Cardiovascular Surgery Aortic Valve replacement

Aortic Valve Replacement (AVR)

Objective

•   To open chest 

•   To expose the heart 

•   To replace the aortic valve. 

Position

•   Supine

•   Catheterization

•   Cleaning and draping.

Anesthesia

General, endotracheal. 

Procedure

   1.  Sternotomy—skin incision with No. 20 blade.

   2.  Saw and cable for sternotomy.

   3.  Pericardiotomy—pericardiotomy with cautery. 

   4.  Pericardial stay 0 1.0 or 2.0 atro silk. 

   5.  Aortic purse string 3.0 T3 single arm suture (2). 

   6.  SVC purse string and cannulation—Cooley clamp, open the SVC insert cannula, remove the clamp, silk tie, connect with venous line. 

   7.  Aaortic cannulation—insert cannula connect the cannula, Bypass on. 

   8.  Cool the patient.

   9.  Aortic cross clamp—No. 11 knife Pott’s for opening the aorta. 

10.  Perfuse left and right coronary. 

11.  Mayo retractor. 

12.  Aortic valve stay 2.0 Ethibond 1/2 pieces. 

13.  Valve is excised. 

14.  Sizer used to measure.

15.  Valve fixed with holder and implanted 2.0 ethibond
17 mm 1/2. 

16.  Closing the aorta 4.0 prolene 3 sutures. 

17.  Cardioplegia cannula for air removal.

18.  Decannulation.

19.  Drainage tubes.

20.  Sponge and instruments count.

21.  Sternotomy closed No. 5 Ethibond.

22.  Muscle 2.0 Vicryl.

23.  Skin 3.0 prolene.

Instruments

•   Cleaning tray 

•   Catheterization set

•   Cardiac set

•   Open heart vascular set

•   Open heart special set

•   Open heart water seal. 

Special Instruments

•   Mayo’s retractor

•   Coronary cannulae (perfusion) 

•   Valve sizer and holder.

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Cardiovascular Surgery Mitral valve replacement

Mitral Valve Replacement (MVR)

Objective

•   To open chest

•   To expose heart

•   To replace the mitral valve.

Position

•   Supine, left semilateral

•   Catheterization

•   Cleaning and draping.

Anesthesia

General, endotracheal.

Procedure

   1.  Sternotomy—skin incision with No. 4 BP handle with No. 20 blade. Rake for holding the skin. Saw and cable for sternotomy.

   2.  Pericardiotomy—pericardiotomy with cautery.

   3.  Pericardial stay 1-0 or 2-0 Atro silk.

   4.  Aortic purse string 3.0 T3 single arm suture (2), followed with snugger and clamped.

   5.  SVC purse string and cannulation—Cooley clamp, scissors for opening the IVC 4/0 CII. S/A followed with snugger and snap.

   6.  Insert IVC cannula, remove the Cooley clamp.

   7.  IVC purse string—4/0 CII, S/A and cannulation—Cooley clamp, open the SVC insert cannula remove the clamp silk tie.

   8.  Aortic cannulation—ready for cannula No. 11 knife for hole in the aorta insert cannula, silk tie; connect the cannula.

   9.  Connect venous lines with SVC and IVC cannula. Aortic cannulae to arterial line.

10.  Cardioplegia purse string and cannulation—cardioplegia cannula, cardioplegia cooling starts.

11.  Aortic cross clamp—after giving cardioplegia the heart stop. 11 No. knife long scissors, open the left atrium, LA retractor, mitral hook. Hang right angle for holding the valve, valve cutting scissors, to excise valve, sizer to measure the valve, take the valve holder and valve, then suture 2.0 Ethibond, LA closure 1st 3.0 Prolene No. 8 Folley’s to check the mitral valve.

12.  Decannulation IVC and SVC cannula taken out and stitched.

13.  Cardioplegia cannula is removed. Aortic cannula is also removed. Aorta stitch 4.0 T3.

14.  Pacing wires—2 pacing wire.

15.  Drainage tubes.

16.  Sponge and instruments count.

17.  Sternotomy closure.

18.  Ethibond.

19.  Muscle

20.  2.0 Vicryl.

21.  Skin 3.0 prolene.

Instruments

•   Cleaning tray

•   Catheterization set

•   Cardiac set

•   Open heart vascular set

•   Open heart special set

•   Open heart water seal.

Special Instruments

•   11 No. knife long handle

•   Nelson scissors

•   Mitral hooks 2

•   Left atrial ret.

•   Long DeBakey needle holder

•   Valve sizers and holder.

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Cardiovascular Surgery Mitral valve Repair

Mitral Valve Repair

Objective

•   To open chest 

•   To repair the mitral valve in mitral regurgitation. 

