DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Unstable angina.
2. Severe calcific triple-vessel coronary artery disease with critical left main coronary artery stenosis with total occlusion of the right coronary artery.
POSTOPERATIVE DIAGNOSES:
1. Unstable angina.
2. Severe calcific triple-vessel coronary artery disease with critical left main coronary artery stenosis with total occlusion of the right coronary artery.
OPERATIONS PERFORMED:
1. Urgent double bypass surgery.
2. Surgical myocardial revascularization using a reverse autologous greater saphenous vein as the aortocoronary conduit bypassing the ramus intermedius coronary artery and using a left internal mammary artery as a conduit to bypass the left internal descending coronary artery with endoscopic vein harvest techniques.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
DESCRIPTION OF OPERATION: The patient was brought to the operating suite and placed in the supine position. After satisfactory induction of general endotracheal anesthesia, the patient was prepped and draped in the usual sterile fashion and the greater saphenous vein was harvested from the left leg using endoscopic vein harvest technique. The tributaries of the vein were divided and ligated and the wounds were closed in layers using Vicryl sutures. A median sternotomy incision was made. The sternum was opened carefully using the electric saw. The pericardium was opened and suspended. The left internal mammary artery was harvested as a pedicle up to the level of subclavian vein and placed in a papaverine-soaked sponge, at which time we heparinized the patient using 4 mg/kg of heparin. This was allowed to circulate. The aorta and right atrium were cannulated in routine fashion. The patient was placed on extracorporeal circulation and systemically cooled. The aorta was gently cross-clamped. Cold blood cardioplegia was used to arrest the heart. This was repeated every 15 minutes and as needed to maintain hypothermic diastolic arrest. Topical coolant was also maintained using iced saline solution to the pericardial well.
Reverse autologous greater saphenous vein was used for the aortocoronary conduit bypassing the ramus intermedius coronary artery. The distal anastomoses were fashioned using running 7-0 Prolene suture. Proximal anastomosis to the aorta using running 6-0 Prolene suture. The left internal mammary artery was then anastomosed in an end-to-side fashion to the left anterior descending coronary artery using a running 8-0 Prolene suture. The pedicle then tacked to the epicardium using a 6-0 Prolene suture. The procedure was performed under one cross-clamp.
The patient was then systemically rewarmed. The heart started to spontaneously beat. Once everything was satisfactory, the patient was easily weaned from cardiopulmonary bypass without difficulty. Protamine sulfate was given to reverse the heparin and the patient was decannulated. Cannulation sites were next reinforced. Warm antibiotic saline solution was used for irrigation. Attention was then directed at closing. Mediastinal and pleural tubes were placed. The sternum was closed using sternal wire. The fascia, skin and subcutaneous tissues were approximated using Vicryl sutures. Dressings were applied and 0.25% Marcaine was used as a parasternal block. The patient tolerated the procedure well and was sent to the cardiovascular intensive care unit in stable condition.
