Cardiothoracic Operative Dictation

TSRA Operative Dictations in Cardiothoracic Surgery
Editors
David D. Odell, MD MMSc

University of Pittsburgh
Cardiothoracic Surgery Resident
Advanced Thoracic Surgery Fellow
TSRA President 2013-2014
Damien J. LaPar, MD MSc
University of Virginia
Cardiothoracic Surgery Fellow
TSRA President 2014-2015
Section Editors
Shawn S. Groth, MD MS
Brigham and Women’s Hospital
University of Pittsburgh
Advanced Thoracic Surgery Fellow
Thoracic Surgery Section
Michael P. Robich, MD MPH

Cleveland Clinic Foundation
Cardiothoracic Surgery Fellow
Adult Cardiac Surgery Section
Muhammed Aftab, MD
Texas Heart Institute, Baylor University
Congenital Cardiac Surgery Section
Copy Editor
Ernest G. Chan, BS
Stony Brook School of Medicine
4th Year Medical Student
Thoracic Surgery Residents Association

www.tsranet.org
TSRA Review of Cardiothoracic Surgery
Copyright © 2014 by the Thoracic Surgery Residents Association, Damien J. LaPar, David D. Odell.
TSRA / TSDA
633 N. Saint Clair Street
Suite 2320
Chicago, IL 60611
www.tsranet.org
Disclaimer
The material presented herein is to the best of our knowledge, accurate and factual to date. The text is provided as a basic
outline of a dictated description of the stated operative procedure. The text is not intended to serve as a guide for the actual
performance of the operation and this book should not be construed as a surrogate for formalized operative instruction.
Further, the descriptions contained in this book represent one safe approach to an operation. The TSRA and the authors make
no claims regarding the superiority of these described approaches relative to other operative strategies as we recognize that
alternate strategies may be safely and efficaciously employed by practicing surgeons.
All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means,
electronic or mechanical, including photocopying or the use of any information storage and retrieval system without written
permission from the copyright owners.
Cover artwork by: Carmina Mery, Ramón Mery, and Mari Pili Guzmán (age 3)
“To Kelly and Jacqueline”
- Damien J. LaPar
“To Alessia, Pietra and Wilson for your unwavering support and love.”
- David D. Odell
Foreword
With this publication, the TSRA extends its record of outstanding contributions to Thoracic Surgical
Education. It provides the reader with a concise and clearly focused overview of the steps of a given
operative procedure, and provides excellent advice on potential pitfalls of the procedure. Such pearls are
invaluable. By providing templates for the dictation of operative notes, it serves as an excellent resource for
the student of Thoracic Surgery as one learns such a large number of procedures.
This volume helps to address an important gap in Thoracic Surgical Education and once again points to the
valuable contributions that the TSRA has made to our specialty. It will go a long way in helping with the
education Thoracic Surgical Residents at all levels.
David A. Fullerton, MD
President, TSDA
Preface
The Thoracic Surgery Residents Association (TSRA) was established in 1997 under the guidance of the Thoracic Surgery
Directors Association (TSDA) to create a unified voice to represent residents during cardiothoracic surgery training. The
organization has developed as a core mission a focus on improving the quality, accessibility and utility of resident education.
In 2010, we released the TSRA Review of Cardiothoracic Surgery. This would be the first of a series of publications, written
by residents, which have sought to address areas of perceived need in cardiothoracic education. The Review provided a
series of short reference chapters introducing key knowledge and concepts in an easily digestible point-of-care format. The
book was a phenomenal success and has now been downloaded in pdf format more than 9000 times and been translated into
several languages. The TSRA followed this publication with the release in 2013 of the Primer in Cardiothoracic Surgery a
book focused on basic concepts within the field of CT surgery which form the foundation for further learning. At the other end
of the continuum of learning, the TSRA Clinical Scenarios in Cardiothoracic Surgery provided a compilation of common, high-
yield, and important scenarios which might arise in the course of a surgeon’s training or practice.
The current publication seeks to provide a resource which may be used in the surgeon’s daily practice as a resource for the
review of the major steps of an operation as well as a guide to the appropriate documentation of the conduct of that operation.
We hope that the text will be useful for both practicing surgeons and residents in training. While the list of operations included
in the text is extensive it is by no means intended to be inclusive of the entire breadth of the field of cardiothoracic surgery.
Additionally, the text provides descriptions of one approach to the operations included. We acknowledge that the approach to
a given operation may vary among surgeons, and institutions. This text is not intended to establish a uniform ‘correct’
approach, nor is it intended as a surrogate for formal residency training.
We strove to attain a high level of technical accuracy with the operative descriptions contained in this text with four levels of
peer review. Each chapter was carefully reviewed by an established faculty member, a section editor as well as the two main
editors. Our main goal was to ensure that the operative dictations contained descriptions of a safe approach to practice.
Despite this rigorous review process, the reader will likely notice differences between the described operations and the
practice in their institutions. The book is intended to be a dynamic resource and space has been left at the end of each section
for the reader to make notes highlighting their individual approach to the operation. We welcome feedback from the reader and
encourage the submission of additional operative descriptions beyond what is included in the text to David D. Odell, MD
MMSc (daviddodell@gmail.com) and Damien J. LaPar, MD MSc (dlapar@virginia.edu). We hope you enjoy the book and
find it a useful resource.
DDO and DJL

Contributors
Muhammad Aftab, MD
Baylor College of Medicine/Texas Heart Institute
Aortic Root Replacement With Homograft For Aortic Root Abscess (Native And Or Prior Bentall), Infra-Cardiac Total
Anomalous Pulmonary Venous Return (TAPVR), Aortic Coarctation Repair With Extended End-To-End Anastomosis,
Modified Blalock-Taussig Shunt (Using Interposition Gore-Tex Tube Graft), Bidirectional Glenn Procedure, Extra-Cardiac
(Non-Fenestrated) Completion Fontan Procedure, Arterial Switch Procedure, Tetralogy Of Fallot Repair - Infundibular
Sparing (Transatrial Repair), Pulmonary Valve Replacement And Reconstruction Of Right Ventricle Outflow Tract, Pediatric
Lung Transplantation: Bilateral Sequential Lung Transplantation
Magdy M. El-Sayed Ahmed, MD

Texas Heart Institute
Pediatric Lung Transplantation: Bilateral Sequential Lung Transplantation
Gorav Ailawadi, MD
Coronary Artery Bypass Grafting With Cardiopulmonary Bypass
Luis F. Alberton, MD
North Shore Long Island Jewish Health System
Laparoscopic Nissen Fundoplication
Uthman Aluthman, MD
University of Calgary
Coronary Artery Bypass Grafting With Mammary and Vein Grafts - Off Pump
Parth Amin, MD
Loyola University Medical Center
Elephant Trunk Part 1, Elephant Trunk Part 2, Endovascular Management of Acute Type B Dissection
Mara B. Antonoff, MD
Washington University
Lung Procurement, Lung Transplantation
Anelechi Anyanwu, MD, MSc, FRCS

Mount Sinai Medical Center
Repair of Post-Infarction Ventricular Septal Defect, Pulmonary Embolectomy
Nicholas Baker, MD
University of Pittsburgh Medical Center
Mediastinoscopy
Jamil Bashir, MD
St. Paul’s Hospital
Biatrial Cox-Maze Ablation for Atrial Fibrillation, Permanent Pacemaker Insertion
Kfir Ben-David, MD
University of Florida
Esophageal Stent Placement
Thomas Birdas, MD
Indiana University School of Medicine
Open Thoracostomy (Eloesser Flap and Clagett Window)
Mark Bleiweis MD
Repair of Partial Anomalous Pulmonary Venous Return
Andrew I.M. Campbell

British Columbia's Children's Hospital
Ventricular Septal Defect: Perimembranous, Completion Lateral Tunnel Fontan, Ross Procedure for the Correction of
Congenital Aortic Stenosis
Thomas Caranasos MD
Repair of Partial Anomalous Pulmonary Venous Return, Esophageal Stent Placement
Stephen D. Cassivi, MD, MSc

Mayo Clinic
Transcervical Thymectomy
Mohiuddin Cheema, MD
Cedars Sinai Medical Center
Endovascular Repair of Descending Thoracic Aortic Aneurysm (TEVAR)
Frederick Y. Chen, MD, PhD

Aortic Valve Replacement for Aortic Insufficiency Or Aortic Stenosis
Jordy C. Cox, MD
University of California San Francisco
Open Ivor-Lewis Esophagectomy
Jonathan D'Cunha, MD, PhD

Tracheostomy
Joseph A. Dearani, MD
Mayo Clinic
Repair of Obstructive Hypertrophic Cardiomyopathy: (Septal Myomectomy), Cone Repair for Ebstein Malformation
Daniel T. DeArmond, MD
University of Texas Health Science Center
VATS Evacuation of Hemothorax
Walter F. DeNino, MD
Medical University of South Carolina
Valve Sparing Root Replacement, Carinal Pneumonectomy
Chadrick E. Denlinger, MD
Carinal Pneumonectomy
Jessica S. Donington, MD
New York University School of Medicine
Chamberlain Procedure, Trans-sternal Thymectomy
Desmond M. D'Souza, MD
Cleveland Clinic
Lung Volume Reduction Surgery
Michelle C. Ellis, MD
University of Michigan
Coronary Artery Bypass Grafting With Aortic Valve Replacement, Transhiatal Esophagectomy
Nicholas Engstrom, MD
Oregon Health and Sciences Center
Diagnositic Thoracoscopy
Lloyd M. Felmly
Carinal Pneumonectomy
Joss Fernandez, MD
Missouri Heart Center, Columbia, MO
Endovascular Management of Acute Type B Dissection
Amy Fiedler, M.D

Aortic Valve Replacement for Aortic Insufficiency or Aortic Stenosis
Charles D. Fraser Jr, MD

Texas Children’s Hospital/Baylor College of Medicine
Arterial Switch Procedure
James J. Gangemi, MD
Complete Atrioventricular Canal Repair
Jose P. Garcia, MD
Massachusetts General Hospital
Orthotopic Heart Transplantation
Erin Gillaspie, MD
Mayo Clinic
Open Lobectomies
Leonard N. Girardi, MD
New York Presbyterian –Weill Cornell Medical Center
Thoracoabdominal Aneurysm Repair
David Graham, MD
Children’s Medical Center of Dallas
Repair of Supravalvular Aortic Stenosis, Pleural Decortication, Pleural Biopsy (Open/Thoracoscopic) (Open/Thoracoscopic)
Eugene Grossi, MD
New York University Langone Medical Center
Mitral Valve Replacement
Jonathon W. Haft, MD
Coronary Artery Bypass Grafting With Aortic Valve Replacement
M. Scott Halbreiner, MD
Cleveland Clinic
Minimally Invasive Directed Coronary Artery Bypass
Michael E. Halkos, MD, MSc

Emory University
Aortic Root Replacement (Endocarditis)
Jeffrey S. Heinle, MD
Infra-Cardiac Total Anomalous Pulmonary Venous Return (TAPVR), Extra-Cardiac (Non-Fenestrated) Completion Fontan
Procedure, Pulmonary Valve Replacement and Reconstruction of Right Ventricle Outflow Tract, Pediatric Lung
Transplantation: Bilateral Sequential Lung Transplantation
Joshua L. Hermsen, MD
Seattle Children’s Hospital
Repair of Truncus Arteriousus (TA)
Jonathan C. Hong, MD
Permanent Pacemaker Insertion, Completion Lateral Tunnel Fontan
John S. Ikonomidis, MD, PhD

Total Arch/Hemiarch Replacement with DHCA – Dissection, Valve Sparing Root Replacement
David M. Jablons, MD
Open Ivor-Lewis Esophagectomy
Mathéau A. Julien, MD, PhD

Tufts Medical Center
DeVega Tricuspid Valve Repair
Narongrit Kantathut, MD
Cleveland Clinic
Aortic Valve Surgery with Upper Hemisternotomy Approach
Sunjay Kaushal, MD, PhD

University of Maryland Medical Center
Pediatric Heart Transplantation
Michael O. Kayatta, MD
Emory University
Aortic Root Replacement (Endocarditis)
Mark J. Kerns, MD
Biatrial Cox-Maze Ablation for Atrial Fibrillation
Kemp Kernstine, MD, PhD

University of Texas Southwestern
Pleural Decortication (Open/Thoracoscopic), Pleural Biopsy (Open/Thoracoscopic)
Zarrish S. Khan, MD
Thoracoabdominal Aneurysm Repair, Open Modified McKeown Esophagectomy
Ali Khoynezhad, MD, PhD
Cedars Sinai Medical Center
Endovascular Repair of Descending Thoracic Aortic Aneurysm (TEVAR)
Teresa M. Kieser, MD
University of Calgary
Coronary Artery Bypass Grafting With Mammary and Vein Grafts - Off Pump
Samuel S. Kim, MD
University of Arizona
Segmentectomy
Paul Kirshbom, MD
Yale University
Partial AV Canal Repair
Sean Kwan, MD
North Shore Long Island Jewish Health System
Laparoscopic Nissen Fundoplication
Geoffrey T. Lam, MD
New York University School of Medicine
Chamberlain Procedure, Trans-sternal Thymectomy
Damien J. Lapar, MD, MSc

Coronary Artery Bypass Grafting With Cardiopulmonary Bypass
Ala Al-Lawati, MD
Ross Procedure for the Correction of Congenital Aortic Stenosis
Juan M. Lehoux, MD
Supra-Cardiac Total Anomalous Pulmonary Venous Return (TAPVR), Aortic Coarctation Repair With Extended End-To-End
Anastomosis, Tetralogy of Fallot: Transventricular Repair
Ryan M. Levy, MD
VATS Pericardial Window, Open Transthoracic Diaphragm Plication, Mediastinoscopy
Jules Lin, MD
Transhiatal Esophagectomy
Chaim Leker Locker, MD

Mayo Clinic
Redo Sternotomy and Difficult Sternal Closure
Gabriel Loor, MD
University of Minnesota
Transcatheter Aortic Valve Implantation (TAVI): (Transfemoral-Transapical Approach)
James D. Luketich, MD
Minimally Invasive Ivor-Lewis Esophagectomy, Laparoscopic Paraesophageal Hernia Repair
Robroy MacIver, MD, MPH

Patent Ductus Arteriosus Ligation
George Makdisi, MD
Mayo Clinic
Unexpected Intraoperative Complications, Redo Sternotomy and Difficult Sternal Closure, Bronchial and Arterial Sleeve
Resection, Chest Wall Tumor Resection and Chest Wall Reconstruction, Extrapleural Pneumonectomy for Mesothelioma
Fahd Makhdom, MD
McGill University
Repair of Atrial Septal Defect- Secundum Atrial Septal Defect
Hari Mallidi, MD, FRCSC

Baylor College of Medicine/ Texas Heart Institute
Donor Heart Procurement
Tomas D. Martin, MD
Hemiarch Replacement with DHCA – Aneurysm
Carlo O. Martinez, MD
University of Texas Health Science Center
VATS Evacuation of Hemothorax
David P. Mason, MD
Cleveland Clinic
Lung Volume Reduction Surgery
Douglas J. Mathisen, MD
Rigid Bronchoscopy, Tracheal Resection and Reconstruction
E. Dean McKenzie
Tetralogy of Fallot: Transventricular Repair, Tetralogy of Fallot Repair - Infundibular Sparing (Transatrial Repair)
D. Michael McMullan, MD
Seattle Children’s Hospital
Repair of Truncus Arteriousus (TA)
Justin R. Van Meeteren, DO