Position

•   Supine or left lateral 

Anesthesia

General.

Procedure

   1.  Catheterization. 

   2.  Cleaning and draping. 

   3.  Skin incision.

   4.  Saw and cable for mid-sternotomy incision.

   5.  Pericardiotomy and pericardial stay suture 2/0 silk. 

   6.  Aortic purse string 3/0 T3 Tevdek followed by snugger. 

   7.  SVC purse string 4/0 CII followed by snugger IVC cannulae. 

   8.  Aortic cannulation with 11 No blade and aortic cannu­lation, connect the cannulae with arterial line. 

   9.  IVC purse string 4/0 with snugger and IVC cannulae, connect venous cannulae with venous line. 

10.  Cool the patient. 

11.  4/0 T3 Tevdek followed by cardioplegic cannulae.

12.  Aortic cross clamp, open LA with No. 11 long knife with long scissors. LA retractor, hard felt with valve sizer to take size. 9 sutures of 2/0 T3, Tevdek DA to repair the valve with felt. 32 or 36 Portex to check the valve. LA closure 3/0 prolene. 

13.  Decannulation, BP, heart rate, ECG maintained. 

14.  Pacing wires.

15.  Chest drainage tubes.

16.  Control hemostasis. 

17.  Sponge and instruments count.

18.  Sternal closure.

19.  Muscle and subcuticle closure.

20.  Dress with betadine.

Instruments

•   Cleaning tray 

•   Catheterization set 

•   Cardiac set 

•   OH special set 

•   OH vascular set 

•   OH water seal pkt. 

Special Instruments

•   Left atrial set

•   Mitral hooks 

•   11 No. knife long handle 

•   Valve sizers

•   Hard felt.

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Cardiovascular Surgery VSD Correction

Ventricular Septal Defect (VSD)

Objective

•   To open chest 

•   To close a defect (hole) in the ventricular septum. 

Position

•   Supine

Anesthesia

General, endotracheal.

Procedure

   1.  Catheterization. 

   2.  Cleaning and draping. 

   3.  Skin knife No. 3 or 4 BP handle with No. 10 to open the skin, cutting cautery sponge. 

   4.  Saw and cable for opening the sternum. 

   5.  Pericardial; Pericostal stay suture. 

   6.  Loop the SVC and IVC. 

   7.  Aortic purse string IVC and SVC purse string. 

   8.  5.0 Prolene 13 mm or 16 mm double arm, 3/0 T3 or 4/0 T3 sutures snugger, 4/0 T3 suture snugger. 

   9.  Aortic cannulation, scissors and No. 11 knife insert cannula, exhaust with arterial line. 

10.  SVC cannulation, scissors; open SVC, pass the SVC cannula, connect the cannula to venous tubing. 

11.  IVC cannulation clamp, No. 11 knife and scissors. 

12.  Open the IVC, put the IVC cannula, connect the cannula to venous line. 

13.  Cardioplegia purse string and cannulation. 

14.  4/0 T3 single arm Tevdek suture. 

15.  RA stay 4.0 T3 - VSD retractors; VSD suture, 6 to 8 pledget sutures with VSD Decron patch. RA closure 5/0 Prolene.

16.  Pacing wire. 

17.  Open the PA. See PV, PA closure.

18.  PA closed 6/0 prolene.

19.  Remove the cardioplegia cannula. 

20.  Decannulation.

21.  Close the SVC, IVC with 5-0 prolene pieces. 

22.  Remove the aortic cannula; stitch 4.0 T3.

23.  Drainage tube sponge and instruments count. 

24.  Sternum closure after all counts. 

25.  No. 2 ethibond.

26.  Muscle closure No. 3/0 Vicryl. 

27.  Skin 4.0 surgilene.

Instruments

•   Cardiac set 

•   Open heart special set 

•   Open heart vascular set 

•   Open heart water seal 

•   Pediatric set.

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Cardiovascular Surgery Coarctation Aorta correction

Coarctation of Aorta (Pediatric)

Objective

In case of narrowing of the distal segment of the aortic arch:

•   To open chest  

•   To expose the site of narrowing 

•   Relieving obstruction to blood flow in the descending aorta. 

Position

•   Right lateral position with left arm stretched above the head. 

Anesthesia

General, endotracheal.

