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Ann Thorac Surg 1997;63:1799
© 1997 The Society of Thoracic Surgeons

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Invited Commentary

Invited Commentary

Division of Cardiovascular and Thoracic Surgery, University of Kentucky Medical Center, 800 Rose St, Lexington, KY 0536-0084

See also page 1797.

To avoid the risk of inadequate length, kink, or possible "steal," IMA dissection in minimally invasive coronary bypass grafting should conform to the same principles followed in sternotomy. These include take-down to the usual proximal and distal dissection points and interruption of side and perforator branches. Approaches remain somewhat controversial between the learning curve and additional cost of thorascopy and access difficulties with the direct approach. The practical technique described here by Jansen and associates adds greatly to visualization and access in the direct IMA dissection method in all but the very occasional patients with an impliable chest wall.

After external elevation of the fourth rib and cartilage adjacent to the minithoracotomy, the third costal cartilage is noted to invariably obstruct access to the second intercostal space perforator and the view of the proximal IMA. We have modified the mechanical principle described by the Utrecht group and use a curved metal bar (Adkin's strut) placed along the under-surface of the third cartilage and rib and held in place within an externally placed encircling sternal wire. The wire is attached to the overhead Rhul retractor as a loop and the wire is then twisted, producing shortening and a mechanically efficient controlled elevation of the third cartilage. The second perforator can then be seen and divided and the dissection carried on to the proximal IMA, where the posterior curvature of the upper chest wall allows better visualization. In the infrequent cases where the chest is rigid, dividing (later reattaching) the third cartilage medially and then using this lever system will allow the required access.

This method has the advantage of simplicity, fixed non--space-occupying retraction, and minimal cost. It can be recommended as an essential routine for direct IMA dissection and obviates the need for cartilage or rib removal.

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Robinson, M. C. Search for Related Content PubMed Articles by Robinson, M. C.