Introduction

This chapter is intended to help the new perioperative practitioner understand the basic cardiac surgical procedures. The specific surgical procedures undertaken are always dependent upon the surgeon’s preferences. Some surgeons never change their surgical steps, while others always change their routine steps. We have not covered any emergency situations in this chapter. For example, while opening the sternum there is a small chance that the innominate vein may be injured, or the right ventricle/aorta could be lacerated. These are real surgical emergencies. Perioperative practitioners must always be prepared for these unexpected situations.

Coronary artery bypass surgery (CABG)

Instruments required:

• Basic heart set

• Cut down set

• Coronary set (general)

• Fine instruments for coronary grafts

• Holmes Sellors chest spreader

• Internal mammary artery retractor (commonly known as IMA retractor)

• Reciprocating saw/Desoutter saw (according to surgeon’s preference list)

• Heart disposable drapes

• Bowl sets x 01

• Adult or child defibrillator paddles.

Extra instruments (from a supplementary pack):

• Red clip applicators – 1

• Blue clip applicators – 1

• Lambert Kay – 1

• Artery clip, curved mosquitoes – 10

• Traverse retractor – 1 (have available but do not open unless needed)

• West retractor – 1 (have available but do not open unless needed)

• Small Langenbeck – 2

• Litre jug – 1

• Handheld diathermy.

Basic heart set

Starting from the right side of the metal tray:

First large pin

• Jesco scissors – 1 (commonly known as tube cutting scissors)

• Tubing clamps – 5 (commonly known as line clamps)

• Artery forceps Roberts – 4

• Artery forceps Duval – 1

• Artery forceps Lahey –1

• Artery forceps O’Shaughnessy – 1

• Debakey clamp curved – 1 (commonly known as Semb)

Second large pin

• Artery forceps – Spencer Wells 16 (commonly known as straight Wells or straight Spencer Wells).

Third large pin

• Artery forceps Dunhill – 15.

Small pin

• Artery forceps mosquitoes – 10.

Left side of the tray:

• Rampley sponge holders – 4 with sponges gripped on the ends of the sponge holders

• Scalpel handles – 4 (2 x No 4 and 2 x 7)

• Needle holders – 5 (3 x Crilewood and 2 x Stille; Crilewood is used to mount sutures like No 2-0, 3-0 and 4-0, whereas Stille needle holders are used to mount sutures like No 1, 1-0 and 2-0).

• Scissors – 5

• Lobectomy scissors –1 (generally used in mitral valve surgery)

• Straight Mayo scissors – 2 (commonly used to cut heavy sutures like silk and vicryl)

• Metzenbaum scissors – 1 (commonly used to cut tissue and also for cutting fine sutures like No 3-0, 4-0, 5-0, 6-0, 7-0 and 8-0)

• Curved Mayo scissors – 1 (generally used in aortic valve surgery)

• Dissecting forceps – 5

• Debakey forceps – 2 (tissue-holding forceps)

• Stille forceps – 1

• Waughs toothed forceps – 2 (commonly used for muscles and skin).

Top left-hand corner of tray:

• Quiver containing towel clip – Backhaus on tape

• Diathermy stick and diathermy knife (handheld pieces of footswitch diathermy used for the purpose of cutting and cauterising the tissue; now available separately in a tray)

• Suction – high pressure Brompton (pack in 100-150mm view pack pouch) Suction – low pressure Brompton (commonly known as metal pump sucker)

• Towel clips (total 7 on the sets, Bachaus – 4, Mayo – 3)

• Silver eye probe – 1 (commonly called a snugger and used to snug the purse string)

• Blalock hook – 1

Top right side of the tray:

• Retractor – Langenbecks – 2

• Cooley clamps – 2 (medium and large)

• Bone awl needle – 1

• Wire-cutting scissors

• Sternal needle holder (commonly called a twister)

• Sternal wire cutter.

