarding stabilization and exposure of the target area. Among these, almost each and every commercially available stabilization and exposure devices were used and tried. Although most of the commercially available systems provide effective stabilization and exposure, their use were generally deemed time consuming and cumbersome. Achieving the same, and even better results with simple traction sutures, has led to the abandonment of commercially available systems. Although not a primary concern, the radial suture traction technique is also extremely cost efficient.
Very infrequently, these sutures may cause bleeding, especially on the right ventricular side of the left anterior descending coronary artery. Such bleeding from tears often does not require any specific treatment and ceases spontaneously. However, an occasional tear might require a 6-0 epicardial suture to control the bleeding, especially in the case of a thin right ventricular wall or very fat heart surface in which one should be careful with the placement of the sutures. In addition, poor and big ventricles are eligible for exposure and stabilization using this technique. Less favorable candidates for this technique may be the patients with acute myocardial infarction with potential necrotic myocardial tissue at the level of the target vessel area.
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References
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- Akpinar B, Güden M, Sagbas E, Sanisoglu I, Aytekin V, Bayindir O. Off-pump coronary artery bypass grafting with use of the Octopus 2 stabilization system Heart Surg Forum 2000;3:282-286.[Medline]
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Abstract
Introduction
