- Technique Overview
-
Procedure Video
- Introduction with Dr. Joseph McGinn (:20)
- 8Set-up and Incisions (1:52)
- 9MICS Retractor Insertion (1:15)
- 10 IMA Harvest (2:15)
- 11 Aorta Preparation for Proximal Anastomosis (5:22)
- 12 Proximal Anastomosis (2:25)
- 13 Pericardial Dissection and Positioning of Starfish® NS (3:24)
- 14 Attachment and Placement of Octopus® Nuvo for
Distal Anastomosis (6:30) - 15 LIMA-LAD Anastomosis (4:38)
- 16 Closing the Pericardium and Checking Distals (:47)
- 17 Post-Op Care Guide (:49)
- 18 Pain Management (1:43)
- Comprehensive MICS CABG Technique Overview (PDF)
Indications, Safety, and WarningsCaution: Federal law (USA) restricts this device to sale by or on the order of a physician. For a listing of indications, contraindications, precautions, and warnings, please refer to the Instructions for Use.
1. Instruments and Disposables
- ThoraTrak® MICS Retractor System
- Octopus® Nuvo Stabilizer
- Starfish® NS Positioner
- U-CLIP® Anastomotic Device
- Mounting System for Octopus® Nuvo and Starfish® NS
- Rultract® with Skyhook Retractor
- Optional Rotating Extender Bar with Cross Square (Rultract®)
- Small and Medium Endoscopic Clip Appliers
- Knot Pusher
- Minimally Invasive (MI) Needle Holder
- Minimally Invasive Curved Scissors
- Minimally Invasive Debakey Forceps
- 14" Chest Tube Passer w/ Lock
- Tangential Occlusion Clamp - 34 mm w/ DeBakey Atraumatic Jaws, Slightly Curved
- DeBakey Aorta Clamp - Full Curved DeBakey Atraumatic Jaws, Curved Shanks, Stainless Steel, 10.5 inch
- Soft Tissue Retractor
- 16 and 18 Fr Red Rubber Catheter
- Extended Bovie Blade
- Biomedicus® Femoral Cannula - Arterial
- Biomedicus® Femoral Cannula - Venous
- Pain Pump
- Standard Off-Pump CABG tray
Indications, Safety, and WarningsCaution: Federal law (USA) restricts this device to sale by or on the order of a physician. For a listing of indications, contraindications, precautions, and warnings, please refer to the Instructions for Use.
*Medtronic products in bold. Rultract is a registered trademark of Rultract. Used without permission.
2. Patient Selection/Inclusion Criteria
- Coronary Anatomy
- Left main coronary artery disease (CAD) with normal right coronary artery (RCA)
- Triple vessel disease with medium to large posterior descending artery (PDA)
- Complex proximal left sided lesions with or without large branch involvement
- Previous unsuccessful stenting
- Co-Morbidities: Includes patients who are at a high risk for problems with median sternotomy
- Long-term steroid use
- Severe chronic obstructive pulmonary disease (COPD)
- Advanced age
- Need for other major operative procedure
- Severe deconditioning
- Patients with arthritic or orthopedic problems
- Patients who want the procedure, are active, and seek out less invasive surgery options
3. Contraindications
- Contraindications
- Emergency cases
- Patients with hemodynamic instability
- Potential Contraindications
- Previous CABG surgery
- Morbid obesity
- Patients with postero-lateral branch disease
- Ejection Fraction < 20%
- Patients with peripheral vascular disease (PVD)
- Moderate to severe aortic insufficiency
4. Patient Positioning
- Position patients in a 15° to 30° right lateral decubitus position (supine), with the right arm extended to allow harvest of the radial artery, if applicable.
- Place a roll longitudinally between the left scapula and spine.
- Drape the patient to allow access to the left groin and right thigh/leg for femoral cannulation (if needed) and saphenous vein harvest, respectively.
- Slightly drape the left elbow from the patient's side to expose the patient’s left lateral thoracic wall.
- The patient's iliac crest (top of the hip bone) should be near the flex break in the table, and the patient is placed in a slightly reversed Trendelenburg position.
5. Anesthesia
- Single-lung ventilation is required in off-pump MICS CABG procedures.
- If pump assistance is used, both lungs can be deflated. However, note that deflating both lungs moves the heart away from the surgeon.
- Perform intubation with either a double or single lumen oral endotracheal tube and a left bronchial blocker to deflate the left lung. The single lumen oral endotracheal tube and bronchial blocker are placed under fiber-optic guidance.
- Place one external defibrillator pad high over the left scapula and one inferior to the right breast extending medially to the nipple line.
- Vasopressors, such as phenylephrine and norepinephrine, and vasodilators, such as nicardipine and nitroglycerine, should be available to control blood pressure during proximal anastomosis.