Mayo Clinic
Repair of Obstructive Hypertrophic Cardiomyopathy: (Septal Myomectomy)
Carlos M. Mery, MD, MPH

Supra-Cardiac Total Anomalous Pulmonary Venous Return (TAPVR), Aortic Coarctation Repair with Extended End-To-End
Anastomosis, Modified Blalock-Taussig Shunt (Using Interposition Gore-Tex Tube Graft), Bidirectional Glenn Procedure
Stephanie Mick, MD
Cleveland Clinic
Aortic Valve Surgery with Upper Hemisternotomy Approach
Jacob Moremen, MD
Indiana University School of Medicine
Open Thoracostomy (Eloesser Flap and Clagett Window)
Raghav Murthy, MD
Children’s Medical Center of Dallas, Texas
Pulmonary Artery Banding, Repair Of Supravalvular Aortic Stenosis
James H. Neel, MD
University of Louisville
Repair of Post-Infarction Ventricular Aneurysm (Dor Endoventricular Circular Patch Plasty (EVCPP))
Andrew B. Nguyen, MD
Laparoscopic Paraesophageal Hernia Repair
Khanh Nguyen, MD
Total Anomalous Pulmonary Venous Return (TAPVR) - Cardiac Type
Francis C. Nichols III, MD

Mayo Clinic
Extrapleural Pneumonectomy for Mesothelioma
David D. Odell, MD, MMSc

Minimally Invasive Ivor-Lewis Esophagectomy
Bharat Pancholy, MD
Rush University Medical Center
Flexible Bronchoscopy
Michael K. Pasque, MD
Lung Procurement
G. Alexander Patterson MD
Lung Transplantation
Subroto Paul, MD
Open Modified McKeown Esophagectomy
Amit Pawale, MD, FRCS

Repair of Post-Infarction Ventricular Septal Defect, Pulmonary Embolectomy, Total Anomalous Pulmonary Venous Return
(TAPVR) - Cardiac Type
Paul A. Perry, MD
University of California Davis
Resection of Atrial Myxoma
Duc Thinh Pham, MD

Tufts Medical Center
DeVega Tricuspid Valve Repair
Allan Pickens, MD
Emory University
VATS Thymectomy
Timothy J Pirolli, MD
Stanford University
Esophagogastroduodonoscopy
Eitan Podgaetz, MD, MPH

VATS Wedge Resection, VATS Sympathectomy
Ourania Preventza, MD
Aortic Root Replacement with Homograft for Aortic Root Abscess (Native And Or Prior Bentall)
Wissam Raad, MD, MRCS

Albert Einstein College of Medicine
Division of Vascular Ring
Ramachandra Reddy, MD, MBA

Pulmonary Embolectomy
J. Matthew Reinersman, MD
Mayo Clinic
Transcervical Thymectomy
Otis Rickman, DO
Vanderbilt University Medical Center
Tunneled Catheter Placement
R. Taylor Ripley, MD
Memorial Sloan-Kettering Cancer Center
Pancoast Tumor
Michael P. Robich, MD
Cleveland Clinic
Septal Myectomy
Valerie W. Rusch, MD
Memorial Sloan-Kettering Cancer Center
Pancoast Tumor
Joseph Sabik, MD
Cleveland Clinic
Minimally Invasive Directed Coronary Artery Bypass
Sameh M. Said, MD
Mayo Clinic
Mitral Valve Repair for Bileaflet Prolapse, Cone Repair for Ebstein Malformation
Sandeep Sainathan, MD
Yale University
Aortic Valve Replacement with Aortic Root Enlargement, Partial AV Canal Repair
Ismael Alejandro Salas De Armas, MD
Aortic Coarctation Repair with Extended End-To-End Anastomosis, Modified Blalock-Taussig Shunt (Using Interposition
Gore-Tex Tube Graft), Bidirectional Glenn Procedure, Tetralogy of Fallot Repair - Infundibular Sparing (Transatrial Repair)
Manu S. Sancheti, MD
Emory University
VATS Thymectomy
Peter Sassalos, MD
Norwood Procedure
Hartzell V. Schaff, MD
Mayo Clinic
Mitral Valve Repair for Bileaflet Prolapse
Lara Schaheen, MD
Tracheostomy
Jeffrey Schwartz, MD
Loyola University Medical Center
Elephant Trunk Part 1, Elephant Trunk Part 2
Vinod Sebastian, MD
Pulmonary Artery Banding, Repair of Supravalvular Aortic Stenosis
Fawwaz R. Shaw, MD
University of Washington
Aortic Root Replacement for Ascending Aortic Aneurysm
Ahmad Y. Sheikh, MD
Stanford University
Esophagogastroduodonoscopy
Robert Shen, MD
Mayo Clinic
Chest Wall Tumor Resection and Chest Wall Reconstruction, Open Lobectomies
Ming Si, MD
Norwood Procedure
Mark S. Slaughter, MD
University of Louisville
Repair of Post-Infarction Ventricular Aneurysm (Dor End ventricular Circular Patch Plasty (EVCPP))
Nicholas Smedira, MD
Cleveland Clinic
Septal Myectomy
Brian Solomon, MD
New York University Langone Medical Center
Mitral Valve Replacement
Tae H. Song, MD
Orthotopic Heart Transplantation
John R. Spratt, MA, MD

Patent Ductus Arteriosus Ligation, VATS Wedge Resection, VATS Sympathectomy
Cameron T. Stock, MD
Rigid Bronchoscopy, Tracheal Resection and Reconstruction
John M. Stulak, MD
Mayo Clinic
Unexpected Intraoperative Complications
Jennifer L. Sullivan, MD
VATS Pericardial Window, Open Transthoracic Diaphragm Plication
Julia C. Swanson, MD
Complete Atrioventricular Canal Repair
Scott J. Swanson, MD
Brigham and Women's Hospital
Repair of Anterior Restrosternal (Morgagni) and Posterolateral (Bochdalek) Diaphragm Hernias, Pleurectomy and
Decortication
Keerit Tauh, MD
Ventricular Septal Defect: Perimembranous
Christo I. Tchervenkov, MD
McGill University
Repair of Atrial Septal Defect- Secundum Atrial Septal Defect
Tom P. Theruvath, MD, PhD

Total Arch/Hemiarch Replacement with DHCA – Dissection
Brandon Tieu, MD
Oregon Health and Sciences Center
Diagnositic Thoracoscopy
Michael Tong, MD, MBA

Cleveland Clinic
LVAD – Heartware, LVAD – Heart Mate II, Total Artificial Heart
Dimitrios Topalidis, MD
Transcatheter Aortic Valve Implantation (TAVI): (Transfemoral-Transapical Approach)
Alexandra Tuluca, MD
Baylor College of Medicine/ Texas Heart Institute
Donor Heart Procurement
Ramanan Umakanthan
Extra-Cardiac (Non-Fenestrated) Completion Fontan Procedure, Pulmonary Valve Replacement and Reconstruction of Right
Ventricle Outflow Tract, Pediatric Lung Transplantation: Bilateral Sequential Lung Transplantation
Edward D. Verrier, MD
University of Washington
Aortic Root Replacement for Ascending Aortic Aneurysm
William H Warren, MD
Rush University Medical Center
Flexible Bronchoscopy
Brody Wehman, MD, MSc

University of Maryland Medical Center
Pediatric Heart Transplantation
Samuel Weinstein, MD, MBA

Albert Einstein College of Medicine
Division of Vascular Ring
Abby White, DO
Brigham and Women's Hospital
Repair of Anterior Restrosternal (Morgagni) and Posterolateral (Bochdalek) Diaphragm Hernias, Pleurectomy and
Decortication
Dennis Wigle, MD, PhD

Mayo Clinic
Bronchial and Arterial Sleeve Resection
James E. Wiseman, MD
University of Arizona
Segmentectomy
Leora T. Yarboro, MD
Coronary Artery Bypass Grafting + Mitral Valve Repair vs. Replacement
J. Nilas Young, MD
University of California Davis
Resection of Atrial Myxoma
Kenan W. Yount, MD, MBA

Coronary Artery Bypass Grafting + Mitral Valve Repair vs. Replacement
David D. Yuh MD
Yale University
Aortic Valve Replacement with Aortic Root Enlargement
Sanford Zeigler, MD
Stanford University
Total Arch Replacement with Deep Hypothermic Circulatory Arrest for Aneurysm
Thomas J. Zeyl, MD
Hemiarch Replacement with DHCA – Aneurysm
Elena M. Ziarnik, MD
Vanderbilt University Medical Center
Tunneled Catheter Placement
Table of Contents
I. General Thoracic Surgery
1. Flexible Bronchoscopy
Essential Operative Steps
Potential Complications and Pitfalls
Template Dictation
2. Rigid Bronchoscopy
Template Dictation
If obstructing tumor
If benign stenosis
3. Esophagogastroduodonoscopy
Template Dictation
4. Mediastinoscopy
Essential Operative Steps:
Potential Complications and Pitfalls:
Template Dictation
5. Chamberlain Procedure
Template Dictation
6. Diagnositic Thoracoscopy
Template Dictation
7. Tunneled Catheter Placement
Template Dictation
8. Open Thoracostomy (Eloesser Flap and Clagett Window)
Template Dictation
9. Pleural Biopsy (Open/Thoracoscopic)
Template Dictation
10. Pleurectomy and Decortication
Template Dictation
11. Pleural Decortication (Open/Thoracoscopic)
Template Dictation
12. Open Transthoracic Diaphragm Plication
Template Dictation
13. Repair of Anterior Restrosternal (Morgagni) and Posterolateral (Bochdalek) Diaphragm Hernias
Morgagni Hernia
Template Dictation
Bochdalek Hernia
Template Dictation
14. VATS Evacuation of Hemothorax
Template Dictation
15. VATS Pericardial Window
Template Dictation
16. Chest Wall Tumor Resection and Chest Wall Reconstruction
Reconstruction Options
Template Dictation
Rotational Latissimus Dorsi Muscle Flap Reconstruction Dictation
Sternal Resection and Reconstruction
17. Pancoast Tumor
Template Dictation
18. Tracheostomy
Template Dictation
19. Tracheal Resection and Reconstruction
Template Dictation
20. Esophageal Stent Placement
Template Dictation
21. Laparoscopic Nissen Fundoplication
Template Dictation
22. Laparoscopic Paraesophageal Hernia Repair
Template Dictation
23. Transhiatal Esophagectomy
Template Dictation
24. Open Modified Mckeown Esophagectomy
Template Dictation
25. Open Ivor-Lewis Esophagectomy
Template Dictation
26. Minimally Invasive Ivor-Lewis Esophagectomy
Laparoscopic Phase
Thoracoscopic Phase
Template Dictation
27. Lung Volume Reduction Surgery
Template Dictation
28. VATS Wedge Resection
Template Dictation
29. VATS Sympathectomy
Template Dictation
30. VATS Thymectomy
Template Dictation
31. Transcervical Thymectomy
Template Dictation
32. Trans-Sternal Thymectomy
Template Dictation
33. Open Lobectomies
Right Upper Lobectomy
Template Dictation
Right Middle Lobectomy
Template Dictation
Right Lower Lobectomy
Template Dictation
Left Upper Lobectomy
Template Dictation
Left Lower Lobectomy
Template Dictation
34. Segmentectomy
Template Dictation
Thoracotomy
Video-Assisted Thoracoscopic Surgery
35. Carinal Pneumonectomy
Template Dictation
36. Extrapleural Pneumonectomy for Mesothelioma
Template Dictation
37. Lung Procurement
Template Dictation
38. Lung Transplantation
Template Dictation
39. Bronchial and Arterial Sleeve Resection
Template Dictation
II. Adult Cardiac Surgery
1. Aortic Root Replacement for Ascending Aortic Aneurysm
Template Dictation
2. Aortic Root Replacement (Endocarditis)
Template Dictation
3. Total Arch/Hemiarch Replacement with DHCA – Dissection
Template Dictation
4. Elephant Trunk Part 1
Template Dictation
Template Dictation
6. Endovascular Management of Acute Type B Dissection
Template Dictation
7. Aortic Valve Replacement for Aortic Insufficiency or Aortic Stenosis
Template Dictation
8. Aortic Valve Replacement with Aortic Root Enlargement
Template Dictation
9. Biatrial Cox-Maze Ablation for Atrial Fibrillation
Template Dictation
10. Coronary Artery Bypass Grafting with Cardiopulmonary Bypass
Template Dictation
11. Coronary Artery Bypass Grafting with Mammary and Vein Grafts - Off Pump
Template Dictation
12. Coronary Artery Bypass Grafting + Mitral Valve Repair VS Replacement
Template Dictation
13. Coronary Artery Bypass Grafting with Aortic Valve Replacement
Template Dictation
14. DeVega Tricuspid Valve Repair
Template Dictation
15. Donor Heart Procurement
Template Dictation
16. Hemiarch Replacement with DHCA – Aneurysm
Template Dictation
17. Aortic Root Replacement with Homograft for Aortic Root Abscess (Native And Or Prior Bentall)
Template Dictation
18. Unexpected Intraoperative Complications
Massive Air Embolism
Template Dictation
Intraoperative Aortic Dissection
Template Dictation
19. LVAD – Heartware
Template Dictation
20. LVAD – Heart Mate II
Template Dictation
21. Minimally Invasive Directed Coronary Artery Bypass
Template Dictation
22. Aortic Valve Surgery with Upper Hemisternotomy Approach
Template Dictation
23. Mitral Valve Replacement
Template Dictation
24. Minimally Invasive Mitral Surgery
Template Dictation
25. Mitral Valve Repair for Bileaflet Prolapse
Template Dictation
26. Orthotopic Heart Transplantation
Template Dictation
27. Thoracoabdominal Aneurysm Repair
Potenital Complications and Pitfalls
Template Dication
28. Permanent Pacemaker Insertion
Template Dictation
29. Repair of Post-Infarction Ventricular Septal Defect
Template Dictation
30. Repair of Post-Infarction Ventricular Aneurysm (DOR Endoventricular Circular Patch Plasty (EVCPP))
Template Dictation
31. Pulmonary Embolectomy
Template Dictation
32. Redo Sternotomy and Difficult Sternal Closure
Redo Sternotomy:
Sternal Closure
Template Dictation
33. Resection of Atrial Myxoma
Template Dictation
34. Septal Myectomy
Template Dictation
35. Endovascular Repair of Descending Thoracic Aortic Aneurysm (TEVAR)
Template Dictation
36. Total Arch Replacement with Deep Hypothermic Circulatory Arrest for Aneurysm
Template Dictation
37. Total Artificial Heart
Template Dictation
38. Transcatheter Aortic Valve Implantation (TAVI): (Transfemoral-Transapical Approach)
Template Dictation
39. Valve Sparing Root Replacement
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III. Congenital Cardiac Surgery
1. Repair of Atrial Septal Defect- Secundum Atrial Septal Defect
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2. Ventricular Septal Defect: Perimembranous
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3. Partial AV Canal Repair
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4. Complete Atrioventricular Canal Repair
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5. Repair of Partial Anomalous Pulmonary Venous Return
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6. Supra-Cardiac Total Anomalous Pulmonary Venous Return (TAPVR)
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7. Total Anomalous Pulmonary Venous Return (TAPVR) - Cardiac Type
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8. Infra-Cardiac Total Anomalous Pulmonary Venous Return (TAPVR)
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9. Patent Ductus Arteriosus Ligation
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10. Aortic Coarctation Repair with Extended End-to-End Anastomosis
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11. Division of Vascular Ring
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12. Pulmonary Artery Banding
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13. Modified Blalock-Taussig Shunt (Using Interposition Gore-Tex Tube Graft)
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14. Norwood Procedure
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15. Bidirectional Glenn Procedure
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16. Completion Lateral Tunnel Fontan
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17. Extra-Cardiac (Non-Fenestrated) Completion Fontan Procedure
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18. Repair of Supravalvular Aortic Stenosis
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19. Ross Procedure for the Correction of Congenital Aortic Stenosis
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20. Repair of Obstructive Hypertrophic Cardiomyopathy: (Septal Myomectomy)
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21. Arterial Switch Procedure
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22. Tetralogy of Fallot: Transventricular Repair
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23. Tetralogy of Fallot Repair - Infundibular Sparing (Transatrial Repair)
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24. Pulmonary Valve Replacement and Reconstruction of Right Ventricle Outflow Tract
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25. Repair of Truncus Arteriousus (TA)
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26. Cone Repair for Ebstein Malformation
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27. Pediatric Lung Transplantation: Bilateral Sequential Lung Transplantation
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28. Pediatric Heart Transplantation
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I. General Thoracic Surgery
Bharat Pancholy MD, and William H Warren MD
Rush University Medical Center, Chicago IL