Retractors

There are a few main instruments that are required to open up the coronary arteries, and to suture a graft into the aorta or onto the coronary artery to enable easy blood flow. The main instruments are Pott’s scissors (forward cutting, reverse cutting and straight cutting). There are also a few fine forceps, such as Gerald’s forceps and top-end forceps. The coronary instruments are very fine, due to the small size of the vessel. There are also various coronary probes which are used to check the size of the coronary artery lumen and to check for any blockages (see Figures 16.6a, 16.6b and 16.6c).

For newcomers to cardiac surgery, it’s best to learn the general cardiac trolley set-up first. However, the trolley set-up for a specific procedure will always depend on the individual perioperative practitioner’s preferences and what they are comfortable with.

Mayo trolley

Bowls set

• Large, small and medium swabs

• 14-gauge suction catheters for snugger x 6

• Assorted selection of syringes x 2.5ml (01), 10ml (01), 20ml (03); and hypodermic needles

• Sutures and ties, according to the surgeon’s preference file

• Aortic punch (4mm is the standard size but other sizes are sometimes used, according to the size of the vessel, e.g. 3mm or 3.5mm).

Important extra instruments for surgery

Step-by-step procedure for assisting coronary artery bypass surgery as a scrub practitioner

• Painting (Betadine or chlorhexidine alcoholic – check for any allergies).

• Give two sponge holders with sponges to the surgeon and the assistant surgeon for painting.

• Drape the patient.

• First place the perineal/groin drape. Please take care to expose both the groin femoral sites. It is very important because there should be easy access to the groins to insert femoral cannulation or an intra-aortic balloon pump in emergency situations.

• Spread the bottom sheet down below the waist, followed by foot drapes.

• Give one large swab to the surgeon to dry the chest, followed by the Opsite/Ioban.

• Give two large drapes as side screens hooked together with a towel clip at the centre.

• Give lamp handles to the surgeon.

• Attach the quiver, diathermy and suction.

• Give a No. 23 knife (in a kidney dish) and two large swabs for the skin incision on the chest.

• Pass the diathermy blade tip to divide the muscles and cauterise the blood vessel.

• Give straight scissors to cut xyphoid sternum.

• Pass the sternal saw for sternotomy.

• Change the diathermy tip to the ball tip and give it to the surgeon when they ask.

• Bone wax is optional.

• Pass out the Holme Sellors retractor to retract the chest, together with the diathermy and Debakey forceps.

• Pass the IMA retractor to harvest the internal mammary artery, followed by the diathermy and the Gerald forceps or fine Debakey and red or blue ligaclips (always give red ligaclips unless the blue ligaclips are requested). Please note that different colour codes (such as red, blue, grey or yellow) may be used for ligaclips in different hospitals.

• Once the mammary artery is harvested, the mammary retractor is removed and two green towels and the chest spreader are given.

• Pericardium is opened using the diathermy and Debakey forceps.

• Pericardial stitches (either silk or Ethibond, according to the surgeon’s preferences) are given on the Stille needle holders, along with Debakey.

Steps for going on bypass

• Two stitches (either 2-0 Ticron or 3-0 prolene or 2-0 Ethibond, according to surgeon’s preference) are given as aortic purse strings on the aorta, followed by the snugger and the Spencer Wells. These stitches are given on the Crilewood/boss needle holder, along with Debakey forceps.

• Pass No. 11/15 knife and aortic pipe followed by a tie (black Vicryl) to secure the pipe.

• Pass the tube clamp to clamp the pipe and an empty bowl for de-airing the aortic pipe. Pass the arterial line to the surgeon who then connects it to the pipe.

• Give a stitch (either Ticron, prolene or Ethibond, according to surgeon’s preference) for the venous purse string which is taken on the right atrial appendage, followed by a snugger and a tie.

• Give 4-0 Surgipro on Crilewood needle holder along with Debakey forceps. This is a purse string which is taken on the left ventricle to insert a retrograde cannula.

• Pass the snugger and Spencer Wells.