- A standard IV drip setup that includes: nitroglycerine, phenylephrine, norepineprine, vasopressin, insulin, and nicardipine is recommended.
- An airway cart with a fiber optic bronchoscope is recommended for placement of a bronchial blocker.
- Lines are routine and include an arterial line and PA catheter. If peripheral access is limited, at least a 16 gauge IV should be placed. A triple lumen catheter is placed along with the PAC – "double stick".
- After intubation, place a bronchial blocker into the left mainstem bronchus with fiber optic guidance. Place the proximal end of the balloon approximately 1 cm to 2 cm below the carina.
- Single-Lung Ventilation:
- Deliver approximately 10 cc/kg of tidal volume prior to and during single-lung ventilation. The tidal volume may need to be decreased with single-lung ventilation because a large tidal volume causes shifting of the mediastinum, which may cause the MICS retractor to slip.
- Keep the O2 saturation greater than 90%. If the saturation begins to decrease:
- Add CPAP of 5 cm H2O to the deflated lung. This can be performed through the bronchial blocker by inserting a 7 ETT connector into the barrel of a 3 cc syringe. Insert the syringe tip into the lumen of the bronchial blocker. Attach the 7 ETT connector to a CPAP circuit.
- CPAP can be increased, but if it is increased too much it will cause the lung to inflate and obscure the surgeon's view.
Indications, Safety, and WarningsCaution: Federal law (USA) restricts this device to sale by or on the order of a physician. For a listing of indications, contraindications, precautions, and warnings, please refer to the Instructions for Use.
Indications, Safety, and WarningsCaution: Federal law (USA) restricts this device to sale by or on the order of a physician. For a listing of indications, contraindications, precautions, and warnings, please refer to the Instructions for Use.
Indications, Safety, and WarningsCaution: Federal law (USA) restricts this device to sale by or on the order of a physician. For a listing of indications, contraindications, precautions, and warnings, please refer to the Instructions for Use.
Indications, Safety, and WarningsCaution: Federal law (USA) restricts this device to sale by or on the order of a physician. For a listing of indications, contraindications, precautions, and warnings, please refer to the Instructions for Use.
Indications, Safety, and WarningsCaution: Federal law (USA) restricts this device to sale by or on the order of a physician. For a listing of indications, contraindications, precautions, and warnings, please refer to the Instructions for Use.
Indications, Safety, and WarningsCaution: Federal law (USA) restricts this device to sale by or on the order of a physician. For a listing of indications, contraindications, precautions, and warnings, please refer to the Instructions for Use.
Indications, Safety, and WarningsCaution: Federal law (USA) restricts this device to sale by or on the order of a physician. For a listing of indications, contraindications, precautions, and warnings, please refer to the Instructions for Use.
Indications, Safety, and WarningsCaution: Federal law (USA) restricts this device to sale by or on the order of a physician. For a listing of indications, contraindications, precautions, and warnings, please refer to the Instructions for Use.
Indications, Safety, and WarningsCaution: Federal law (USA) restricts this device to sale by or on the order of a physician. For a listing of indications, contraindications, precautions, and warnings, please refer to the Instructions for Use.
Indications, Safety, and WarningsCaution: Federal law (USA) restricts this device to sale by or on the order of a physician. For a listing of indications, contraindications, precautions, and warnings, please refer to the Instructions for Use.
17. Post-Op Care Guide
- Extubation is usually achieved 2-6 hours after surgery.
- Pain management: Pain pump
- Start patients on daily enteric-coated 325 mg aspirin on the day of the operation.
- Resume clopidogrel, 75 mg, in patients with coronary stents.
- Unless contraindicated, resume antihypertensive medications on the first postoperative day.
- Patients undergoing MICS CABG with a radial artery graft are prescribed dihydropyridine calcium channel blockers for 6 months.
- Post-op Day 1
- Patient ambulating and all drains out
- Evaluate discharge needs and prepare for discharge
- Transfer to telemetry
- Bedside exercise, ambulate with assistance
- Post-op Day 2 and Beyond
- Ambulate with minimal or no assistance
- Evaluate for discharge
- Ad-lib activities
- Visiting nurse referral
- At Home
- No physical restrictions
- Remove pain pump as instructed
18. Pain Management
- After protamine administration, 2 soaker catheters can be placed:
- One subpleura
- One subcutaneous
- Catheters remain in place per pain pump instructions.
- Administer Marcaine® in a .25% dosage level
Indications, Safety, and WarningsCaution: Federal law (USA) restricts this device to sale by or on the order of a physician. For a listing of indications, contraindications, precautions, and warnings, please refer to the Instructions for Use.