Flexible bronchoscopy in a non-intubated patient
1. Monitoring = continuous pulse oximetry, non-invasive blood pressure monitoring, electrocardiographic monitoring.
2. IV access – peripheral or central IV access.
3. Apply supplemental oxygen either via nasal cannula or non-rebreather mask.
4. Sedation for comfort and cooperation:
5. Intravenous opiates (analgesic and antitussive)
6. Benzodiazepines (anxiolysis and antegrade amnesia)
7. Topical anesthetic – spraying hypopharynx with 1% or 2% lidocaine using atomizer
8. If inserting through nares –ask patient to plug one nare and inhale through other nostril. Then reverse. Whichever
nare appears to be able to ventilate better, plan to introduce bronchoscopy through that nare. Place cotton tip
applicator through the nare with lidocaine gel to anesthetize. Leave cotton tip applicator in place for 1 minute and
then remove.
9. Introduce bronchoscope through the nose or mouth
10. Once true vocal cords visualized, inject 5 ml of 4% lidocaine – this will anesthetize the larynx and allow for easier
advancement of the bronchoscope.
11. Visualization and inspection of the larynx, and vocal cords.
12. Assess vocal cord mobility
13. All lobar and segmental bronchi must be examined.
14. Tracheobronchial tree remote from the area in question is assessed first.
15. Bronchus leading to the known area of disease is examined.
16. Perform bronchoscopic procedure as indicated – biopsy, brushing, bronchoalveolar lavage, transbronchial needle
aspiration.
17. Remove bronchoscope at termination of procedure
Flexible bronchoscopy in an intubated patient
1. Apply swivel adapter to endotracheal tube
2. Maintain ventilation through side arm of adapter
3. Bronchoscope is passed through tight fitting diaphragm on the adapter
4. Perform bronchoscopy and any associated procedures
5. Remove bronchoscopy, remove adapter.

1. Hypoxemia
2. Hypercapnia pre procedure/during/post procedure
3. Respiratory depression
4. Aspiration
5. Analgesic in elderly and debilitated patients should be minimized
6. Liver failure patients should not receive any benzodiazepines
7. Bleeding (risk is increased in following)
8. Increased with PT >40% of normal
9. Platelet count < 50,000
10. Uremia
11. Pulmonary hypertension
12. Pneumothorax after patient undergoing transbronchial biopsy
13. Bronchospasm
14. Increase in patients with asthma and severe chronic obstructive disease
15. Laryngospasm
16. Usually because of inadequate anesthetic to vocal cords and tracheobronchial tree.
17. Sepsis (usually after BAL)
18. Do not perform in patients with bilateral vocal cord paralysis
19. Can lead to edema resulting in life-threatening airway obstruction
Template Dictation
Preoperative Diagnosis: [INDICATION– e.g. severe/change in cough, hemoptysis, diffuse lung disease, bacteriologic
sampling, lung abscess, aspiration)
Postoperative Diagnosis: Same
Procedure(s) Performed: Flexible bronchoscopy (with associated procedures)
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE]year old [GENDER]with [DURATION]history of [COMPLAINT–e.g. worsening
cough and unresolving pneumonia]. Chest xray and sputum culture reveals [FINDINGS – collapse of lobe with gram stain with
gram negative rods.].
Description of Procedure: The flexible bronchoscopy tower and bronchoscope was brought to the patient’s room on [DATE].
The patient’s identity and planned procedure were verified, and a time out was performed. Monitors and supplemental oxygen
were applied. We proceeded to anesthetize the patient topically. The flexible bronchoscope was inserted
[TRANSORALLY/TRANSNASALLY]. The vocal cords were visualized and bilateral movement was noted [or abnormal
movement on the (left/right) side was noted]. 1% lidocaine was injected through the bronchoscopy port anesthetizing the
larynx. The tracheobronchial tree remote from the area of interest was assessed first. All lobes and segments were clearly
visualized. Pathologic findings included [FINDINGS, e.g. bronchial irritation, edema, etc). The bronchoscope was then
moved to the area of concern. Findings of (e.g. large purulent mucous with edema) was identified in (area of
tracheobronchial tree)]. (Further diagnostic procedures performed as indicated and described). Specimens removed
included [X, e.g bronchoalveolar lavage]. The bronchoscope was successfully removed without complication. Patient’s
hemodynamics continued to be [X, e.g. stable] at the end of procedure. The patient remained in a monitored bed post
procedure.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
2. Rigid Bronchoscopy
Cameron T. Stock, MD and Douglas J. Mathisen, MD
Massachusetts General Hospital, Boston, MA

1. Induction of anesthesia is initiated when all equipment and team members are present
2. The patient’s neck is extended and a teeth guard is placed on the upper incisors
3. The bronchoscope is used to lift the epiglottis revealing the vocal cords
4. The bronchoscope is rotated 90 degrees while passing through the cords to minimize trauma
5. The bronchoscope is connected to the ventilator
6. The bronchoscope is advanced under direct vision to the area of interest
7. Serial dilations should proceed with gentle pressure and small incremental increases in the diameter of the
bronchoscope. A gentle corkscrew action under direct vision is best.

1. Failure to clearly visualize the epiglottis and vocal cords by being posterior and under the larynx
2. Creation of a mucosal flap with the tip of the bronchoscope by advancing forcefully or without clearly visualizing the
tracheal lumen
3. Perforation of the tracheal lumen by using excessive force or by not being in the axis of trachea when dilating a
stenotic segment
4. Inadequate ventilation leading to CO2 retention, acidosis and potential for arrhythmias
Template Dictation
Preoperative Diagnosis: Tracheal stenosis, tracheal malignancy
Procedure(s) Performed: Rigid bronchoscopy, dilation of tracheal stenosis, dilation of endobronchial tumor
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with known [tracheal tumor, tracheal stenosis, newly diagnosed
asthma] who presented with increasing dyspnea and audible stridor. The patient was noted to be hypoxic with an increased
work of breathing. Humidified facemask oxygen was administered, and the patient’s symptoms stabilized. The patient was
observed in the ICU while waiting for the operating room to open. The patient was brought expeditiously to the operating room
for evaluation.
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient was identified with two
unique identifiers and the correct procedure was confirmed. The patient was placed supine on the operating table. After all
necessary equipment and all members of the surgical team were confirmed present, general anesthesia was administered. Rigid
bronchoscopes of sizes ranging from 3.5 mm to 9 mm and Jackson-Pilling esophageal bougies were available in the operating
room. After the patient was preoxygenated with mask ventilation, the #7 rigid bronchoscope was passed into the patient’s
mouth and the glottis was clearly visualized. Care was taken not to lever the scope off the patient’s incisors. The epiglottis was
retracted anteriorly using the tip of the bronchoscope revealing the vocal cords. Both cords were noted to be moving
symmetrically and no glottic edema was noted. The bronchoscope was passed through the cords by rotating the scope 90
degrees to enter the trachea parallel to the cords. The scope was cleared of secretions. The visualized tracheal mucosa was
noted to be free from inflammation. We discussed with the anesthesiologist paralyzing the patient or using deep inhalation
anesthesia. It was decided to proceed with our preferred method of spontaneous ventilation under deep inhalation anesthesia as
the patient was adequately ventilating.
[Choose One:]
If obstructing tumor: We observed a near obstructing endobronchial tumor at the takeoff of the right mainstem
bronchus. The #7 rigid bronchoscope was able to pass distal to the lesion along the membranous wall revealing a normal
appearing bronchus intermedius that was not involved with tumor. The lesion was initially biopsied with a cupped biopsy
forceps to check for consistency and avascularity. Next, using the beveled tip of the bronchoscope and advancing slowly with a
constant rotary motion, the center of the tumor was cored out. After several passes with the bronchoscope in this manner, we
were left with a patent bronchial lumen. Bleeding was controlled with direct pressure applied by the bronchoscope, and tumor
fragments were removed with the suction catheter. At the conclusion of the procedure the bronchoscope was able to easily
pass through the right main bronchus into the bronchus intermedius.
If benign stenosis: At 3 cm distal to the vocal cords, we observed a tight tracheal stenosis consistent with the patient’s
known post-intubation stenosis. The tracheal lumen appeared to narrow to a diameter of 2-3mm, and the surrounding tracheal
mucosa appeared injected and inflamed. Secretions were cleared with a long suction catheter. Serial dilations of the stricture
were initiated using the Jackson-Pilling esophageal bougies beginning with the smallest and progressively increasing their size.
Next the #7 bronchoscope was withdrawn, and the 3.5 mm bronchoscope was advanced to the lesion. Using firm but gentle
pressure and slight rotation of the bronchoscope, the scope was advanced past the stenotic segment. Care was taken not to exert
excessive force so as to avoid perforating the membranous trachea proximal to the lesion. The bronchoscope was immediately
connected to the ventilator and the patient was bag ventilated to facilitate clearance of CO2. The 4 mm bronchoscope was next
used to traverse the lesion. We incrementally increased the size of the bronchoscope until the 8 mm bronchoscope was able to
pass easily through the area of previous stenosis. Small tissue fragments were carefully removed using the biopsy forceps and
suctioning. Areas of bleeding were tamponaded using the bronchoscope and topical dilute epinephrine was also used to control
oozing from the tracheal lumen. At this point no further dilations were thought to be necessary. At the conclusion of the
procedure, the patient was well oxygenated and hemodynamically stable. All instrument, sponge, and needle counts were
confirmed to be correct. The bronchoscope was withdrawn. The patient was awoken from anesthesia and brought to the
recovery room in stable condition. In anticipation of some swelling following our dilation, Decadron 10 mg IV then 4 mg IV
every 6 hours for 24 hours was ordered for the patient. A chest x-ray was ordered.
3. Esophagogastroduodonoscopy
Timothy J Pirolli, MD and Ahmad Y. Sheikh, MD
Stanford University Hospital and Clinics, Stanford, California

1. Lines and Monitoring
2. General endotracheal anesthesia with single-lumen endotracheal tube or monitored anesthesia care
3. Checking all equipment to ensure the video monitor, insufflation and saline infusion ports are working adequately.
4. Insert gastroscope into esophageal inlet (direct laryngosopy may be used to facilitate insertion of scope)
5. Advance gastroscope with insufflation and examine the esophagus. Assess for mucosal changes. Document location
of z-line (gastroesophageal junction) and diaphragmatic pinch to assess for a hiatal hernia.
6. Advance gastroscope with insufflation and examine the gastric mucosa
7. Retroflex gastroscope to examine the cardia. Endoscopically grade (i.e., Hill classification) of the gastroesophageal
valve.
8. Advanced gastroscope with insufflation to examine the pylorus and duodenum.
9. Take biopsies as needed
10. Retract gastroscope with desufflation under direct vision
11. Extubate patient and transfer to PACU

1. Oropharyngeal trauma
2. Difficulty positioning gastroscope down the esophagus due to anatomical anomalies or strictures. A pediatric
gastroscope and or gentle dilatation may be helpful
3. Bleeding
4. Esophageal or gastric perforation
5. Failure to desufflate the gastrointestinal lumen
Template Dictation
Preoperative Diagnosis: [INDICATION - e.g. Dysphagia, GERD]
Procedure(s) Performed: Esophagogastroduodenoscopy.
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT– e.g. increasing
dysphagia and reflux]. After the risks and benefits were describe to the patient, he/she signed informed consent and proceeded
to the operating room for an esophagogastroduodenoscopy
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure verified with a surgical timeout, and the patient was placed on the operating room table in the supine position.
General anesthesia with a single-lumen endotracheal tube was obtained. The flexible adult gastroscope was inserted into the
posterior oropharynx and posterior to the left arytenoid, into the esophageal inlet. Insufflation was gently used to expand the
lumen. The cricopharyngeus was located at [DISTANCE] from the incisors. The cervical and thoracic esophagus were
inspected and normal mucosa was observed. There were no strictures, esophagitis, erosions, ulcers, petechiae, or other
abnormalities. The gastroesophageal junction was located at [DISTANCE] from the incisors. There was no evidence of
Barrett’s esophagus, hiatal hernia or other abnormalities. [Insert abnormal findings] We then entered the stomach. The
gastroscope was retroflexed to examine the cardia, which was normal. A Hill class [X] valve was noted. The remainder of
the stomach was examined and appeared normal. The gastroscope was then advanced to the pylorus, which was widely
patent. The scope was inserted through the pylorus without difficulty, and the first, second and third portions of the duodenum
were inspected and found to be normal, without evidence of ulcer disease. The duodenum and stomach were evacuated free of
air and debris and the scope withdrawn into the distal esophagus. There was no evidence of perforation or mucosal
irregularity. We then removed the gastroscope without difficulty.
All instrument, sponge and needle counts were confirmed to be correct x 2 at the end of the operation. The patient was
extubated and subsequently transferred to the post-anesthesia care unit in stable condition.
4. Mediastinoscopy
Nicholas Baker, MD and Ryan Levy, MD
University of Pittsburgh Medical Center, Pittsburgh, PA.
Essential Operative Steps:

1. Right radial arterial line
2. General endotracheal anesthesia
3. Prep and drape entire neck and chest in the event an emergent median sternotomy is required
4. Transverse skin incision one fingerbreadth above sternal notch
5. Divide platysma transversely and strap muscles longitudinally in midline
6. Palpate for high innominate artery
7. Incise pretracheal fascia and enter with mediastinoscope
8. Blunt finger dissection to develop the pretreacheal plane to the level of the carina, staying on the trachea during the
dissection
9. Insert mediastinoscope with tip angled toward airway
10. Identify carina and level 7 lymph nodes
11. Identify left tracheobronchial angle and level 4L nodes
12. Identify right tracheobronchial angle and level 4R nodes
13. Biopsy superficially with care not to injure deep structures.
14. Check for hemostasis
15. Approximate strap muscles, platysma, and skin
Potential Complications and Pitfalls:

1. Review preoperative CT for calcified lymph node targets, high innominate artery and aberrant anatomy
2. Place patient with head at top of bed with full neck extension
3. Eye protection for the patient
4. Monitor arterial line to identify excess pressure on innominate artery
5. Palpate for high innominate artery.
6. Mediastinoscope must be under pretracheal fascia
7. Keep tip of mediastinoscope angled toward airway when advancing in to chest
8. Stay on the trache and mainstem bronchi
9. Biopsy superficially only visible nodes
10. Structures at risk for injury when biopsying level 7 nodes: esophagus, deep main pulmonary artery, anterior
pericardium, left atrium
11. Structures at risk for injury when biopsying level 4L nodes: lateral aorta and left recurrent laryngeal nerve (NO
CAUTERY due to the risk of nerve injury)
12. Structures at risk for injury when biopsying level 4R nodes: lateral azygos , pleura, right pulmonary artery
13. Control bleeding with pressure the pretracheal space (DO NOT REMOVE MEDIASTINOSCOPE WHEN YO
ENCOUNTER BLEEDING). Pack the pretracheal plane, keep calm, assess the situation and assure you hav
adequate IV access and help. A Sternal saw should be kept in the room at all times during this operation so that it
may be immediately available in an emergency.
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. Lung cancer, lung nodule, mediastinal lymphadenopathy]
Procedure(s) Performed: Video assisted mediastinoscopy
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [Complaint – e.g. lung mass,
nodule, or mediastinal lymphadenopathy].
Description of Procedure: The patient was taken to the operative suite on [DATE]. The patient’s identity and planned
procedure verified and the patient was placed supine of the operating table. Following an uneventful induction of general
anesthesia, the patient was intubated with a single lumen endotracheal tube without incident. A right radial arterial line was
placed. The patient’s arms were tucked, a shoulder roll was placed, and the neck was extended as much as safely possible.
Eye protection goggles were placed on the patient. The patient’s neck and entire chest was prepped and draped in a sterile
standard fashion.
The skin was marked one finger breadth above the sternal notch. A transverse two centimeter skin incision was made and
electrocautery was used to incise the platysma in a transverse fashion. The strap muscles were divided in the midline in a
longitudinal fashion. The trachea was identified, pretracheal fascia was sharply incised with Metzenbaum scissors and the
pretracheal space was developed using blunt finger dissection.
Next the mediastinoscope was placed into the pretracheal space just above the trachea and advanced into the mediastinum.
Blunt dissect with a mediastinoscope sucker with intermittent touch cautery was, used to dissect along the anterior trachea
down to the level of the carina. The right and left main stem bronchus were identified. Blunt dissection with suction and touch
electrocautery was used to identify level 7 lymph nodes. Cup biopsy forceps were used to superficially biopsy visible level 7
nodes. Next, the left tracheobronchial angle was identified. Blunt dissection without using electrocautery was used to dissect
level 4L lymph nodes. Cup biopsy forceps were used to superficially biopsy visible level 4L nodes. Next, right
tracheobronchial angle was identified. Blunt dissection with suction and touch electrocautery was used to dissect level 4R
lymph nodes. Cup biopsy forceps were used to superficially biopsy visible level 4R nodes.
Hemostasis was obtained with careful electrocautery and pressure from packing a sponge into the wound. The sponge was
removed and hemostasis was acceptable. The mediastinoscope was removed. The strap muscles were approximated with #2-0
absorbable stitch, the platysma was approximated with a #2-0 absorbable stitch, and the skin was approximated with a #4-0
absorbable stitch. Benzoin, steri-strips, and dry sterile dressing were applied.
All instrument, sponge, and needle counts were confirmed to be correct x 2 at the end of the operation. The patient was
extubated in the operating room and subsequently transferred to the post anesthesia care unit in stable condition.
5. Chamberlain Procedure
Geoffrey T. Lam, MD, and Jessica S. Donington, MD
NYU School of Medicine, New York, NY

1. Lines and monitoring
2. General endotracheal anesthesia: double-lumen tube preferable but not essential
3. Bronchoscopy: to confirm double-lumen tube placement
4. Transverse mediastinotomy in second left intercostal space
5. Preservation of internal mammary artery
6. Biopsy
7. Evacuation of pleural air if pleural space entered
8. Closure of incision

1. Injury to internal mammary artery or vein
2. Injury to aorta or pulmonary artery
3. Pneumothorax
4. Injury to phrenic nerve
5. Injury to recurrent laryngeal nerve
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. mediastinal lymphadenopathy, anterior mediastinal mass]
Procedure(s) Performed: Chamberlain procedure with biopsy, fiberoptic bronchoscopy
Assistants: [BLANK]
Anesthesia: [BLANK]
Fluids: [BLANK]
EBL: [BLANK]
Specimens: [BLANK]
Drains: [BLANK]
Indication(s) for Procedure: [AGE]year old [GENDER] with [MEDIASTINAL LYMPHADENOPATHY]. Preoperative
imaging revealed [FINDINGS].
Description of Procedure: Informed consent for surgery was obtained from the patient, including a discussion of risks,
benefits and alternatives, and the form was documented in the chart. The patient was taken to the operating room on [DATE]
and placed on the operating room table in the supine position. Anesthesia inserted appropriate intravascular access and
hemodynamic monitoring lines. Preoperative IV antibiotics were administered. A time out was observed to identify the
correct patient, procedure and anatomic location. General endotracheal anesthesia through a double-lumen tube was then
induced. Bronchoscopy was performed, which confirmed proper placement of the endotracheal tube. The patient was left in
the supine position with the neck extended and the arms tucked. A Bair Hugger was applied and all pressure points were
padded. The left lung was isolated [IF SINGLE LUNG VENTILATION USED] . The neck and chest were prepped and
draped in sterile fashion.
A 3 cm transverse incision was made in the second intercostal space to the left of the sternum. The pectoralis muscle was
divided in the direction of its fibers, thereby exposing the chest wall. The intercostal fibers were divided from the superior
aspect of the third rib, taking care not to injury the internal mammary artery. The mediastinal space was entered. Exposure
was obtained by retracting the internal mammary artery medially, and by dissecting the mediastinal pleural free from the
posterior sternum and retracting it laterally. The aortopulmonary window was digitally palpated and examined for enlarged
lymph nodes. Lymph nodes were sampled from station 5 and 6 [DIRECTLY/USING THE MEDIASTINOSCOPE] and
were passed off the field. The vagus and phrenic nerves were seen along the aortic arch and preserved. Hemostasis was
achieved by direct pressure. Because the pleural space was entered, a small red rubber catheter was placed into left pleural
space. The incision was closed in layers. The pectoralis fascia was closed using a running 0 Vicryl suture. The patient’s
back was then raised, and the left lung was re-inflated with the end of the red rubber catheter submerged under saline. When
the bubbling ceased, the catheter was removed. The subcutaneous layer was closed using 2-0 Vicryl, and the skin was closed
using a running 3-0 Monocryl subcuticular stitch. Sterile dry dressings were applied.
The patient tolerated the procedure well. The patient was extubated in the operating room and transferred in stable condition
to the recovery room. At the end of the case, the sponge, needle and instrument counts were correct x2.
6. Diagnositic Thoracoscopy
Nicholas Engstrom, MD and Brandon Tieu, MD
Oregon Health and Sciences Center, Portland, Oregon

2. Single lumen endotracheal intubation
4. Dual lumen endotracheal exchange
5. Positioning (lateral decubitus)
1. Axillary roll
2. Bean bag
3. Elevated arm support
4. Bed Flexion
6. Camera port 7th intercostal space, mid-axillary line
7. Working port in 5th intercostal space, anterior axillary line
8. Parietal pleural visualization
9. Mediastinal pleural visualization
1. Anterior
2. Posterior
10. Diaphragm visualization
11. Inspection of the fissures
12. Palpation of the Lung
13. Biopsy
14. Assess hemostasis
15. Intercostal nerve blocks
16. Chest tube placement
17. Assess lung re-inflation

1. Chest entrance injuries
1. Lung
2. Diaphragm
3. Heart (left sided approach)
2. Biopsy site bleeding
3. Post op air-leak
4. Insufficient visualization
Template Dictation
Preoperative Diagnosis:
Postoperative Diagnosis:
Procedure(s) Performed: Diagnostic Thoracoscopy
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: Patient is a (AGE) year old (GENDER) with (DURATION)history of (COMPLAINTS).
He/she was evaluated with (TESTS) and found to have (FINDINGS). A formal discussion regarding diagnostic thoracoscopy
was held with the patient including but not limited to the following risks: (RISKS). The patient agrees to proceed.
Description of Procedure: After obtaining informed consent, the patient was identified in the preoperative holding area, taken
to the operating room, and placed in the supine position on the operating room table. All appropriate monitoring devices were
placed. Following an uneventful induction of general anesthesia, the patient was intubated using a single lumen endotracheal
tube. A timeout was conducted. Flexible bronchoscopy was performed. A complete examination of the lower trachea,
bilateral mainstem and lobar bronchi, and segmental bronchi was performed. No blood, pus, or endobronchial lesions were
noted. The patient has normal endobronchial anatomy.
The single lumen endotracheal tube was exchanged for a dual lumen endotracheal tube. The patient was then turned to the
(SIDE) lateral decubitus position. An axillary roll was placed. The arms were secured in an elevated arm support with a
padded arm board. Site identification was rechecked, and the patient was prepped and draped in sterile fashion. Anatomical
landmarks were identified, and the camera port was created in the 7th intercostal space in the anterior axillary line. The
thoracoscope was then introduced, and the chest wall was inspected. A second working (SIZE) incision was made in the
(INTERSPACE)interspace (LOCATION). There was no pleural effusion. The anterior and posterior mediastinal pleura
were visualized. The parietal pleura was inspected. No abnormalities were noted. The lung was then retracted to the anterior
working incision to allow digital palpation. The fissures were then investigated visually and by palpation. The thoracoscope
was changed to the working incision to allow thorough investigation of the diaphragm. Biopsies were taken from (SITES OF
BIOPSY)and the specimen(s) were sent for frozen section. Frozen sections demonstrated the presence of (FINDINGS).
Hemostasis at the biopsy and port sites was assured. Multilevel intercostal nerve blocks were performed using (LOCAL
ANESTHETIC) from one rib space above the most cranial port site to one rib space below the most caudal port. A 28
French single chest tube was placed through the camera port and secured to the skin using 0 silk suture. Double lung
ventilation was initiated and the (SIDE) lung fully inflated under direct vision. All sponge and instruments counts were
correct. The anterior working incision was closed using 2-0 vicryl for musculofascial closure, 3-0 vicryl for deep dermal, and
4-0 vicryl for subcuticular closure. Sterile dressings were applied. The patient was extubated in the OR and transferred to
the PACU in stable condition.
7. Tunneled Catheter Placement
Elena M. Ziarnik, MD and Otis Rickman, DO
Vanderbilt University Medical Center, Nashville, TN

1. Patient positioned in lateral decubitus, 30 degrees. Effusion side up.
2. Ultrasound guidance to evaluate the location of effusion, lung and diaphragm
3. Mark point of entry (approximately 4th-5th intercostal space at the mid-axillary line).
4. Mark exit site (at the costal margin in the midclavicular line)
5. Prep and drape, centering on the entry and exit site marks
6. Infiltrate skin and subcutaneous tissue with 5cc 1% lidocaine
7. Infiltrate exit site and planned tunnel with 10cc 1% lidocaine
8. Access fluid with the introducer needle (placed through the catheter) while applying suction with syringe
9. Remove needle and syringe, place guidewire through catheter, remove catheter
10. Make incisions for entry and exit sites with #11-blade. Exit site should be just big enough to tightly fit tunneling
device. Access site should be large enough to accommodate catheter and peel-away trochar
11. Using tunneling device, create a tunnel from catheter exit incision to access incision
12. Position the catheter cuff just deep to the exit site
13. Sequentially dilate pleural tract over the guidewire, and insert the large bore peel-away trochar via Seldinger
technique
14. Insert tunneled pleural catheter through trochar and peel away. Have patient hum to minimize air entry into pleural
space.
15. Connect to drainage device to ensure catheter is not kinked
16. Secure catheter at exit site with #2-0 silk
17. Close access site with #2-0 silk horizontal mattress
18. Drain fluid as needed, can connect to low wall suction using provided adapter for initial drainage
19. Disconnect from drainage and secure to patients side with padded dressing.

1. Lung injury
2. Pneumothoarx
3. Bleeding, intercostal artery laceration
4. Positioning the catheter below the diaphragm
5. Pain with too aggressive initial drainage
6. Poorly positioned exit site (posteriorly or on a rib), which can increase patient discomfort
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. Malignant pleural effusion]
Procedure(s) Performed: Indwelling tunneled pleural catheter placement, US guidance for catheter placement
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER]with [DURATION]history of [COMPLAINT– e.g. increasing
shortness of breath]. Pre-procedure CXR reveals [SIDE] pleural effusion. [Recurrent after thoracentesis, known malignancy,
trapped lung}
Description of Procedure: The patient was positioned in lateral decubitus position with the head of bed at 30 degrees with the
[AFFECTED]side up. Pleural fluid was identified on the [AFFECTED]side using ultrasound. The access site at the 5th
intercostal space in the midaxillary line, and exit site just below the [AFFECTED SIDE]costal margin were marked. The
chest was prepped and draped in the usual sterile fashion. The tunnel and exit site were anesthetized with 10 cc of 1%
lidocaine, and the access site to pleural space was anesthetized with an additional 5 cc 1% lidocaine. Appropriate choice of
the access site was confirmed by free flow of pleural fluid upon aspiration with a finder needle. The pleural space was
accessed with a small-bore catheter over a needle. After confirming access into the pleural space by free flow of pleural fluid,
the needle was removed, and catheter was left in the pleural space. The wire was advanced into the pleural space through the
catheter. Stab incisions were made at the planned exit and access sites with an #11-blade scalpel. Using the tunneling device,
the catheter was tunneled through subcutaneous tissue. The cuff was positioned about 5 cm from exit incision. A tapered
dilator and peel away sheath trochar were advanced over the wire and advanced into the pleural space. The inner dilator and
wire were removed, and the tunneled catheter was fed into the pleural space without resistance. The peel away trochar was
pulled apart while advancing and holding pressure on the catheter until the trochar was removed and the catheter was
completely in the pleural space. There was no kinking of the catheter. Pleural fluid was easily drained from the catheter.
The access site was closed with a #2-0 silk horizontal mattress suture, and the catheter was secured at exit site with a #2-0 silk
suture in a Roman sandal fashion. The catheter was capped after cleaning it with alcohol. Skin at the exit site was prepped.
Foam padding and a bio-occlusive dressing were applied.
8. Open Thoracostomy (Eloesser Flap and Clagett Window)
Jacob Moremen, MD and Thomas Birdas, MD
Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana

3. Two lung ventilation (unless empyema not drained and potential for lung reexpansion)
4. Lateral decubitus positioning
5. Skin incisions vary (must include most dependent portion of chest, may include prior incisions and tube thoracostomy
site if possible)
6. Clagett window: Lateral 6-8 cm thoracotomy and extended in a “Y” fashion laterally and medially; or elliptical
incision may be used
7. Eloesser flap: uses U-shaped incision
8. Raise skin flaps
9. Clagett: 2-3 cm circumferentially
10. Eloesser: Single long flap (area inside the U-curve)
11. Removal of 1-3 ribs (ensure large access to most dependent portion of pleural space)
12. Complete debridement of necrotic tissue and irrigation of space
13. Marsupialize space with heavy absorbable suture
14. Clagett: sew edges of flaps to thickened parietal pleura circumferentially
15. Eloesser: sew large skin flap into base of opened area
16. Ensure adequate hemostasis
17. Pack with sterile moist gauze

1. Large window is key
2. Inadequate thoracostomy can result in premature closure of skin before deep space granulation
3. Incision too cephalad may not completely drain basilar space
4. May require single lung ventilation if empyema not fully drained preoperatively
5. Used in patients too frail or with inadequate tissue for muscle flap thoracoplasty or as part of staged repair of
bronchopleural fistula
6. Inadequate drainage of infection, debridement of necrotic tissue
7. Chronic apical space problems are better managed with extrapleural thoracoplasty
Template Dictation
Preoperative Diagnosis: Chronic basilar space infection [ADDITIONAL SPECIFICS – e.g. bronchopleural fistula
tuberculosis]
Procedure(s) Performed: Open thoracostomy [Clagett window or Eloesser flap]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of basilar pleural space infection
following [ORIGINAL PROCEDURE/DIAGNOSIS] and failed conservative therapy with antibiotics and tube thoracostomy
Prior decortication did not successfully obliterate space and is here today for open drainage and thoracostomy.
Description of procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure verified, and the patient was placed on the operating room table in the supine position. Appropriate intravenous
antibiotics and subcutaneous heparin were administered prior to the induction of anesthesia. General anesthesia was induced,
and the patient was intubated with a double lumen endotracheal tube. Position of the tube was verified via flexible
bronchoscopy and was found to be adequate. The patient was then placed in the [SIDE] lateral decubitus position. The tube
thoracostomy was removed, and the entire chest prepped and draped in sterile fashion. An 8 cm posterolateral thoracotomy
incision was made over the most dependent portion of the right pleural space. Cautery dissection was carried down through
muscle layers, and the pleural space was entered on the superior aspect of the rib. A finochietto rib retractor was inserted.
The skin incision was extended in a Y-shaped fashion [or ELIPTICALLY]for better exposure of the ribs. A 2 to 3 cm skin
flap was raised circumferentially. The [NUMBER] ribs were identified for resection to optimally expose the basilar space.
A 6-8 cm length of each rib was exposed and freed from the surrounding tissue attachments circumferentially with Doyen
dissector. A bone cutter was used to divide each rib laterally and medially, and the [NUMBER] ribs were resected. The
neurovascular bundles were suture ligated proximally and distally and Intervening tissue resected and discarded.
With the space fully exposed, a sample of the empyema fluid was sent for culture. All necrotic, infected debris was
decorticated from the lung and chest wall. A sample of the empyema rind was sent for culture. The chest was irrigated with
two liters of warm antibiotic-containing saline. Hemostasis was achieved. Skin flaps were sutured with 0 Prolene suture in
interrupted fashion to the thickened parietal pleura circumferentially. The wound was packed with several rolls of moist gauze
and a large dry dressing applied over the defect.
subsequently transferred to the postoperative surgical intensive care unit in critical condition.
9. Pleural Biopsy (Open/Thoracoscopic)
David Graham, MD, and Kemp Kernstine, MD, PhD
University of Texas-Southwestern, Dallas, Texas

3. Single lung ventilation with bronchial blocker or dual-lumen endobronchial tube
4. Lateral decubitus position
5. Mark potential thoracotomy incision (generally resection of 7th rib via S-shaped incision)
6. Ask anesthesia to deflate lung on the operating side
7. Open Technique
1. Review preoperative imaging and mark an area along the thoracotomy line where there appears to be significant
thickened pleural tumor
2. Make a limited 1-4 cm incision depending on thickness of soft tissue from the skin to chest wall
3. Divide latissimus dorsi, dissect onto chest wall
4. Dissect above rib dividing intercostal muscles and identify the hard, white pleural mass
5. (A mediastinoscope can be used to facilitate exposure)
6. Sharply resect (scalpel or biopsy forceps) a 1 cm square piece of pleura for improved histology and
microbiology studies
7. If more tissue needed, obtain more biopsies along the chest wall near the incision site
8. Place saline into the wound and have anesthesia give a Valsalva maneuver up to 30 mmHg. If no bubbling, close
wound in layers. If bubbling, place a Blake drain and close wound in layers.
8. Thoracoscopic Technique
1. According to the chest computed tomogram findings and the topographical anatomy of the chest wall, use 25-
guage sounding needle to locate effusion; send fluid for cytology/culture
2. Make a skin incision and insert a 5 or 12 mm trocar into this location
3. Place the 5 mm 30-degree thoracoscope into the trocar to confirm chest entry and to inspect pleura
4. Insufflate with 5-10 mmHg CO2 as needed to help with visualization
5. Aspirate fluid and send to pathology for culture/cytology/gram stain
6. Use mediastinal biopsy forceps or thoracoscopic biopsy forceps within the same port to remove tissue
7. An additional port may be required (along the previously placed thoracotomy incision) if single port/incisional
access inadequate
8. Obtain hemostasis with hook electrocautery as needed
9. Place chest tube (Blake or Argyle) through port site and secure using Nylon or Ethibond suture

1. Certain tumors especially mesothelioma has a propensity to seed and subsequently grow in surgical sites; therefore,
keep all biopsy incisions within the planned line of thoracotomy incision.
2. NEVER biopsy the visceral pleura without using a stapling device; this will cause a persistent air leak and delay
treatment
3. If additional tissue is needed, do not resect more pleural rind on the lung (Pitfall #2, obtain more tissue along chest
wall)
4. Take care not to dissect too deeply into chest wall when taking parietal pleural biopsies as meddlesome bleeding can
occur
5. If definitive procedure planned in the near future, chest tube placement without pleurodesis is appropriate; however,
if delay is anticipated, then palliation of the effusion can be performed. If the lung fully expands, intraoperative talc or
Betadine pleurodesis is an option. If the lung is entrapped, a tunneled, valved pleural catheter for external intermittent
drainage would be best for palliation.
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. Recurrent bloody pleural effusions, Pleural thickening, Pleural neoplasm]
Procedure(s) Performed: Open pleural biopsy
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT– e.g. increasingly
dyspnea and recurrent bloody pleural effusions, preoperative imaging shows concern for pleural thickening and prior attempts
for percutaneous biopsy and cytology have been negative. Thoracic surgery was consulted for open surgical biopsy.
procedure verified, and the patient was placed on the operating room table in the supine position. General anesthesia was
obtained and a dual-lumen endobronchial tube was then placed. The patient was positioned in the lateral decubitus position.
We then proceeded to prep and drape the chest in sterile fashion. An Ioban dressing was placed. A time out was performed.
A posterolateral thoracotomy incision was marked at approximately the level of the 6th intercostal space. A 2 cm incision was
made using a #15 blade along this marking in the posterior axillary line. The dissection was carried down through the
latissimus dorsi and onto the chest wall using electrocautery. The intercostal muscles were divided on the superior border of
the rib. A white firm mass was encountered. Sharp resection of this mass was performed and sent to pathology for
examination. Saline was placed into the wound and anesthesia provided a Valsalva maneuver at 30 mmHg. No air leak was
noted. The wound was closed in layers using Vicryl suture followed by a subcuticular monofilament suture. Tegaderm was
placed as the sterile dressing.
subsequently transferred to the postoperative cardiac surgical intensive care unit in critical condition.
10. Pleurectomy and Decortication
Abby White, DO and Scott J. Swanson, MD
Brigham and Women’s Hospital, Boston, Massachusetts

1. Arterial catheter
2. Central Venous Catheter
3. Naso-gastric tube help avoid esophageal injury
2. General endotracheal anesthesia via dual lumen endotracheal tube.
3. Bronchoscopy
4. Posterolateral thoracotomy, through latissimus dorsi and sparing serratus anterior muscles
5. Sixth rib resection
6. Blunt and cautery dissection between endothoracic fascia and parietal pleura starting at the vicinity of entry and
proceeding laterally, anteriorly and posteriorly before reaching the apex.
7. Careful attention must be drawn to avoiding injury to the subclavian vessels, phrenic and vagal nerves, superior vena
cava, azygous vein, esophagus and the internal mammary vessels.
8. Packing with lap pads for hemostasis along raw surface areas to minimize blood loss
9. Mobilization of the pleura from the mediastinum, taking care to avoid injury to the phrenic and recurrent laryngeal
nerves.
10. Inferior dissection of the pleural off of the diaphragm
11. Mobilization toward the diaphragmatic sulcus, starting from the posterior costophrenic angle and moving anteriorly.
12. Avoid entry into the peritoneum where possible, though this is particularly difficult when dissecting around the
central tendon. Entry is repaired as soon as it is seen. We prefer to use running 2-0 Vicryl.
13. Dissection is carried to the posterior pericardium, which is removed en bloc if no planes between tumor and
pericardium can be safely identified.
14. Once dissection is complete to the hilum, the parietal pleura is entered and the visceral decortication undertaken.
15. Dissection in the fissures is undertaken with caution, using inflation and deflation of the lung for hemostasis and
identification of tissue planes between pleura and parenchyma respectively.
16. Systematic interlobar, hilar and mediastinal lymphadenectomy is done routinely
17. Hemostasis is obtained, often with the help of an Argon beam electrocaogulator to control raw surface area bleeding
at the chest wall.
18. The chest is irrigated with multiple liters of normal saline and water.
19. In carefully selected patients, intraoperative heated chemotherapy (IOHC) is delivered. We use weight-based dosing
of cisplatin and gemcitabine. We use a 60-minute chemotherapy run; shorter runs are utilized for patients with
borderline renal function.
20. If pericardial resection is required to achieve a complete resection, we reconstruct the pericardium with fenestrated
PTFE (0.1mm) to prevent cardiac herniation and epicarditis. The patch is fenestrated to prevent tamponade from
accumulation of pericardial fluid or blood
21. If the tumor extension involves the diaphragmatic muscle, with the diaphragm is reconstructed with PTFE (2 mm).
Two pieces of 20 x 30 DualMesh are stapled together to create a loose patch that decreases tension, reduces the
incidence of patch dehiscence and herniation of abdominal organs into the chest. We secure the diaphragmatic patch
circumferentially, using both interrupted 2-0 Prolene and the ProTack device.
22. Three chest tubes are placed, one anteriorly and directed towards the apex, one posteriorly and directed towards the
apex, and one right-angled chest tube along the diaphragm. Wide drainage is necessary to control air leaks and to
allow complete re-expansion of the lung.
23. The thoracotomy incision is closed in standard fashion.

1. Be prepared to manage significant blood loss and maintain closed loop communication with the anesthesia team
regarding this. We have typed and cross-matched blood available and in the operating room throughout the duration of
the procedure.
2. Injury to the subclavian vessels can occur at the apices bilaterally.
3. On the right, the superior vena cava and azygous vein are at risk with dissection of the mediastinal pleural in this
area.
4. On the left, the plane between tumor and adventitia of the aorta, intercostal vessels, and the esophagus should be
sought judiciously.
5. Vocal cord injury should be treated with prompt injection medicalization to prevent aspiration in the early
postoperative period.
6. A tight pericardial patch can predispose to positional hemodynamic compromise and cardiac tamponade.
7. A tight diaphragmatic patch around the IVC can result in impaired cardiac filling
8. When delivering IOHC, careful attention must be paid pre-, intra- and post-operatively to adequate fluid resuscitation
to avoid potential renal toxicity from cisplatin
Template Dictation
Preoperative Diagnosis: [Indication – eg. [EPITHELIOD/BIPHASIC] Malignant Mesothelioma of the [LEFT/RIGHT]]
Postoperative Diagnosis: Same (Add invasion of relevant structures)
Procedure(s) Preformed: Bronchoscopy, [RIGHT/LEFT] pleurectomy and decortication, +/- diaphragmatic resection and
reconstruction, +/- pericardial resection and reconstruction, +/- Intraoperative Heated Chemotherapy (IOHC), and mediastinal
lymph node dissection
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure
Description of Procedure: The patient was brought to the operating room on [DATE]. Name, birthdate and nature of the
procedure were verified. After an uneventful induction of general anesthesia, the patient was intubated with a single-lumen
endotracheal tube without incident. Flexible bronchoscopy was performed. There were minimal secretions. No endoluminal
abnormalities or anatomic variations were noted.
Single-lumen endotracheal tube was exchanged to a [RIGHT/LEFT]-sided double lumen endotracheal tube and the patient
was repositioned in the [RIGHT/LEFT] lateral decubitus position and was prepped and draped in the usual sterile fashion. A
[RIGHT/LEFT] posterolateral thoracotomy was performed, transecting the latissimus muscle. The serratus anterior muscle
was preserved and retracted anteriorly. The sixth interspace was entered, and 15 cm of the rib was excised. Standard rib and
scapular retractors were placed. The extrapleural dissection proceeded circumferentially around the thoracotomy. Starting
posteriorly and inferiorly, we were able to define the extrapleural plane down to the base of the diaphragm and then superiorly
to the apex, taking care to identify and protect the subclavian vessels, aorta and esophagus. We then performed a radical
visceral pleurectomy and decorticated the tumor off the fissure and all lobes to the level of the hilar reflection. All gross
disease was resected. Because the diaphragm was involved, it had to be avulsed circumferentially.
Argon beam coagulation was used for tumorolysis and hemostasis along the entire lung surface into the fissures and chest wall.
A chemical scrub was performed with 3 cycles of hydrogen peroxide in 1 liter of water followed by 1 liter of saline. The chest
was then pulse lavaged. Intracavitary heated chemotherapy was then performed with cisplatin and gemcitabine for 60 minutes.
The abdominal peritoneum was inspected and any defects repaired primarily with running #2-0 Vicryl. The chest was
evacuated; all chemotherapy fluid was recovered. The chest was irrigated and checked for hemostasis. A Gore-Tex 1 mm
[2mm on Left] Dualmesh patch was fashioned to reconstruct the diaphragm and secured to chest wall with #2-0 Prolene
sutures around the chest wall thru the 8th interspace and thru the tip of the 5th rib anteriorly. The patch was secured posteriorly
using a laparoscopic tacking device. The rest of the patch was secured to the anterior chest wall and to the pericardium with
interrupted #0-Prolene sutures.
After ensuring hemostasis, three [RIGHT/LEFT]-sided chest tubes were placed as follows: a 28 French anterior angled chest
tube over the dome of the diaphragm into the costophrenic sulcus, a 28 French straight anterior, and a 28 French straight
posterior to the apex along the gutter. Number 2 Vicryl pericostal sutures were placed, and the lung was allowed to re-inflate
completely. The incision was closed in layers with Vicryl sutures. One previous port site excised completely down to chest
wall. The double lumen endotracheal tube was then exchanged to a single-lumen tube. Toilet bronchoscopy showed moderate
amount of secretions that were suctioned to clear. The patient was taken to the ICU intubated in stable condition. All note,
sponge, needle, and instrument counts were correct at the end of the operation.
11. Pleural Decortication (Open/Thoracoscopic)
David Graham, MD, and Kemp Kernstine, MD, PhD
University of Texas-Southwestern, Dallas, Texas

