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perkins05

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PREOPERATIVE DIAGNOSIS:
Coronary artery disease.

POSTOPERATIVE DIAGNOSES:
Coronary artery disease.

NAME OF OPERATION:
Coronary artery bypass x3.


FINDINGS:
This patient underwent placement of left internal mammary artery to
the LAD which was 1.75 mm in size. Saphenous vein which was
harvested using endoscopic technique was placed to the main right
coronary artery 2.5 mm, second obtuse marginal 1.75 mm tapering to
1.5 mm.

PROCEDURE IN DETAIL:
After placement of adequate intravenous access, arterial lines, and
Swan-Ganz catheter where indicated, general endotracheal anesthesia
was induced. An NG tube, endotracheal tube, and Foley catheter were
placed. Routine sterile prep and drape was conducted on the chest,
abdomen, and lower extremities. A suitable portion of the saphenous
vein was harvested. A sternotomy was performed per routine. The
skin was sharply incised and soft tissue was divided with the
electrocautery. The sternum was split in the midline and hemostasis
was obtained in the cut edges with the use of the electrocautery and
application of a thin film of bone wax where necessary. Where
indicated, the left internal mammary artery was dissected from the
surrounding tissue using our standard technique. A Favaloro
retractor was placed and soft tissue and lungs were swept away.
Parallel incisions were made on either side of the pedicle. Then,
using our standard technique, the left internal mammary artery was
dissected from the chest wall. Hemostasis was obtained for this
dissection with the use of the electrocautery and application of
small Hemoclips were necessary. Prior to transecting the vessel,
the patient was systemically heparinized with 3 mg/kg of heparin.
The vessel was then doubly ligated distally and transected. Into
its tailored end, a small needle was inserted. Papaverine solution
was used to hydrostatically dilate the vessel and to check for
hemostasis. Hemostasis was obtained no the chest wall. The
Favaloro retractor was removed and replaced with a standard sternal
spreader. Soft tissue overlying the ascending aorta was divided in
anatomic lobes to the level of the innominate vein. The pericardium
was entered in the midline and a pericardial sling was constructed
per routine. The ascending aorta was carefully palpated to
establish whether there was any significant calcification. Two
concentric pursestrings were placed on the anterior surface of the
ascending aorta proximal to the takeoff of the innominate artery. A
stab wound was placed in the center of these pursestrings and a 20
French aortic cannula was introduced, secured in position, deaired,
and connected to the arterial line of the extracorporeal circuit.
The terminal end of the internal mammary artery was dissected from
surrounding tissue and an arteriotomy was made and free flow was
measured. A pursestring was placed on the right atrial appendage
which was subsequently incised and a Research Medical 5136 dual
stage venous cannula was inserted, secured in position, and
connected to the venous return of the extracorporeal circuit. A
cardioplegia delivery device was inserted in the anterior surface of
the ascending aorta. Extracorporeal circulation was initiated. The
patient was started on a cooling cycle, as coronary artery anatomy
was inspected and arteriotomy sites chosen. An aortic cross-clamp
was placed. An initial 500 cc of crystalloid cold cardioplegia was
delivered antegrade. Additionally, the heart was protected by
packing it in an ice solution with care taken to prevent application
of ice in the region of the phrenic nerves. Attention was then
placed towards creating the distal anastomoses. Vein grafts were
anastomosed to the coronary artery using running 7-0 Prolene. Care
was taken to demonstrate distal patency prior to securing the
anastomosis. The vein grafts were tacked to the epicardium, brought
to the ascending aorta, sized, and transected. Cardioplegic
solution was infused at appropriate 20 minute intervals. The
internal mammary artery where used was anastomosed using a running 8-
0 Prolene. Three way patency was demonstrated prior to securing
this anastomosis and the pedicle was tacked to the epicardium at
several sites. The patient was started on a warming cycle during
the completion of the last distal anastomosis. Upon completing the
distal anastomoses, the cross-clamp was released, the heart was
shocked to a normal sinus rhythm where necessary, and a partial
occluding clamp was placed. Anastomoses of the vein grafts were
constructed. Two aortotomy sites were created with a 4.8 mm punch
using a running 5-0 Prolene. Prior to securing these anastomoses,
the vein grafts were back bled to deair them and the aortic root.
Hemostasis was then checked at all sites and achieved as necessary.
Marking rings were placed around the proximal vein anastomoses. A
single ventricular pacing wire was placed and exteriorized. When
the patient was adequately rewarmed, the patient was weaned from the
extracorporeal circuit. With the patient stable off the pump, the
venous cannula was removed. The previously placed pursestrings were
tied for hemostasis and the site was oversewn with a heavy silk.
The patient was transfused the contents of the extracorporeal
circuit and then the aortic cannula was removed. The previously
placed pursestrings were tied for hemostasis. The site was oversewn
with a 4-0 Prolene. Protamine was given at this time to reverse the
heparin effect. A single sump tube was introduced into the anterior
mediastinum via a separate stab wound. When there was adequate
hemostasis, the pericardium was loosely approximated and the soft
tissue was closed over the ascending aorta. The sternum was then
approximated using seven heavy stainless steel wires. The soft
tissue was closed in layers using absorbable sutures and final skin
closure was with the placement of surgical staples. At the end of
the procedure, an appropriate dressing was placed. The chest tube
was connected to an
autotransfusion device and the patient was transported to the SCU in
stable condition.


Codes wanting to use
33533
33519
33508

Any help is greatly appreciated!!
 

emoates

Contributor
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33533 for the LIMA to LAD
33518 SVG to RCA, SVG to OM
33508 Endoscopic vein harvest

HTH,
Erin
 
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