Most surgeons use a median sternotomy because it allows the anatomy to be evaluated more accurately. A left thoracotomy incision is used in some patients, especially if the banding is performed in conjunction with the repair of a coarctation.

Through a median sternotomy, the pericardium is opened longitudinally after resecting the thymus. (Removing the entire thymus in this surgery makes dissection at reoperation easier.) A patent ductus arteriosus, if present, is first ligated (see Chapter 14). The main pulmonary artery is dissected free from the aorta and the origin of the right pulmonary artery is identified. A band of Silastic 3- to 4-mm wide is placed around the proximal pulmonary artery and tightened until the pressure distal to the band is approximately one-third systemic with an arterial oxygen saturation no less than 75% on 50% inspired oxygen (Fig. 16-1). The constriction site on the band is made permanent with stainless steel clips or interrupted sutures. The band is then secured to the adventitia of the pulmonary artery at various intervals with interrupted 6-0 or 5-0 Prolene sutures (Fig. 16-1, inset).

Through a left thoracotomy, the pericardium is incised anterior and parallel to the phrenic nerve. The main pulmonary artery is isolated, and the Silastic band is passed around it and narrowed as described previously.