3. Single lung ventilation with bronchial blocker or dual-lumen endobronchial tube
4. Bronchoscopy to evaluate for bronchial obstruction
6. Mark posterolateral thoracotomy incision (2 fingerbreadths below scapular tip in an S-shaped fashion. Planned
incision in the 5th intercostal space)
7. Ask anesthesia to deflate lung on the operating side immediately prior to entering the pleural space
8. Open Technique
1. Posterolateral thoracotomy. Divide the latissimus dorsi; spare the serratus anterior.
2. Divide the intercostal muscles above the 6th or 7th rib (5th or 6th intercostal space) and enter pleural cavity taking
care to avoid injury to the lung
3. Drain fluid and send to pathology for cytology/gram stain/culture-aerobic, anaerobic, mycobacterial and fungal
4. Place rib spreader (Tuffier or Finochietto)
5. Mobilize lung by detaching pleural adhesions and divide inferior pulmonary ligament
6. Remove gelatinous/fibrinous deposits and blood clots (if present)
7. Decorticate chest wall and diaphragm
8. Sharply incise visceral pleural rind
9. Carefully develop plane between the lung and the visceral pleural rind, and circumferentially decorticate the
visceral pleural peel, thereby freeing the entire lung and allowing it to fully expand. Traction is applied to the
peel (Tonsil/Pean clamp) with counter-traction applied to the lung (peanut Kitner, sponge stick). In addition,
maintaining lung inflation (and even a Valsalva maneuver) is helpful to develop the dissection plane.
10. Resect necrotic tissues (if necessary)
11. Send pleural rind from each lobe to pathology (to rule out malignancy) and to microbiology (for mycobacterial
and fungal stains and aerobic, anaerobic, mycobacterial and fungal cultures)
12. Irrigate hemithorax with sterile saline or water (antibiotic containing saline or water can be used but there is no
evidence to support its use)
13. Widely drain the pleural space with e large bore anterior and posterior chest tubes and secure to skin. Though
there is no strong evidence to support it, many surgeons place small bore infusion catheters to infuse saline or
antibiotic solution to keep the large drains clear.
14. Place pericostal sutures for rib reapproximation (#2 Vicryl) in a fashion to avoid intercostal bundle entrapment
15. Close wound in layers: serratus fascia, latissimus dorsi fascia, deep dermal tissues, and subcuticular layer.
16. Injection of bupivacaine with epinephrine in the intercostal areas 2-3 interspaces above and below the
intercostal space entered and around each of the drains placed. Paravertebral, extra-pleural and intra-incisional
catheters may be placed to provide continuous and intermittent infusion of bupivacaine.
9. Thoracoscopic Technique
1. Enter chest cavity via anterior incision approximately 2 cm below and lateral to the nipple, approximately the 5th
intercostal space or in a fashion as directed by the preoperatively performed contrast-enhanced chest computed
tomogram (CT). In pleural spaces that appear complex on the CT, we often place a 5 mm port first as there is
less parenchyma damage if the thoracoscope is incorrectly placed. It can be enlarged to a 12 mm scope as
necessary.
2. Insert the 5 mm 30-degree thoracoscope into the trocar to confirm chest entry and to inspect pleura for adhesions
3. Insufflate with 5-10 mmHg CO2 as needed to help with visualization and assist in the dissection
4. Place 1-3 additional thoracoports: 5 or 12 mm port in the mid-axillary line just above the diaphragm
(approximately the 7th intercostal space) and one posteriorly. In the more complex pleural spaces as determined
by direct visualization and the CT, thoracoports may be placed in areas to provide the greatest opportunity for
visualization and decortication.
5. Mobilize lung by detaching pleural adhesions and divide inferior pulmonary ligament, as with the open technique
6. Using a 5 or 10 mm suction-irrigator system, drain fluid collections and send to pathology for cytology/gram
stain/culture; a curved ring forceps may be required to remove gelatinous fibrous deposits and blood clots, if
present.
7. Sharply incise into pleural rind using endoshears or electrocautery
8. Carefully develop plane between the lung and the rind. Decorticate the visceral pleura, releasing the lung in its
entirety. Traction is applied to the peel (thoracoscopic tissue grasper or a Forrester clamp) with counter-traction
applied to the lung (thoracoscopic Kitner). Spinning the grasper on the peel can aid in pleural stripping. In
addition, to help better define the plane, maintaining lung inflation and even a Valsalva maneuver can help
provide traction; this can be challenging thoracoscopically due to the small working space.
9. Continue diligently until all affected surfaces are released and lung re-expansion is unhindered. Use intermittent
lung inflation to check adequacy of decortication and reexpansion.
10. Send rind to pathology to rule out malignancy and to pathology for culture
11. Irrigate hemithorax with saline or water.
12. Place large bore anterior and posterior chest tubes through port sites, using posterior port as a viewing port, and
secure to skin.
13. Intercostal block with bupivicaine
14. Close remaining thoracoport sites in a subcuticular fashion using absorbable suture

1. Try not to violate the lung parenchyma; this will cause a air leak and bleeding; although these small air leaks are
typically well tolerated and will resolve in time
2. The thoracoscopic approach may be time consuming and result in only a partial decortication; failure to progress may
warrant open thoracotomy
3. If technically impossible (marked lung injury, failure to develop correct plane), incisions into the visceral pleura
either parallel or checkerboard may help allow the lung to expand.
4. Difficult areas to decorticate include the fissures and diaphragmatic surface. Diligence and patience is required.
5. Overnight mechanical ventilation with PEEP of 8 to 10 mmHg is helpful to facilitate lung expansion and to tamponade
bleeding
6. Make sure the lung remains fully expanded. Widely drain the pleural space, and keep chest tubes on suction for at
least 48 hours. Incomplete expansion (of all or a portion of the lung) can lead to pleural space complications
7. Inadequate pain control for either surgical approach induces splinting and failure to produce adequate cough and
clearance of secretions.
8. A portion of rib may need to be removed to facilitate open or thoracoscopic decortication in the case of fibrothorax
or limited exposure.
Template Dictation
Preoperative Diagnosis: [INDICATIO N– e.g. Parapneumonic empyema, Empyema thoracis, Chronic pleural effusion,
Entrapped lung, Fibrothorax]
Procedure(s) Performed: Open thoracotomy with full lung decortication
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AG E] year old [GENDER]with [DURATION]history of [COMPLAINT– e.g. recent
history of pneumonia, increasingly dyspnea, fever, leukocytosis, preoperative imaging shows multi-loculated pleural fluid
collections. Thoracic surgery was consulted for decortication.
procedure were verified. The patient was placed on the operating room table in the supine position. General anesthesia was
obtained and a dual-lumen endobronchial tube was then placed. Flexible bronchoscopy was performed. The left and right
mainstem bronchi, lobar bronchi and segmental bronchial orifices were examined. There were endoluminal masses, bloody
secretions, purulent secretions or other endoluminal abnormalities. The patient was positioned in the lateral decubitus position.
We then proceeded to prep and drape the chest in sterile fashion. Ioban dressing was placed. A time out was performed.
A posterolateral thoracotomy incision was made using a #10 blade scalpel staying 2cm below the scapular tip. Dissection was
carried down through the latissimus dorsi and onto the chest wall using electrocautery, sparing the serratus anterior. The
dissection continued into the fifth interspace, dividing the intercostal muscles superior to the sixth rib. The operating lung side
was deflated by anesthesia. The pleura was incised where cloudy fluid was encountered. This was sent for culture, gram stain,
and cytology. After extensive pleural division both anteriorly and posteriorly, a Finochietto rib spreader was placed.
Adhesions were noted from the lung to the chest wall and were divided using electrocautery. The inferior pulmonary ligament
was divided. Copious amounts of gelatinous fibrous debris were removed. The chest wall and diaphragm were decorticated.
The rind on the lower lobe including the visceral pleura was incised with a scalpel until the underlying parenchyma was
encountered. Careful dissection using traction/counter-traction ensued until the peel was fully removed from the entire lung. A
peanut dissector aided this process. Small rents in the lung were created during the visceral pleural decortication. Overall,
there was minimal parenchymal injury. Intermittent lung ventilation guided the decortication until full release of the lung was
achieved. The peel was sent to pathology to rule out malignancy and to microbiology for culture. The chest was irrigated with
antibiotic containing saline. Hemostasis was assured. Anterior and posterior 32 Fr chest tubes were placed and secured to the
skin using 0 Nylon suture. Pericostal #2 Vicryl sutures were used to re-approximate the ribs. Rib blocks were performed 2
ribs above and 2 ribs below the thoracotomy space with 0.25% Marcaine. The wound was closed in layers using Vicryl suture
followed by a subcuticular monofilament suture. Tegaderm was placed as the sterile dressing.
All instrument, sponge and needle counts were confirmed to be correct x 2 at the end of the operation. The patient was left
intubated and subsequently transferred to the postoperative cardiac surgical intensive care unit in guarded condition.
12. Open Transthoracic Diaphragm Plication
Jennifer L. Sullivan, MD and Ryan Levy, MD
University of Pittsburgh Medical Center, Pittsburgh, PA

3. Double lumen endotracheal tube or bronchial blocker for lung isolation
5. Thoracotomy incision
6. Identify attenuated portion of diaphragm
7. Pledgeted horizontal mattress sutures
8. Tight repair so diaphragm now in position of maximum end-inspiration
11. Thoracotomy closure

1. Not enough sutures or loose re-approximation can lead to recurrence.
2. Too much tension can cause dehiscence
3. Injury to underlying abdominal viscera with bleeding or sepsis
4. High thoracotomy can make it difficult to place sutures adequately
5. Avoid phrenic nerve branches on the diaphragm
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. diaphragm paralysis)
Procedure(s) Performed: [RIGHT, LEFT] thoracotomy, diaphragm plication
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT –e.g. DOE,
orthopnea] and [CAUSE – e.g previous surgery, history of trauma, cancer, central line placement]. A Chest CT/CXR revealed
[FINDINGS – e.g. elevated hemidiaphragm, pleural pathology]. A SNIFF test was performed showing paradoxical motion of
the affected hemidiaphragm, confirming diaphragm paralysis.
procedure were verified, and the patient was placed on the operating room table in the supine position. General anesthesia
was induced, and the patient was intubated with a double lumen endotracheal tube. Appropriate placement of the tube was
verified via bronchoscopy. The patient was placed in the [LEFT, RIGHT]lateral decubitus position, taking care to pad all
pressure points. The chest was then prepped and draped in a sterile fashion.
A low posterolateral thoracotomy incision was made using a 10-blade scalpel and electrocautery was used to dissect the
muscle to enter the 8th intercostal space. A 1 cm segment of the rib was shingled posteriorly and then a Finochietto retractor
was used to spread the ribs. Examination of the pleural cavity showed good lung isolation and no pleural effusions or lesions.
The elevated, attenuated area of the diaphragm was identified and grasped with a Babcock clamp to elevate the muscle from
the underlying abdominal viscera. Starting on the posterior surface of the diaphragm, a pledgeted #0 Ethibond suture was
placed in a horizontal mattress fashion, going lateral to medial, taking wide bites of the muscle. Several rows of these sutures
were placed, each about 2 cm apart, going from the posterior to the anterior surface of the diaphragm. The sutures were then
tightened, gathering the diaphragm tissue into several pleats, and the knots secured. The diaphragm was then re-examined,
showing appropriate at the base of the thorax and the muscle was seen to be taut and drum-like.
Adequate hemostasis was observed. A 24 Fr Blake drain was placed into the diaphragmatic recess and a 28 Fr chest tube was
placed along the posterior pleural cavity up to the apex. The tubes were brought out through separate skin incisions in the
anterior axillary line and secured to the skin with 0-silk suture. The lung was then re-inflated under direct visualization.
Four interrupted pericostal #1 Vicryl sutures were used to re-approximate the ribs. The underlying musculofascial layers were
then closed with #0 Vicryl suture in a running fashion. The deep dermal layer was then closed with #2-0 Vicryl suture in s
running fashion. The skin was re-approximated with #4-0 Monocryl in running fashion. The incision was covered with sterile
dressings.
All instrument, sponge and needle counts were confirmed to be correct at the end of the operation. The patient tolerated the
procedure well, with no apparent intraoperative complications. The patient was subsequently transferred to the cardiothoracic
surgical intensive care unit in stable condition.
13. Repair of Anterior Restrosternal (Morgagni) and Posterolateral
(Bochdalek) Diaphragm Hernias
Abby White, DO and Scott J. Swanson, MD
Brigham and Women’s Hospital, Boston, Massachusetts
Morgagni Hernia
Typically not identified or repaired until adulthood, hernias through the Foramen of Morgagni result from failure of fusion of
the septum transversum with the sternum and anterior chest wall or muscular agenesis at the retrosternal position of the
diaphragm. This type of hernia rarely causes pulmonary hypoplasia or compromise in the neonatal period.
1. Arterial catheter can be useful in the setting of acute obstruction and/or suspected strangulation
2. Naso-gastric tubes (NGT) can be useful for prevention of aspiration and decompression of obstruction,
especially when the hernia sac contains stomach or proximal small bowel Caution placing NGT if volvulus is
suspected.
2. General endotracheal anesthesia via dual lumen endotracheal tube.
3. Supine positioning, with arms tucked.
4. Safe peritoneal entry for laparoscopy
1. Decision for initial port placement based on surgeon experience, hernia contents and patient-related factors such
as prior surgery, anticipated adhesions, body habitus, etc.
2. Typical port sites:
1. Two 11mm epigastric ports, one for a 10mm camera and one working port
2. Two or three 5mm working ports for retraction and exposure, typically at the right and left lateral costal
margins, and a 5mm Nathanson liver retractor (or other self-retaining liver retractor) where anatomy
dictates.
5. Reverse Trendelenberg positioning facilitates reduction of hernia contents and allows stomach and omentum to fall
away from the hiatus.
6. Reduction of hernia sac and contents
1. Careful lysis of adhesions and dissection of the hernia sac using available energy sources (LigaSure, Harmonic
Scalpel, electrocautery)
2. Atraumatic hand-over-hand reduction of the hernia sac and contents, minimizing the amount of tissue grasping
with retractors.
3. Assessment of viability of herniated structures. ie. bowel viability
4. Resection and removal of hernia sac.
7. Primary repair with non-absorbable sutures (small, amenable defects)
1. Accomplished when there is an anterior cuff of muscle
2. Leave fascia on diaphragm muscle where possible
3. Interrupted simple or horizontal mattress sutures with braided non-absorbable suture
4. +/- Gore-Tex or Teflon pledgets
8. Tension-free repair with prosthetic mesh (Gore-Tex or bioasborbable)
1. Secured circumferentially with interrupted 0-Ethibond suture.
2. When there is no anterior muscle cuff, the diaphragm can be fixated to anterior chest wall interspaces (between
costal cartilages) or to the rectus muscle or both. This is easily accomplished with a Carter-Thomason guide and
suture passer.
9. Hemostasis and closure