• Give No. 11 knife and Metzenbaum scissors, followed by retrograde cannula, which then goes into coronary sinus. Note: Not all surgeons use retrograde cardioplegia cannula.

• Pass ties to the surgeon to secure the cannula, which is then attached to the retrograde extension with a three-way stopcock.

• Give 4-0 Surgipro on Crilewood/Boss needle holder and Debakey forceps. This purse string is taken on aorta and is known as an antegrade purse string.

• After purse string, pass snugger and Spencer Wells.

• Give antegrade needle and a Spencer Wells and ties.

Preparation of greater saphenous vein

By this time, the saphenous vein has been harvested by the surgical care practitioner or senior house officer and is then checked by surgeons for any leaks.

• Give 20ml syringe with blood to the surgeon and a fine Debakey to the assistant surgeon

• Give ties or red/blue ligaclips as required

• Sometimes 7/0 or 8/0 prolene is needed to repair the vein.

The greater saphenous vein can be harvested by three different methods: open, bridging or endoscopic.

Open method

This requires the usual cut-down set and extras.

Cut-down set:

• Rampley sponge holder – 1

• BP scalpel handles – 2 (No. 3, No. 4) –1 each

• Mayo curved scissors – 1

• Metzenbaum scissors – 1

• Dissecting forceps – Mclonde – curved – 1

• Dissecting forceps – Waughs toothed – 1

• Artery forceps – mosquito – curved – 10

• Hook blunt – 1

• Needle holder Mayo – 1

• Blue clip applicators – 1

Bridging method

This requires all the instruments needed for open vein harvesting as well as a West retractor and a small Langenbeck retractor.

Endoscopic vein harvesting method

Equipment needed:

• Stack system

• CO₂ cylinder

• Light cable

• Camera

• Haemoprobe unit

• Vein grafting set

• Small Langenbeck retractor

• West retractor

• Vesiloop (if required).

Disposables:

• Camera drape

• CO₂ ¼ line with filter

• Endoscopic vein-harvesting kit

• Lens cleaner/Elvis pack

• Sticky tape (Blue)

• 1 litre saline pack with towel/kidney dish

• 20ml syringe

• Loban/plain steridrape for the groin and leg.

Heparin administration

An intravenous bolus of 5000 IU heparin should be administered systemically just a few minutes before sealing the skin incision port, to reduce the intraluminal clot strand formation inside the vein during CO₂ insufflation (Raja & Sarang 2013).

Local policy:

All patients to be given 5000 IU heparin, except patients who received anticoagulation until their surgery (e.g. aspirin etc). These patients are given a reduced amount – 2500 IU heparin.

Procedure:

Find the vein just below the knee before opening any kit.

• Open all the disposables; connect the camera with the light cable to the stack system. Cover the camera lead with the camera drape.

• White balance the camera before using it.

• Place the saline pack with the towel under the patient’s knee and drop the leg end of the table to provide more room for the endoscopic vein-harvesting scope.

• Expose more vein and insert the camera scope system inside the leg. Check the CO₂ on 12mmHg pressure and close the incision site with the port and inject 10-15ml of air into the side port.

• Once the tunnel opens-up with CO₂, dissect the vein with the cone anteriorly, posteriorly and sideways.

• Change the tip of the cone to the normal camera tip and mobilise the vein with the C-hook and dissect the branches with the haemoprobe.

• Once the vein is completely mobilised check with a C-hook, ligate the distal and proximal end of the vein with a ligaclip and cut it out. Alternatively, make a small skin incision on the thigh area just above the vein, locate the vein and dissect it.

• Insert the vessel cannula on the proximal end of the vein and gently inject heparinised blood, tie all the branches with 4/0 vicryl ties and transfer into the heparinised blood pot.

• Check for any bleeding in the wound site. If satisfactory, insert a leg drain and do the normal closure of the incisions with 2/0 vicryl and 3/0 vicryl to the skin.

• Apply a small dressing, and pressure bandage from the ankle to the thigh.

Disposal of the equipment:

• Sharp items to the sharp bin.

