Full Spectrum Cardiac Surgery Through a Minimal Incision

Instructional Video Full Spectrum Cardiac Surgery Through a Minimal Incision Donald B. Doty, MD
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*Primary Incision and Exposure*
A midline incision is made over the lower portion of the sternum. The incision is deepened to the sternum.
	The sternum is divided transversely at the third intercostal space and vertically from that point to the xyphoid process using an oscillating saw.
A modified Favalaro retractor is used to elevate the intact portion of the sternum. This incision brings the exposure right down over the heart.

*Procedures for Crossclamping and Cannulation*
	The aortic occlusion clamp is brought into the open right pleural space through a separate stab incision on the right side below the clavicle.
The upper portion of the ascending aorta is accessible beneath the elevated sternum for cannulation using a 24Fr percutaneous-type cannula. A two-stage single venous cannula is usually used for operations on the mitral valve. Retrograde perfusion of the coronary sinus with cold cardioplegic solution is used for myocardial protection.
	A 24Fr thin-walled catheter with multiple holes is passed over a guidewire into the internal jugular vein and advanced into the right atrium for coronary bypass operations. This keeps the venous cannulae out of the primary incision to allow access to the back of the heart.

*Techniques for Coronary Artery Bypass Operations*
A gauze sponge placed between the sternum and the apex of the heart, which has been displaced into the open right pleural space, holds the heart and provides exposure of the marginal branches of the circumflex.
	The third and second marginal branches are grafted with saphenous vein.
The first marginal branch is also bypassed with a saphenous vein graft.
	The first diagonal branch is a relatively easy target, being more anterior on the heart. The left anterior descending artery is bypassed using the left internal mammary artery. This bypass graft is prepared just after making the incision.
There is sufficient space on the ascending aorta to anastomose saphenous vein grafts, even in combined coronary bypass and aortic valve operations.

*Techniques for Valve Operations*
	In this case, a posterior leaflet resection and leaflet advancement repair is supported by a Cosgrove annuloplasty band. The mitral valve is competent after the repair.
Preparatory to operation on the aortic valve, a transverse aortotomy is extended to transect the aorta above the sinotubular junction.
	For combined operations on the aortic and mitral valves, the aorta is completely divided and the aortic root displaced inferiorly to expose the left atrium for incision. This exposure is greatly enhanced with the aorta divided and provides good exposure of the mitral valve using a self-retaining retractor.
Complex operations, such as the Ross procedure, are possible through a ministernotomy.

Instructional Video

Full Spectrum Cardiac Surgery Through a Minimal Incision

Donald B. Doty, MD