1. As with all hernias, elective repair is associated with the greatest success rate. Patients presenting with acute
obstruction and/or strangulation require careful monitoring, appropriate fluid resuscitation and careful monitoring
postoperatively for infection in either pleural space, the mediastinum or the peritoneum.
2. Unique to Morgagni hernias, the internal mammary vessels should be considered when dissecting the hernia at the
anterior surface, and when fixating mesh to the anterior chest wall.
3. Care should be taken when dissecting hernia sac from the pleura or pericardium. Rarely does a clinically significant
pneumothorax develop, but heightened awareness and consideration should given when direct entry into the pleural
space is seen intraoperatively. Most pneumothoraces can be safely observed.
Template Dictation
Preoperative Diagnosis: [Indication – [INCARCERATED/STRANGULATED] Morgagni Diaphragmatic Hernia containing
[STOMACH/SMALL BOWEL/COLON/STOMACH/SPLEEN, OMENTUM, ETC]
Procedure Preformed: Diagnostic laparoscopy, repair of diaphragmatic hernia with mesh
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: This is a [BLANK] year-old [SEX] with a history of [SYMPTOMS] who was found to have a
[SIZE] anterior diaphragmatic hernia containing [CONTENTS]. Repair was indicated to prevent strangulation. (Typically not
indicated for shortness of breath, however, compression of lung from mass effect can be mentioned here).
endotracheal tube without incident. The patient was positioned supine with both arms tucked and the abdomen prepped and
draped in usual sterile fashion.
Safe peritoneal entry was accomplished via a small stab incision in the left upper quadrant with Veress needle introduction and
insufflation of the abdomen with carbon dioxide to a pressure of 15 mmHg. Two 11 mm incisions were made just to the left
and right of midline, halfway between the xiphoid process and umbilicus in the epigastrum and trocars inserted. A 10mm
camera was used and laparoscopy confirmed the presence of a [BLANK x BLANK cm] anterior diaphragmatic hernia
containing [CONTENTS]. Two additional, right and left lateral 5 mm ports were placed under direct visualization, 2 cm
beneath the costal margins.
The hernia sac and its contents were carefully reduced in a hand-over-hand technique, minimizing tissue grasping and tension
where possible. The Ligasure device was used to lyse adhesions and free the hernia sac from associated attachments. The
fascia overlying diaphragmatic muscle was left intact. The hernia sac was excised and removed. To avoid undue tension, an
acellular dermis patch was placed in an underlay fashion and secured using a combination of interrupted nonabsorbable
monofilament suture and titanium tacks placed with an automatic device.
The 11 mm port sites were closed with absorbable braided suture. Hemostasis was verified and all port sites were inspected.
The carbon dioxide was evacuated and the skin at the port sites closed with absorbable suture. All sponge, needle and
instrument counts were correct.
Bochdalek Hernia
Typically identified in the prenatal period, the classic Bochdalek hernia is a 2-4cm, left-sided posterolateral defect in the
diaphragm through which the abdominal contents have migrated, more commonly without the development of a hernia sac.
Compression of the lung from herniated contents results in pulmonary hypoplasia and/or pulmonary hypertension, the
physiology of which is often the more devastating factor to neonates. Surgical repair is secondary to physiologic
cardiopulmonary stabilization
1. As dictated by neonatal physiology.
3. Left subcostal incision for the more-common left-sided defects.
4. Retractors in the left upper quadrant facilitate visualization of the hernia and contents
5. Careful reduction of abdominal contents, typically using a dry sponge stick
6. Diaphragmatic remnant defect identified and assessed
7. At the posterior recess, the diaphragm can be mobilized from the posterior peritoneum just caudal to the left kidney,
allowing for less tension on the repair.
8. Repair of the defect with simple, interrupted, nonabsorbable sutures
1. In repairs without a posterior cuff of diaphragm, a prosthetic patch, such as GORE-TEX can be used.
2. Where there is no diaphragm in the posterior location, sutures can be placed around the 11th or 12th rib. The
prosthetic mesh may need to be removed if chest wall development is hindered by the fixed mesh on the side of
the repair.
9. Once the defect has been repaired, inspect the abdominal contents for rotational anomalies and replace then in a
normal anatomic position prior to closure.
10. Closure and hemostasis
1. Occasionally, an external silo is needed for a mal-developed abdominal cavity
2. A chest tube is left only for those patients on ECMO as surveillance for bleeding.

1. Timing of the operation should be considered in conjunction with a multi-disciplinary pediatric team.
2. Caution when reducing the contents of the hernia, as the left lobe of the liver and spleen are frequently involved and
are easily avulsed in neonates.
3. Follow-up data using bioprosthesis closure of the diaphragm showed earlier hernia recurrence as well as a higher
incidence of multiple recurrences.
4. Patients are at increased lifetime risk of small bowel obstruction from volvulus or hernia recurrence and parent
education is a must.
5. Yearly AP chest radiographs can be performed to detect asymptomatic recurrence.
Template Dictation
Preoperative Diagnosis: Left posterolateral diaphragmatic hernia
Procedure Preformed: Repair of Diaphragmatic Hernia [+/- MESH]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: This is a [BLANK] year-old [SEX] with a [SIDED] congenital diaphragmatic hernia. Following
adequate cardiopulmonary stabilization and cooperative care in a multi-disciplinary fashion, the decision was made to proceed
with operative repair.
endotracheal tube without incident. The abdomen was prepped and draped in usual sterile fashion.
A left-sided subcostal incision was made and the muscle fibers split for peritoneal entry. The peritoneum was grasped,
elevated and sharply entered.
A body wall retractor was placed and the peritoneal cavity was explored. The diaphragmatic defect was identified. A sponge
stick was used to reduce the abdominal contents into the abdomen. A [SIZE] cm defect remained. The hernia sac was excised.
A transverse incision was made in the posterior peritoneum to reduce tension on the repair and allow for mobilization of the
posterior diaphragm.
The diaphragm was repaired with simple, interrupted, #2-0 Ethibond sutures. Following closure of the diaphragm, the
abdominal contents were inspected for rotational anomalies and were oriented in usual anatomic position prior to closure.
Hemostasis was verified. The anterior and posterior rectus sheath were reapproximated with running #2-0 PDS suture and the
wound closed in layers. All sponge, needle and instruments counts were correct.
14. VATS Evacuation of Hemothorax
Carlo O. Martinez, MD and Daniel T. DeArmond, MD
University of Texas Health Science Center, San Antonio, TX

2. General endotracheal anesthesia with double-lumen endotracheal tube
3. Bronchoscopy
4. Repositioning in lateral decubitus positioning, leaned back slightly to allow access to the anterior intercostal spaces
and positioned with the hip over the central break to allow for further opening of the intercostal spaces
5. Place first incision at sixth intercostal space in the midclavicular line
6. Thoracoscope is inserted to assess lung parenchyma, adhesions, and site for second incision
7. Second incision is placed low, at the eight intercostal space in the posterior axillary line
8. Evacuate the retained hemothorax
9. Place chest tube at the lowest incision
10. Ensure lung re-expands completely
11. Close incisions
12. Extubate

1. The hemothorax should be completely evacuated or chronic pleural effusions (from the oncotic effects of blood),
fibrothorax, lung entrapment or empyema may unsue.
2. An organized, chronic hemothorax may require a thoracotomy for complete decortication to allow the lung to fully
expand.
3. Avoid inadvertent parenchymal injury.
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. hemothorax from chest wall trauma]
Procedure(s) Performed: Video Assisted Thoracoscopic Surgery (DETAILS – e.g. Diagnostic, with Decortication, with
Pleurodesis)
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE]year old [GENDER]with [DURATION]history of [COMPLAINT–e.g. trauma].
Initial chest tube thoracostomy insufficient in evacuating hemothorax. Imaging demonstrates retained hemothorax with
increasing WBC, compressive atelectasis, etc.]
Description of Procedure:
General: The patient was identified in the holding area. The procedure, benefits, risks, and alternatives were discussed with
the patient and [his/her] family including the risks of, recurrence, infection, injury to surrounding structures, and prolonged
airleak. The patient verbalized understanding of information provided and agreed to proceed. The informed consent form was
signed and placed in the chart.
The patient was taken to the operating room on [DATE]. A Time Out was performed verifying the correct patient, correct
procedure, and correct side. Pertinent imaging was available. Perioperative IV antibiotics were administered. The patient was
placed on the operating room table in the supine position. Following the induction of general anesthesia, a double-lumen
endotracheal tube was placed.
Bronchoscopy: Flexible bronchoscopy was performed. The bronchoscope was inserted through each of the lumens of double-
lumen endotracheal tube in order to verify proper positioning. A complete examination was performed. There was no blood,
mass, foreign object or other abnormalities. Excess secretions were suctioned out of the airways. The scope was withdrawn.
VATS with Hemothorax Evacuation: The patient was then repositioned in the [left/right] lateral decubitus with [right/left]
side up. [His/Her] hips were positioned over the central break to allow flexion and opening of the intercostal spaces. The
patient was prepped and draped in standard surgical fashion. An incision was made in the sixth intercostal space along the
midclavicular line and directed posteriorly. Entry into the thoracic cavity was uncomplicated and digital inspection revealed
no pleural adhesions. The scope was inserted and some retained hemothorax was noted. The [left/right] lung demonstrated
[good/fair/poor] isolation and was [completely/partially/poorly] deflated. The second incision at the eighth intercostal space
at the posterior axillary line was performed and entry into the thoracic cavity was performed under direct visualization. The
thoracoscope was then inserted in the lower incision to obtain a wide view of the thoracic cavity. The retained hemothorax
was evacuated with suction through the anterior incision. The thoracic cavity was inspected for areas of active bleeding and
hemostasis was obtained. A [28-french] chest tube was inserted through the lower incision, directed apically and posteriorly,
and secured with a suture. The [left/right] lung was reinflated completely under direct visualization and double lung
ventilation was re-established. The scope was removed.
Closure: The incisions were closed in layers with a #2-O Vicryl deep dermal layer and #3-O Monocryl for subcuticular
closure. The incisions were cleaned and dried and Dermabound was applied. A sterile dressing was applied to the chest tube.
All instrument, sponge and needle counts were correct at the end of the operation. The patient was extubated and taken to
PACU in satisfactory condition.
15. VATS Pericardial Window
Jennifer L. Sullivan, MD and Ryan M. Levy, MD
University of Pittsburgh, Pittsburgh, PA

1. Lines and Monitoring (arterial line)
3. Double lumen endotracheal tube or bronchial blocker for lung isolation
4. Lateral decubitus position.
5. Identify phrenic nerve
6. Tent pericardium away from heart
7. Creation of window
9. Pericardial drain and chest tube placement
10. Port site closure

1. Identify and avoid injury to phrenic nerve
2. Injury to heart, especially if pericardium is adherent to heart
3. Too small of a window will scar closed with recurrence of effusion
4. Herniation of heart with too large of a window
5. Bleeding from pericardial edges
6. Be prepared for patient to become unstable after anesthesia induction from tamponade physiology
7. VATS approach not appropriate for unstable patient who can not tolerate lung isolation – perform subxiphoid
approach
8. Failure to recognize a loculated effusion on preoperative echocardiography.
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. pericardial effusion)
Procedure(s) Performed: [LEFT, RIGHT] VATS pericardial window
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT–e.g. increasing
SOB, chest discomfort]. Preoperative echocardiography revealed [FINDINGS - e.g. size, signs of tamponade]. A Chest CT
revealed [FINDINGS – e.g. location, presence of loculation, evidence of pleural pathology].
procedure were verified, and the patient was placed on the operating room table in the supine position. Appropriate
preoperative prophylactic antibiotics were administered. General anesthesia was induced and the patient was intubated with a
double lumen endotracheal tube. The patient was placed in the [LEFT, RIGHT]lateral decubitus position. The chest was
then prepped and draped in a sterile fashion.
A 15-blade scalpel was used to make the camera port at the 8th intercostal space in the posterior axillary line. A 10 mm 30
degree thoracoscope was inserted through the port. Adequate lung isolation was confirmed and the pleural cavity was
examined for effusions and lesions. [FINDINGS]. A 10 mm incision working port was placed at the 5 th intercostal space in
the mid-axillary line. A 5 mm port was placed in the anterior axillary line in the 6th intercostal space.
The distended pericardium was visualized. The phrenic nerve was identified running along the pericardium and care was
taken to avoid contact with the nerve throughout the case. A long Allis clamp was used to grasp the pericardium to tent the
tissue away from the underlying heart. An endoshear was used to create an initial opening in the pericardium about 1 cm
anterior to the phrenic nerve. A [SEROUS/BLOODY] effusion was observed coming from the pericardial space. The Allis
clamp was used to provide traction on the free edge of the pericardium. The pericardium was further incised with the
harmonic scalpel, creating about 3 cm square defect in the pericardium. Several other areas of small fenestration were created
as well to ensure adequate decompression into the pleural space. The pericardial tissue was sent to pathology as a permanent
specimen for further evaluation.
After completion of the window, the pericardial space was then gently probed with the Yankauer sucker to break any fibrinous
septa and ensure complete drainage of the effusion. Adequate hemostasis was observed. A 24 Fr Blake drain was placed
through the window into the pericardial space and brought out through a separate incision in the skin. A 28 Fr chest tube was
inserted along the posterior pleural cavity with the tip at the apex and brought out through the initial camera port incision. The
tubes were secured to the skin with #0 silk suture. The lung was then re-inflated under direct visualization.
The fascia was then closed with #0 Vicryl suture and the deep dermal layer was then closed with #2-0 Vicryl suture. The skin
was re-approximated with #4-0 Monocryl in running fashion. The incisions were covered with sterile dressings.
All instrument, sponge and needle counts were confirmed to be correct at the end of the operation. The patient tolerated the
procedure well, with no apparent intraoperative complications. The patient was subsequently transferred to the cardiothoracic
surgical intensive care unit in stable condition.
Dr. [BLANK], the attending, was present and scrubbed for [BLANK] elements of this procedure.
16. Chest Wall Tumor Resection and Chest Wall Reconstruction
George Makdisi, MD, K. Robert Shen, MD
Mayo Clinic, Rochester, MN
Note: there are a variety of resection locations and reconstruction options, to limit the size of the chapter, we describe the most
common locations (anterior/lateral chest wall and sternal resection); with skeleton reconstruction (mesh, cadaveric rib grafts
and plates) followed by rotational muscle flap (latissimus dorsi) as well as pectoralis muscle flap advancement for sternal
resection. Other resections and reconstructions follow same principles.

1. A combined multidisciplinary approach planning with the anesthesia, plastics and thoracic surgery
2. Preoperative biopsy either percutaneous or incisional is often beneficial to make definitive diagnosis. This will
determine how much surgical margin will be necessary
4. General endotracheal anesthesia with double-lumen endotracheal tube
5. Include the biopsy site in your incision
6. Identify, defined and assess the extent of resection
7. Assess for local invasion and resectability
8. Get frozen section to assure negative margins, if positive resect more
9. Resection, assess the size of the defect
10. Reconstruct the bony defect
11. Cover material used to reconstruct bony defect with vascularized soft tissue
12. Good hemostasis and good drainage of any skin flaps to avoid development of seroma
13. Close monitoring to the flap necrosis/ might need early débridements
Reconstruction Options
1. Management of chest wall defect :
1. Not needed if small defect <5 cm or those located posteriorly underneath the scapula above the fourth rib.
2. Mesh: Should be thick at least 2 mm: Polypropylene, Marlex, composite Marlex methyl methacrylate, PTFE,
biologic mesh.
3. Mesh and plates.
4. Mesh and artificial ribs (i.e., titanium rib plates with cadaveric rib graft).
2. Management of chest wall soft tissue defect:
1. Primary closure.
2. Muscle advancement: pectoralis major
3. Rotational muscle/musculocutaneous flap: latissimus dorsi, serratus anterior, rectus abdominis, external oblique
muscle.
4. Omental transposition flap with split-thickness skin grafting immediately or 48 hours later.

