Off-Pump Coronary Artery Bypass Grafting Surgery through Manubrium Sparing Mini-Sternotomy

Abstract

The importance of off-pump Coronary Artery Bypass Grafting (CABG) surgery through manubrium sparing mini-sternotomy was presented in this article under the light of previous literature and our own technique was mentioned on the basis of an operated case. Off pump CABG surgery with manubrium sparing mini-sternotomy is a plausible choice of surgical treatment for the suitable patients and leads to fast recovery in the postoperative period due to lesser surgical trauma. All of these outcomes will result in the lower cost of hospitalization and higher patient’s satisfaction.

Keywords: Coronary; Sternal; Bypass; Cardiac surgery; Incision; Quality of life

Introduction

Coronary artery bypass surgery which has been changing and progressing very rapidly since 1960s, has come to a point that could not be foreseen at the onset of its history. While in those days, the questions which techniques and which grafts need to be used couldn’t be duly answered [1] and much earlier, in 1910, while Alexis Carrel reported a negative report that would discourage other surgeons to perform this surgery [2], whereas today’s surgeons are now pursuing the questions of what the smallest incision is, how much little invasive it is, and how much cheap and successful the coronary bypass surgery can be done. For example, robotically assisted minimally invasive coronary bypass surgeries are no longer a freak for anyone [3].

On the other hand, when considering the increasing population rate and increasing number of patients today, it is also important that any surgical method has to be as cost effective as less invasive. From this point of view, it is a bit of imagination to hope that the robotic surgeries will become widespread all around the world. The biggest obstacle in this regard is the equipment, requiring high cost and therefore only a limited number of surgeons can have sufficient experience in this area.

For all these reasons, the main objective should be to develop and disseminate surgical methods that are less invasive than open heart surgery but less expensive than robotic surgery.

In this article, we aimed to present our technique in which it’s possible to do smaller skin incision with the sparing of manubrium.

The Short Communication on the Basis of a Patient

When the literature is reviewed, it is possible to see different alternative surgical methods including mini-sternotomy in the surgical treatment of different cardiac diseases in order to achieve this aim. Alternative incisions for aortic or mitral valve diseases, proximal aortic aneurysms or dissections, coronary artery diseases, some congenital heart diseases or some mandatory applications due to special conditions like tracheal stoma can be seen [4-10].

Among these applications, we hereby want to especially present our surgical method on the basis of one of our patients by comparing it to the report [6] of Su and coworkers. According to the report of Su and coworkers, they developed a new surgical method, which is an off-pump coronary artery bypass approach with lower distal ministernotomy (TM-OPCAB) for multivessel coronary revascularization. They compared two different groups to each other. The first group underwent TM-OPCAB and the second group underwent Standard Off-Pump Coronary Artery Bypass Surgery (S-OPCAB).

After completing their research, they found significantly shorter periods on ventilation, shorter postoperative in-hospital stays and lower blood transfusion rates in the group of TM-OPCAB. In order to measure graft patency rates, they measure transit-time flow measurement and they observed that there was no significant difference in postoperative graft patency between both groups. They also analyzed that overall survival, the percentage of patients freed from major adverse cardiac, and cerebrovascular events were similar between both groups. When compared to the results of S-OPCAB patients, these successful results including postoperative clinical superiorities of the TM-OPCAB patients resemble the results of previous articles in the literature about mini-sternotomy or other minimal invasive coronary bypass surgeries.

In their method for the patients in the TM-OPCAB group, an approximately 14cm midline skin incision was made. The mean length of the skin incision in the patients in the TM-OPCAB group was 15.0cm and 22.6cm in the S-OPCAB group.

Precisely at this point, we herein want to present one of our patients who underwent off-pump coronary artery bypass surgery through a mini-sternotomy incision, and want to mention about the difference of our surgical technique.

A 67-year-old male patient underwent off-pump coronary artery bypass grafting surgery through mini-sternotomy incision for single- vessel coronary artery disease in our center (Left Internal Thoracic Artery (LITA) to left anterior descending coronary artery). The operation was planned and performed by the first author (IA) of this article. As seen in (Figure 1) which was taken in his postoperative period, the skin incision was only 9cm. Total length of his sternum is 23cm as seen between the index fingers of the nurse in the same photograph.

    

    

    Figure 1:  A postoperative photograph of our patient who underwent off-pump
coronary artery bypass grafting surgery through a mini-sternotomy incision.
Please note that the length of the incision is only 9cm. It would be a 23-cmlength
incision, if his sternum was totally incised as indicated by the index
fingers of the nurse.