• Telescope, lead cable, diathermy to sterilisation department.

• Stack system and camera to be cleaned or wiped with soap and water and transferred to the proper place.

Preparation of left internal mammary artery

• The left internal mammary artery (LIMA) is prepared. For this we need to give two mosquito forceps and backward/forward cutting scissors and fine forceps.

• Papaverine is prepared for LIMA: a 30mg ampule in 30ml of normal saline.

• A Papaverine-soaked swab and injection is given to the surgeon in 10ml syringe on blue/orange/ IMA needle/jelco. (Papaverine is antispasmodic; it is also used to dilate the artery.) Some surgeon’s spray the Papaverine on the artery.

• Note: Not all surgeons use Papaverine; some use Nitroglycerin or Nitroprusside or no vasodilator.

• Once the vein and the IMA have been checked, the patient is commenced on bypass, the aorta is cross-clamped, cardioplegia is given and the patient is cooled down.

• Pass cold wet swabs to the surgeon using the Debakey forceps. Cold wet swabs are put behind the heart to retract it.

Bottom-end coronary grafting

• Give No. 15 knife and fine Debakey to mark the coronary site.

• Give forward-cutting scissors, backward-cutting scissors, followed by 7/0 or 8/0 stitch mounted on Castro needle holder and fine forceps (Ring tip, Gerald, top-end forceps according to surgeon’s preference).

• This process is repeated till we graft all the bottom ends and then we start with the top ends which are grafted on the aorta.

Top-end coronary grafting

• Give Lambert-Kay clamp or side biting clamp to clamp the aorta. It is important to tell the perfusionist to go on half flow while applying the clamp and then go back to full flow to the patient. This is vital; otherwise there is a chance of aortic wall injury when it is full flow of blood in the aorta. It is difficult to apply a clamp on the tense/pressurised aorta.

• Give No. 11 knife and top end forceps, followed by mosquito and then aortic punch to make a hole on aorta.

• Give 6-0 stitch mounted on the Boss needle holder and top end forceps.

• This procedure is repeated till we finish grafting all the top ends.

• Give 26-gauge needle (commonly known as orange or brown needle), mounted on mosquito, to remove the air from the vein graft.

• The patient is warmed up slowly and all the grafts are checked for bleeding. If everything is fine, the patient is weaned off bypass.

• Pass tubing clamp to clamp the venous pipe, followed by a No. 11 knife or scissors to cut the secured ties. Then the venous pipe is removed from the right atrium.

• Protamine is given to reverse the action of heparin. As we are waiting for the pressure to come down, to take the aortic pipe out, the drains are inserted into the chest cavity and the chest is checked for any bleeding.

• Once everything is done, the aortic pipe is taken out.

• Give the No. 11 knife/Metzenbaum scissors to cut the ties and the tubing clamp. The aortic pipe is out.

Chest drain insertion

• Pass the No. 23 knife to make a small cut on the skin. Give a big No. 1 Soft Silk to the surgeon to take a drain stitch. (Some surgeons use 1 silk and 1 nylon stitch.)

• Pass the Roberts clamp and drains.

• Once the count (swabs/needles/instruments) is done; and having ensured that there is no bleeding and the mammary bed is fine, the sternum is closed using sternal steel wires, which are mounted on the sternal needle holder commonly known as a twister. The end of the wire is mounted on the straight Spencer Wells, then this is passed to the surgeon.

Normally 3–4 sternal wires are taken, depending upon the weight of the patient. Wire holes are checked for bleeding and then the wires are crossed and tightened.

• Pass the twister to fix the wires.

• Once the chest is closed, give 1 Vicryl stitch on the Stille needle holder and Bonney’s tooth forceps to stitch the muscles.

• Antiseptic Betadine or normal saline (optional) is given to put on the side of the wound.

• Give 3-0 Monocryl on a straight needle for the skin closure.

• Clean the wound with a saline wet swab, then wipe it with a dry swab and dress the wound.

Step-by-step procedure for assisting valve surgery