CABG in Pectus Carinatum Chest

Fig 1: Chest wound 4 days after corny artery bypass grafting

A 48 year old non diabetic non hypertensive patient came to hospital with complaints of intermittent chest pain since 1 month which was insidious in onset gradually progressive, increased on exertion and relieved by rest. His ECG showed ST changes. Coronary Angiography  done which showed triple vessel coronary artery disease.

He was a small stunted man with history of fall in childhood. He has short neck with pectus carinatum ( pigeon chest)-Fig 1 and Fig 2.

Sternum was short but wide. Left internal mammary harvesting was abnormal course but harvested well with precision and given to left anterior descending artery.  Rest of the grafts were Long Saphenous Veins.

Fig. 2: Chest wound 4 days after coronary artery bypass grafting. Side view with clearly seen short sternum with pectus carinatum chest.

Recovery was uneventful with normal wound healing. The photos were taken at the time of discharge.

 

 

 

 

 

 

Cardiac surgery procedures

Steps for Cardiac Surgery:

  • Arrange the trolley for CABG.
  • Painting and draping- The area of surgery is cleaned throughly with betadine solution. After that the surgical fluid is isolated from other areas with drapes.
  • Incision site is cleaned with spirit, then one meter sheet to dry it.
  • Place IOBAN at incision site.
  • Apply light handles on the light.
  • Ready cautery and suction

Sternotomy

  • No 3 SUTUPAK for marking
  • BP handle with 21 no blade for skin incision with one large sponge.
  • After that cautery for cutting soft tissues
  • For suprasternal space use Czerney, vascular forces and cautery.
  • Use Syringe needle to locate midline for parasternal both sides.
  • Pericardium and pleura are separated by fingers.
  • Use heavy scissor for cutting xiphoid process.
  • Use sternal saw for sternotomy.
  • Use large sponge and apply bone wax in the bone marrow to control bleeding.
  • Both the tables of the sternum cauterised.
  • Use chest retractor.
  • Use bone wax for upper 1/3rd of the sternum.

Internal Mammary Harvesting:

  • Place IMA retractor.
  • First separate the endothoracic fascia over the IMA with the help of cautery and vascular forces.
  • Start harvesting the pedicled IMA using force and cautery.
  • Use Clip and dry gauze piece.
  • Once harvesting is completed use 7 inch artery forcep for clamping IMA and then use metzenbaum scissor for cutting it.
  • Check blood flow and use bull dog.
  • Use Papaverine cause for covering IMA to prevent spasm.
  • Use SUTUPAK to tie the distal already clamped artery. Use metzenbaum scissor to cut the suture.
  • Check for bleeding in the IMA harvesting site, achieve homeostasis if any and remove IMA stand.
  • Use hot and wet sponge for mopping and place chest retractor.

Pericardiotomy-

  • Use vascular forcep with cautery.
  • Use 2 kocher’s for left side.
  • Remove chest retractor.
  • Use 2 large sponge on both sides and place chest retractor and remove kochers.
  • Pericardial stay application with no 3 SUTUPAK using golden handle needle holder with vascular forcep. Use curved artery forcep to hold it to the green sheet.

Purse String:

  • Use 3-0 Prolene with golden handle needle holder with vascular forcep for aortic purse string and cannulation.
  • Cut the needle with metzenblum scissor and use snugger with rod to secure the purse string in place using a curved artery to hold it.
  • Use 3-0 proline with older handle needle holder with vascular forcep for venous cannulation.
  • Cut the needle with metzenblum scissor and use snugger and curved artery to hold the suture.

Mammary preparation-

  • Octopus, mist blower should be ready.
  • Use coronary instrument.
  • Take 25 cm sheet
  • Use ring forcep and metzenbaum scissor.
  • Use forward scissor to cut as appropriate.
  • Use dilator. 1mm first then 1.5mm.
  • Use ligature clip and remove bulldog.
  • Use metzenbaum scissor then tenotomy scissor.
  • Use bulldog
  • Use 2 mosquito forceps
  • Use ring forcep and forward forcep.
  • Use dilator 1mm and 1.5mm.

Vein Preparation-

  • Use 25 cm sheet.
  • Take vain with vein-filler with syringe.
  • Use tenotomy if needed.
  • Use ring forcep and metzenbaum scissor.
  • Use forward scissor to cut vein.
  • Keep it back in bowl.

Arteriotomy-

  • Use hot and we sponges to elevate the heart.
  • Use octopus, make suction on and tighten it.
  • Use Gerald forcep with no 15 blade to make the artery visible properly. Use bulldog.
  • Use no 11 blade to give nick on the artery. Take forward scissor to cut as appropriate.
  • Use shunt.
  • Take vein with mosquito.
  • Use 7-0 proline suture.

Proximal anastomosis-

To be written…