Internal mammary retractor

Management of large mediastinal masses: surgical and anesthesiological considerations

Large mediastinal masses are rare, and encompass a wide variety of diseases. Regardless of the diagnosis, all large mediastinal masses may cause compression or invasion of vital structures, resulting in respiratory insufficiency or hemodynamic decompensation. Detailed preoperative preparation is a prerequisite for favorable surgical outcomes and should include preoperative multimodality imaging, with emphasis on vascular anatomy and invasive characteristics of the tumor. A multidisciplinary team should decide whether neoadjuvant therapy can be beneficial. Furthermore, the anesthesiologist has to evaluate the risk of intraoperative mediastinal mass syndrome (MMS). With adequate preoperative team planning, a safe anesthesiological and surgical strategy can be accomplished.

Subxiphoid multi-arterial OPCAB: surgical technique and initial case report

BACKGROUND

The surgical technique of transsternal coronary artery bypass grafting (CABG) has remained relatively stagnant for the past three decades. Unlike general and orthopedic surgery, cardiac surgery has made very little progress in converting our most common procedure into a minimally invasive alternative. Minithoracotomy techniques introduced in 1995 enjoyed a brief period of popularity but were inherently single vessel (LIMA-LAD) procedures and thus not an answer to the need for a less invasive multivessel operation. Totally endoscopic CABG has been performed in a small number of cases but the learning curve is very steep and the rate of conversion to open surgery remains high with only a few successful multivessel cases. There remains a great need for a less invasive approach that has the potential to graft all coronary targets without disturbing the chest wall and which can be performed by all current and future surgeons with acceptable hospital costs. A small subxiphoid incision has been used for single vessel grafting to anterior or inferior targets, but until now lateral wall grafting has not been considered possible. Development of a successful multivessel subxiphoid technique on the beating heart, including lateral wall grafting, is now reported in this article.

METHODS

Subxiphoid multi-arterial bypass grafting was performed on a 79-year-old male using commercially available equipment but modified surgical techniques. Instead of midline sternotomy, full exposure to the heart was obtained by four essential steps: (1) removal of the xiphoid process, (2) vertical lifting of the lower sternum, (3) caudal retraction of the diaphragm, and (4) spreading of the wound using a specific retractor to create an adequate working portal. Both internal mammary arteries were harvested for their full length as skeletonized conduits using only direct vision (headlight and loupes). Off-pump distal anastomoses to the left anterior descending (LAD) and first obtuse marginal branch of the circumflex (OMB-1) were performed using available stabilizer systems. The obtuse marginal was exposed using the Medtronic Starfish suction-positioner without any hemodynamic compromise. The wound was closed with a simple running fascial suture and the patient discharged on postoperative day 4 with no complications and no angina.

CONCLUSIONS

Most practicing surgeons are reluctant to perform multiple distal grafts through small incisions because of the difficulty in simultaneously mastering a host of new skills at the same time (robotics, endoscopics, beating heart techniques). The subxiphoid approach offers the potential to perform distal anastomoses to all regions of the beating heart with excellent exposure while utilizing the same skill sets that surgeons now possess. There is potential that further evolution of this technique will permit outpatient CABG while providing long-term clinical outcomes superior to coronary stenting.

Sternal retractor for internal mammary artery

A sternal retractor for easy visualization of the internal mammary artery and retrosternal area is described. We have successfully used this retractor for all internal mammary dissections without sternal or costochondral fractures in the past 6 months.

New modification of a mammary artery retractor

A new accessory instrument to the self-retaining internal mammary artery retractor was developed. This instrument presses the chest wall inward, relieves the concavity of the inner surface of the chest wall, and provides good exposure of the internal mammary artery.

Anterior sternal retraction for reoperative median sternotomy

The incidence of reoperative median sternotomy for repeat cardiac surgery is increasing. Reoperative median sternotomy is associated with a higher morbidity and mortality than first-time cardiac surgery. A portion of this morbidity and mortality may be due to direct injury to the heart and great vessels in the process of reopening the sternum. We report a new technique utilizing anterior sternal retraction that allows division of adhesions between the undersurface of the sternum and the heart and great vessels under direct vision. This technique enables the surgeon to minimize the risk of serious injury to these underlying structures during reoperative cardiac surgery.

A new concept in sternal retraction: applications for internal mammary artery dissection and valve replacement surgery

A new, unique sternal retractor that greatly facilitates exposure and dissection of the internal mammary artery is described. In addition, a built-in mechanism permits steady and adjustable retraction during valve replacement surgery.

Healing basis and surgical techniques for complete revascularization of the left ventricle using only the internal mammary arteries

Long-term follow-up data from several leading centers concerning patients undergoing coronary artery bypass clearly demonstrate the superiority of the internal mammary artery (IMA) with patency rates of 83 to 94% at 7 to 12 years compared with the saphenous vein and its patency rates of 41 to 53%. Our experimental studies provide a biological basis for understanding this difference. Thin-walled arterial autografts undergo no histological change after being implanted in the arterial system, while venous autografts undergo major changes with an initial scattered loss of endothelium and marked thickening due to a proliferative reaction. The challenge to the cardiac surgeon is to revascularize the entire left ventricle with the IMAs. We have found this possible in most patients with advanced three-vessel disease by using both IMAs either as in situ grafts or free grafts with as many sequential anastomoses as necessary to achieve full revascularization. Our use of the term in situ refers to the graft's origin from the subclavian artery as opposed to a free IMA graft arising from another site.