DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Coronary artery disease.
POSTOPERATIVE DIAGNOSIS: Coronary artery disease.
PROCEDURES PERFORMED:
1. Endoscopic vein harvesting.
2. Coronary artery bypass grafting x4 (left internal mammary artery to left anterior descending, saphenous vein graft sequentially to obtuse marginal 1 and obtuse marginal 2, saphenous vein graft to posterior descending artery).
SURGEON: John Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed supine on the operating table. General anesthesia was induced without complication. The patient was prepped and draped in the usual sterile fashion. Preoperative antibiotics had been appropriately completed. The right greater saphenous vein was harvested endoscopically, and the wound was closed with 0 Vicryl and 3-0 Vicryl suture and a 4-0 Monocryl running subcuticular closure. Simultaneously, a median sternotomy was performed and the left internal mammary artery dissected off the anterior chest wall. It was injected with papaverine and placed in the papaverine-soaked sponge.
The pericardium was opened and a cradle raised. The 3-0 Prolene ascending aortic cannulation stitches were placed followed by a 2-0 Ethibond atrial cannulation stitch. After achieving an adequate ACT, a soft-flow aortic cannula was introduced followed by a dual-stage venous cannula. An ascending aortic cardioplegia/root vent was inserted as well as a retrograde cardioplegia cannula into the coronary sinus.
The patient was then placed on cardiopulmonary bypass and the temperature allowed to drift down to 33 degrees. An aortic cross-clamp was applied and 500 mL of cold blood antegrade cardioplegia given with prompt arrest. This was followed by an equivalent amount of retrograde cardioplegia.
Attention was turned to the inferior wall where the posterior descending artery was dissected out and opened longitudinally. The segment of saphenous vein was reversed, spatulated, and anastomosed to it in an end-to-side fashion. The proximal anastomosis was performed to the right side of the ascending aorta and an additional dose of retrograde cardioplegia was given.
Attention was then turned to the lateral wall where the second obtuse marginal branch was dissected out and opened longitudinally. The remaining saphenous vein conduit reversed, spatulated, and anastomosed to it in an end-to-side fashion. A side-to-side transverse anastomosis was constructed between the same segment of saphenous vein and the first obtuse marginal branch. An additional dose of retrograde cardioplegia was given and then the proximal anastomosis was performed to the left side of the ascending aorta.
The patient was then systemically rewarmed. The left internal mammary artery was brought through the lateral pericardium and trimmed and spatulated appropriately. It was anastomosed to the distal left anterior descending coronary artery in an end-to-side fashion. A hot-shot of cardioplegia was given, first retrograde and then antegrade. The aortic cross-clamp was removed, and there was spontaneous return of sinus rhythm. The patient was quickly and easily weaned from cardiopulmonary bypass on a low-dose dopamine. Protamine sulfate was administered without complication, and all cannulas were removed.
Cannulation sites were oversewn with 3-0 Prolene suture. The right atrial appendage cannulation site was reinforced with a heavy silk tie. After assuring adequate hemostasis, pleural as well as mediastinal chest tubes were placed in addition to a ventricular pacing wire.
The pericardium was then closed and the sternum approximated with #6 sternal wires. The wound was irrigated with warm antibiotic solution and closed in layers with 0-Vicryl and 3-0 Vicryl suture and a 4-0 Monocryl running subcuticular closure. Sterile dressings were applied. The patient tolerated the procedure well without any complications. Cross-clamp time was 78 minutes. Cardiopulmonary bypass time was 90 minutes. The patient was transferred intubated in stable condition on a dopamine drip to the cardiovascular ICU. Sponge and needle count was correct at the end of the case.
