How to construct the proximal anastomosis in MIDCABG: tips and tricks !!!#proximalanastomosis

CABG through the minimally invasive approach requires higher skills and is said to have a steep learning curve. With training and practice, I guess one can successfully perform a bypass grafting operation and in this video, I have listed some tips and tricks that I know and practice for the benefit of the viewers. Depending on the scenario described in this video, the surgeon has to change his or her strategy to effect a good proximal anastomosis. This video is only for those surgeons who use saphenous vein grafts as a conduit for CABG.

First option:
Not much fat on pericardium. open it up to the aortic reflection and put on stay sutures. The aorta will appear in view fully.

Second Option:
Open the pericardium up to its aortic reflection and divide the fat pad over it, leaving it insitu. Place the stay sutures through the fat pad. Leaving the fat-pad behind occupies some space that would have been helpful if removed for proximals. However, this is least traumatic and after stay sutures, some more fat may be divided for good view of the aorta. Post CABG, it covers the aorta and provides protection, just in case a redo has to be done.

Third Option:
Remove all fat over the pericardium unto the phrenic nerve and then open the pericardium unto its aortic reflection. This gives good room for proximals as well as lateral distals. Trick is to open the pericardium over the plastic sucker so as to avoid cardiac injury and fibrillation from diathermy ..etc.

Make sure the SVG is marked well for lie to avoid twisting and check it for leaks, adventitial constrictions, ectasias, etc.

Scenario 1:
the aorta is well seen, the pulmonary artery is not dilated or tense,and the aorto pulmonary junction is well seen.
Place a rolled large gauze piece behind the aorta to as to bring it closer to the incision. This is common to almost any scenario in midcabg proximals. Dissect the aortopulmonary area and free the aorta away from the pulmonary artery. This makes placing the side biting clamp a bit smooth.

It takes time to place the side biting clamp correctly and one has to have some patience here. The important points to see here is that the clamp is not causing after load problems to the heart, there is no aorta beyond the clamp tips and that the clamp is well supported. Applying PEEP on the R lung will also bring the heart towards the surgeon.

Scenario 2:
Gauze behind the aorta and then place the side biting clamp. The Aorto-PA area is not suitable for freeing the aorta from the pa and this helps in some set of patients.

Scenario 3;
Aorta is quite posterior and not easily accessible. After the gauze is placed behind the aorta,try placing the side biting clamp and then use the octopus to press the RVOT and MPA posteriorly to construct a good proximal
anastomosis. Makes life easier...The octopus used is the routine one used everyday.

Scenario 4:
Aorta is deep and cant be seen after thoracotomy. Place the gauze piece first. then pass the octopus Novo from outside and depress the RVOT and PA annulus down to see the aorta. Then one can free the aorta from MPA and then place the side biting clamp...this is the least traumatic I guess..

Grafting:

Orient yourself to be operating from the assistant side. Use the same technique you use for proximals through sternotomy as this will avoid any confusion. It may take some more time..so have patience..anastomotic bleeding is not good and may be difficult to control..so dont take any chances with bleeding ;
Lie of the vein graft and Cobra hood formation is important..lest the purpose will be defeated. Always check the proximals for bleeding before closing...

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