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Asian Cardiovasc Thorac Ann 1999;7:76-77
© 1999 Asia Publishing EXchange Pte Ltd

HOW TO DO IT

A Simple and Safe Technique of Exposing Coronary Arteries

Soma Guhathakurta, MCh, Henry Alfred Deacon, MB, Ashok Kumar Sharma, FRACS

Department of Cardiothoracic Surgery Wellington Public Hospital Wellington South, New Zealand
For reprint information contact: Ashok Kumar Sharma, FRACS Tel: 64 4 385 5999 Ext. 5222 Fax: 64 4 385 5883 Department of Cardiothoracic Surgery, Wellington Public Hospital, Riddiford Street, Wellington South, New Zealand.

   Abstract
TOP
 Abstract
Introduction
 Technique
 Discussion
 References
 
A gauze sling technique using two long thick gauze strips to rotate the heart on its longitudinal axis is described. This gives excellent exposure to the inferior and posterolateral wall of the heart. Any coronary system can be exposed easily by manoeuvring the free ends of the tapes for anchorage without requiring an assistant to hold the heart.


   Introduction
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 Abstract
 Introduction
Technique
 Discussion
 References
 
During coronary artery bypass graft surgery, the most common method of exposing the posterior left ventricular branch, the posterior descending artery, or the obtuse marginals is by using an assistant to hold the heart upside down by lifting and rotating. With this manoeuvre, it is not easy to maintain a steady position and the heart tends to slip and distend, which may call for venting of the heart. We devised a gauze sling technique using two long thick gauze strips to rotate the heart on its longitudinal axis, giving excellent exposure to the inferior and posterolateral wall of the heart.


   Technique
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 Abstract
 Introduction
 Technique
Discussion
 References
 
Two 40-cm long strips of wet roller gauze tape of 2.5-cm width and 0.5-cm thickness are required. One of the strips is passed from the right side of the aorta through the transverse sinus and the right free end is anchored to the right arm of the sternal retractor at the same level. The other end is kept free for the manoeuvre of rotating the heart. The second strip is passed through the oblique sinus from the right side of the inferior vena cava, keeping both ends free for future manoeuvring and anchorage to expose the prescribed target coronary. Since the position of the required coronaries varies, the fixation and anchorage of these free ends also vary.

Manipulation of the transverse sinus tape is necessary for exposure of the posterior left ventricular branch and the posterior descending artery. The left-sided free end of the tape is brought down to the oblique sinus and anchored to the junction of the right bar and the inferior bar of the sternal retractor by which the heart is rotated clockwise as shown in Figures 1 and 2GoGo. Oblique sinus tape mani-pulation is necessary for the exposure of the obtuse marginals. The right free end of the tape is anchored at the lower part of the right bar and the left free end is brought from the left side over the heart anteriorly and attached to the upper part of the right bar of the sternal retractor. This rotates the heart anticlockwise and gives clear access to the obtuse marginal arteries at any level. These two tapes individually rotate the heart clockwise or anticlockwise and fix it in a steady position to give unhindered views without the need for an assistant.



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  		Figure 1. The two broad arrows point to the tape around the inferior vena cava. The small arrow shows the left free end of the transverse sinus tape brought through the oblique sinus and secured to the right hand bar of the sternal retractor.

 


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  		Figure 2. The broad arrows indicate the tape around the inferior vena cava. The small arrow shows the left free end of the transverse sinus tape. The smallest arrows point to the secured right end of the same tape. The posterior left ventricular branch is exposed.

 

   Discussion
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 Abstract
 Introduction
 Technique
 Discussion
References
 
Using this technique, any coronary artery can be approached with considerable ease, keeping the heart immobile in a fixed position with excellent exposure. The surgeon can perform the procedure single-handedly. This technique has proved particularly valuable in facilitating access to the coronaries in the posterolateral aspect of the heart. With this method we do not require any expensive retractors or heart support devices, nor do we have to fix the mediastinal pleura that may be required after the heart flip technique.1–3 The best advantage of the procedure is the avoidance of extra operating theater personnel, which may become a rare commodity with the current hospital budget constraints. Moreover, in practice, the assistant-held heart requires several readjustments to prevent slipping and to obtain a perfect anastomosis, thereby prolonging the bypass time. Continuous adjustments may give rise to myocardial or epicardial injury as well as premature rewarming.3 This can be avoided with the described sling technique. As the sling is thick and broad it does not injure the myocardium. Overall, the procedure is a faster, less expensive, and effective alternative. We have used this technique for almost ten years and have not encountered any technical difficulties or complications. This technique has always resulted in adequate exposure of the posterior left ventricular branch, the posterior descending artery, and the obtuse marginals.


   References
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 Abstract
 Introduction
 Technique
 Discussion
 References
 

  1. Rousou JA, Engelman RM, Flack JE III, Deaton DW. Cardiac retractor for coronary bypass operations. Ann Thorac Surg 1991;52:877–8.[Abstract]

  2. Jahnke WH. Heart support for coronary bypass surgery involving the circumflex artery system. J Thorac Cardiovasc Surg 1974;67:883–4.[Medline]

  3. Splittgerber FH, Friedrich I, Falk B, Kroncke G, Talbert JG. Exposing the circumflex coronary artery: the heart-flip technique. Ann Thorac Surg 1996;61:1019–20.[Abstract/Free Full Text]





This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
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Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Ashok Kumar Sharma
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Guhathakurta, S.
Right arrow Articles by Sharma, A. K.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Guhathakurta, S.
Right arrow Articles by Sharma, A. K.

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