Procedure

   1.  Cleaning and draping. 

   2.  Operation for left thoracotomy. 

   3.  BP handle No. 3 with No. 10 skin blade attached to it. 

   4.  Finochietto chest retraction with small sized (No. 2) blades attached to it. 

   5.  Pleural stay - 3-0 on 4-0 atro silk. 

   6.  Straight Mosquito’s clamp to be given for stay suture. 

   7.  Small aortic (angled) clamps to be given. If infant use Castaneda clamps for the aorta.

   8.  Clamps to be placed above and below the coarctation. 

   9.  Operation of coarctation of aorta usually is done by direct end to end anastomosis by resecting the narrow area of the aorta. 

10.  Occasionally a tubular dacron prosthesis or similar graft is required to bridge the gap. 

11.  Pleura to be sutured with 3-0 or 4-0 atro silk loaded on a Sarrot NH. 

12.  Sponge, gauze pieces and instruments count. 

13.  Insertion of chest tube in the pleural cavity. 

14.  Chest closure. 

Instruments

•   Cleaning tray 

•   Cardiac set 

•   Pediatric set 

•   Water seal set 

•   PDA set (above 5 years)

•   Castaneda vascular clamps 

•   Gemini right angle clamp

•   Castroviejo needle holders.

Any questions be sent to drmmkapur@gmail.com  

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Cardiovascular Surgery ligation PDA

PDA Ligation

Objective

•   Open chest

•   Suture ligation of patent ductus arteriosus.

Position

Right lateral (Left side up).

Anesthesia

General, endotracheal.

Procedure

   1.  Skin incision No. 3 BP handle with No. 10 blade.

   2.  Separation of muscle, Zerney’s retractor and Morris retractor.

   3.  Rib separation with cautery.

   4.  Finechietto retractor with small blade.

   5.  Exposure of ductus.

   6.  Right angle and silk-2, to tie the ductus.

   7.  Pleural closing 4.0 Atrosilk.

   8.  Chest drainage tube.

   9.  Pericostal and closure 0-catgut on round body needle.

10.  Muscle closing 3.0 Vicryl or 3.0 Dexron.

11.  Dressing with betadine.

Instruments

•   Cardiac set as in pericardiectomy.

•   Bailey Glovers PDA clamps, 2 set     

•   DeBakey angled clamp small, 1 set  In case PDA to be

•   DeBakey angled clamp curved, 1 set       sutured.

•   Cooley clamp, 1 set                            

•   Harken clamp, 1 set

•   Ligature carrier, 1 set

•   Scissors Metzenbaum, 1 set

•   Scissors Pott’s 7", 1 set

•   Debakey needle holder 7", 1 set

•   Bailey needle holder 8", 1 set

•   Retractor, malleable, small, 1 set

•   Debakey dissecting forceps 7", 3 set

•   Morse Andrews suction tip big, 1 set

•   Morse Andrews suction tip small, 1 set

•           Gemini right angle clamp, 1 set.

Any questions be sent to drmmkapur@gmail.com

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Cardiovascular Surgery repair ASD

Atrial Septal Defect Closure (ASD)

Objective

•   To open chest

•   To close a defect (hole) in the atrial septum.

Position

•   Left semilateral/supine.

Anesthesia

General, endotracheal.

Procedure

   1.  Catheterization: Cleaning and draping.

   2.  Skin incision with No. 4 BP handle with No. 20 blade.

   3.  Saw and cable for sternotomy.

   4.  Pericardiotomy: Stay suture 2/0 At. silk.

   5.  Loop the SVC and IVC.

   6.  Keep ready for venous tubing, aortic tubing and cardio­plegia tubing.

   7.  Aortic purse string 3.0 T3 single arm suture (2) cannulated.

   8.  IVC purse string and cannulation.

   9.  SVC purse string and cannulation.

10.  Aortic cannulation No. 11 knife for hole in the aorta. Insert cannula, silk tie. Connect the venous and arterial line in SVC and IVC.

11.  Cardioplegia stitch 4.0 T3 single arm, arterial line, scissors, snugger medium snap, cardioplegia cannula, silk tie.

12.  Scissors for opening the RA.

13.  Direct closure 4.0 T3 stitch or Dacron patch 4/0 Surgilene.

14.  RA closure 5/0 Prolene.

15.  Decannulation, Pacing wire.

16.  Drainage tube.

17.  Sponge and instruments count.

18.  Sternum closure—muscle and subcutaneous.

Instruments

•   Cleaning tray

•   Catheterization set

•   Cardiac set

•   Open heart vascular set

•   Open heart special set

•           Open heart water seal.

Any questions be sent to drmmkapur@gmail.com

All older posts are stored in archive for accessand reiew

Thosewho follow may post contributions to the site,please writo tp address above.

To create consumer/provider enagement visit www.surginstruatlas.blogspot.com

www.drmmkapur.blogspot.com                 www.surgseminar.blogspot.com

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