1. A combined multidisciplinary approach with plastic and reconstruction surgeons, thoracic surgeons, anesthesia and
critical care specialists affords the best functional results after chest wall resection.
2. Three principles of surgical resection should be maintained 1). Resect all devitalized tissue 2). If a large chest wall
resection if performed, the rigid chest wall should be restored to preserve chest wall mechanics and prevent a flail
chest. 3). Healthy soft tissue coverage to obliterate pleural dead space, protect the viscera and great vessels, and
prevent infection.
3. Location, size, depth, presence of an infection, prior radiation therapy, recurrence of residual cancer, patient
performance status, patient comorbidities, immunosuppression, and prognosis are important factors in planning
resections and reconstructions.
4. Surgical margins of 4 cm are desirable, for most malignant chest wall tumors. This is influenced by tumor location,
pathology, location of tumor recurrence and reconstruction possibilities. For lower grade malignant chest wall
tumors or benign tumors, surgical margins of 2cm may be sufficient. For metastatic tumors negative margins are
adequate.
5. Reconstruction of the bony chest wall is not necessary and primary soft tissue closure can be performed for small
defects <5 cm or those located posteriorly underneath the scapula above the fourth rib.
6. Adequate pain control, early mobility, physical therapy and aggressive pulmonary hygiene are very important factors
in postoperative period.
7. Careful hemostasis should be performed to avoid hematomas.
8. Careful monitoring of flap ischemia and necrosis.
9. Complete resection with wide margins >4cm in the first operation is the most important factor in patient survival and
recurrence rate as the frozen section is often unreliable in assessing the extent of involvement of the ribs.
Template Dictation
Preoperative Diagnosis: [INDICATION– e.g. primary bone tumors benign/malignant, primary soft tissue tumors, metastatic
and recurrent breast cancer, chronic infection…]
Postoperative Diagnosis: [Same]
Procedure(s) Performed: Chest wall resection with [BLANK] reconstruction
Assistants: [BLANK]
Anesthesia: General endotracheal anesthesia, Thoracic epidural
Indication(s) for Procedure: [Mr/ Mrs.] [BLANK] is a [age] year-old [gender] who presented with progressive enlarged
mass [or infection] in the [location] chest wall. Workup included [CXR, CT, PET], a core needle biopsy had been
performed, and the findings are consistent with a [pathology]. [Mr/ Mrs.] [BLANK] is brought now for surgical resection in
conjunction with plastics surgery
Description of Procedure: The patient was brought to the operating room and had a thoracic epidural catheter placed by the
Anesthesia Team. The patient was then placed supine on the operating table and underwent an uneventful induction of general
endotracheal anesthesia. A double-lumen endotracheal tube was placed. We positioned the patient in the [RIGHT/LEFT]
lateral decubitus position. The [RIGH T/LEFT]-sided chest wall and [RIGHT/LEFT] arm were sterilely prepped
and draped.
A curvilinear incision was made, centered over the mass in the [RIGHT/LEFT] anterior portion of the chest in order to
encompass the prior needle biopsy site. Dissection was carried down through the subcutaneous tissue to the pectoralis major
muscle fascia. We then raised soft tissue flaps superiorly and inferiorly as well as medially and laterally. We were able to
then mark out a planned 4-cm wide resection encompassing most of the pectoralis major muscle as well as the pectoralis minor
muscle, and en bloc resection of the anterior portions of ribs [RIB NUMBERS]was performed. Dissection through the
muscle was performed using Bovie electrocautery. Once the medial extent of the planned rid resection was reached, the ribs
were scored with Bovie cautery to mark the resection border and the periosteum then stripped with a periosteal elevator. The
medial portions of the ribs were sectioned with a microsagittal saw, and the neurovascular bundles then clamped, ligated with
2-0 silk ligatures, and divided. The lateral portions of the ribs were then divided in a similar fashion. The specimen was then
removed from the field after marking sutures were placed for orientation, and all our gross surgical margins were clear.
Frozen section showed [FINDINGS]. The final diagnosis is held over for permanent section. The mass was quite mobile on
the chest wall and did not grossly appear to involve any of the underlying ribs. We then carefully palpated the
[RIGHT/LEFT] lung and examined the pleura. No tumoral invasion or masses were noted. We then placed a [SIZE]
AlloDerm biologic mesh to fill in the chest wall defect. The mesh was attached to the ribs medially and laterally with mattress
style No. 1 Polypropylene sutures, and then superiorly and inferiorly it was secured by suturing it around ribs [RIB
NUMBERS], also with No. 1 Polypropylene. We then reconstructed the bony chest wall defect using titanium rib plates to
replace the resected ribs [RIB NUMBERS]. The rib plates were bent to the appropriate curvature and then secured to the
medial and lateral portions of the ribs using three appropriately sized bicortical locking screws on each side of the rib.
On rib [RIB NUMBERS]we also interposed a cadaveric rib graft, which was secured to the rib plate also using four
interlocking appropriately sized bicortical screws. In addition, on rib plates [RIB NUMBERS] fibular cadaveric bone grafts
were secured to the plate to bridge the bony rib defect.
Rotational Latissimus Dorsi Muscle Flap Reconstruction Dictation

Patient was brought to the operating room. A thoracic epidural catheter was placed by the Anesthesia Team. Following an
uneventful induction of general endotracheal anesthesia, the patient was intubated with a double-lumen endotracheal tube. We
subsequently positioned the patient in the [RIGHT/LEFT] lateral decubitus position. The [RIGHT/LEFT]-sided chest wall
and [RIGHT/LEFT] arm were sterilely prepped and draped.
We proceeded with to harvest the latissimus dorsi as a pedicled muscle flap. We marked a curvilinear incision extending from
the [RIGHT/LEFT] posterior axillary line towards the spine at the mid thoracic region. This was opened sharply, and then
Bovie electrocautery was used to dissect the skin and fat into and through the dorsal thoracic fascia from the underlying
latissimus muscle. For the large vessels, surgical clips were used to maintain hemostasis. We then identified the borders of
the latissimus anteriorly and superiorly. These were dissected free from the underlying serratus anterior muscle. Once the
correct plane had been identified, the latissimus muscle was divided just lateral to the midline and then inferiorly above the
posterior iliac crest. Dissection was then continued distal to proximal elevating the latissimus muscle from the underlying
serratus, trapezius, and rhomboids. As we elevated the flap towards the axilla, the thoracodorsal bundle was identified. Care
was taken to protect it from injury. After elevation of the entire muscle and vascular pedicle along the posterior surface of the
latissimus dorsi, we buried the elevated muscle in a subcutaneous pocket that was created while harvesting the latissimus
muscle. Two 10 flat JP drains positioned in the cavity, brought out through separate stab incisions in the axilla, and secured to
the skin using 2-0 nylon suture. The curvilinear incision was closed using 0 Polypropylene in an interrupted fashion for the
fascial layer, a running 3-0 Monocryl for the deep dermal layer, and a 4-0 Monocryl subcuticular suture for the skin closure.
Wound was dressed with 1-inch Steri-Strips. The patient tolerated the procedure well. There were no intraoperative
complications. All needle, sponge, and instrument counts were correct after two counts
Sternal Resection and Reconstruction

Patient was brought to the operating room. A thoracic epidural catheter was placed by the Anesthesia Team. Following an
uneventful induction of general endotracheal anesthesia, the patient was intubated with a double-lumen endotracheal tube. A
roll between the scapulae, and the chest and the abdomen were prepared and draped. We began by making a vertical
curvilinear incision centered over the mass [a transverse incision underneath the breast folds can be used for the lesions in the
lower sternum and chest especially in females] starting at the level of the manubriosternal joint and extending inferiorly to the
xiphisternum. An elliptical segment of skin incorporating the biopsy scar was excised. The subcutaneous tissues were then
dissected and divided using Bovie electrocautery. The pectoral muscles were dissected off as flaps from the costal cartilages
on both sides. The lesion was identified, and the necessary extent of resection was assessed. After dissection of the
xiphisternum and dissecting up to the costal cartilages, the internal mammary arteries were identified, ligated and divided on
[ONE/BOTH] sides with 2-0 silk suture. The medial portioned of ribs [RIB NUMBERS]were scored with Bovie cautery
and the periosteum of these ribs was stripped with a periosteal elevator. After the neurovascular bundles were clamped and
divided and ligated with 2-0 silk ligatures, the medial portion of the ribs [RIB NUMBERS]and costal cartilages were
divided with a microsagital saw giving an adequate tumour clearance of approximately 4 cm. The sternum is then divided
with the sternal saw and scissors. The specimen was then removed from the field. We did mark the specimen for orientation,
and all our surgical margins were grossly clear. Frozen section showed [FINDINGS]. The final diagnosis is held over for
permanent section.
After assuring hemostasis, we assessed and measured the defect. The resection resulted in a defect of [SIZE] in the anterior
chest wall exposing the pericardium and [RIGHT/LEFT]lung. A 28 french straight chest tube was inserted into the
[RIGHT/LEFT] pleural space. The sternum and chest wall were reconstructed with Alloderm. The mesh was attached to the
ribs medially and laterally with mattress style #1 Polypropylene sutures. Superiorly and inferiorly, it was secured by suturing
it around ribs [RIB NUMBERS] with #1 Polypropylene. Once the mesh was in place the pectoral muscles were reattached to
the costal cartilages and the prosthesis. Two #10 Jackson-Pratt drains were positioned over the neosternum, brought out
through separate stab incisions, and secured in place using 2-0 nylon suture. The pectoral muscles and presternal fascia are
sutured together using #0 Vicryl suture in the midline to cover the mesh. After securing hemostasis, the subcutaneous layer was
approximated with continuous absorbable suture using #1 Vicryl suture. The skin was closed using a running 4-0 Monocryl
subcuticular suture. The patient tolerated the procedure well. No intraoperative complications. All needle, sponge, and
instrument counts were correct on two occasions
17. Pancoast Tumor
R. Taylor Ripley, MD, Valerie W. Rusch, MD
Memorial Sloan-Kettering Cancer Center, New York, NY

1. Neoadjuvant chemoradiotherapy.
2. Insertion of double lumen endotracheal tube.
3. Lateral decubitus position with slight anterior rotation.
4. Exploratory thoracotomy through standard posterolateral incision.
5. Assessment for metastasis, resectability, and extent of chest wall resection.
6. Removal of Finochietto chest retractor and placement of Rultract internal mammary artery retractor to elevate tip of
scapula.
7. Periscapular incision with division of latissimus dorsi and trapezius muscles and detachment of the serratus anterior
muscle.
8. Detachment of scalene muscles and elevation of paraspinous muscles to expose first rib and transverse processes.
9. Chest wall resection starting anteriorly with 3-4 cm margin and sending anterior piece for pathological analysis as
specimen margins (permanent sections).
10. Posterior division of involved ribs also submitted for pathological analysis.
11. Dissection along superior border of first rib.
12. Exposure of subclavian artery and vein and brachial plexus
13. Determination of nerve root involvement with liberal use of frozen section analysis.
14. Possible T1 nerve root resection.
15. Involvement of a neurosurgeon for completion of spine resection.
16. Mediastinal lymph node dissection of subcarinal and either right level 4 or left levels 5 and 6 lymph nodes.
17. Right or left upper lobectomy with en bloc removal of lobe and chest wall.
18. Closure of thoracotomy with chest tube placement.
19. Reconstruction of chest wall, usually with PTFE patch to support tip of scapula.
20. Closure of wound.
21. Reintubation with single lumen endotracheal tube.
22. Toilet bronchoscopy.

1. Proceeding without neoadjuvant chemoradiotherapy.
2. Withholding surgery in patients with radiologically stable disease (persistent mass does not predict pathological
response).
3. Pulmonary resection of less than a lobectomy.
4. Bulky N2 disease.
5. Inadequate chest wall margin, especially along spine.
6. Not involving spinal surgeon for posterior spinal resection.
7. Resection of brachial plexus roots other than T1.
8. Failure to ligate nerve root leading to CSF leak and pneumocephalus.
9. Inadequate post-operative pain control and pulmonary toilet.
Template Dictation
Pre-Operative Diagnosis:
1. Right (or Left) Superior Sulcus Non-Small Cell Lung Cancer (Pancoast Tumor).
2. Status Post Induction Chemoradiotherapy.
Post-Operative Diagnosis: Same
Procedure(s) Performed:
1. Right (or Left) Thoracotomy.
2. Right (or Left) Upper Lobectomy.
3. En Bloc Chest Wall Resection (Ribs I – X).
4. Chest Wall Reconstruction with PTFE (if needed).
5. Mediastinal Lymph Node Dissection.
6. Flexible Bronchoscopy.
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure [Age] year old [Gender] was diagnosed with a locally advanced non-small cell lung carcinoma
of the right superior sulcus (Pancoast tumor). [Additional statements: The tumor involved adjacent vertebral bodies; therefore
it was classified as T4. The tumor involved the T1 nerve root, therefore it was classified as T3.] This patient underwent
induction chemoradiotherapy with a good clinical response [Additional statement: with decrease in pain and/or a reduction in
the SUV on the PET scan] and is being taken to the operating room for resection of the residual primary tumor.
Description of Procedure: Following induction of satisfactory level of general anesthesia and insertion of a double-lumen
endotracheal tube, the patient was rotated into the [left/right] lateral decubitus position. The patient was rotated slightly
anteriorly to improve the exposure to the posterior chest wall. The [right/left] chest was prepped and draped in the usual
sterile manner. We started with an exploratory thoracotomy as a standard posterolateral incision into the fifth intercostal
space. The Finochietto chest retractor was inserted. The chest was explored to determine that the patient did not have
metastatic disease, had a potentially resectable tumor, and the extent of a chest wall resection.
The Finochietto chest retractor was then removed. The Rultract internal mammary artery retractor was used to elevate the tip
of the scapula. The incision was extended posteriorly to the base of the neck and anteriorly around the anterior border of the
scapula to the mid-axillary line, thereby making the incision periscapular in extent. The serratus anterior muscle was
completely detached from the chest wall and the latissimus dorsi and trapezius were divided which provided full exposure to
the upper portion of the chest wall. The scalene muscles were detached from the first and second ribs. The paraspinous
muscles were elevated to the spinous processes to expose the costovertebral junction and the transverse processes.
The resection was started with the anterior portion of the chest wall. The [RIB NUMBERS, e.g., first through fifth]ribs
were divided with at least 3-4 cm margin. A small piece of each of the ribs anteriorly was sent for permanent analysis. A
portion of the posterior 5th rib was resected to facilitate anterior mobility. Next, the posterior resection was completed by
resecting the entire posterolateral aspect of the first, second, third, and fourth ribs. Small portions of the ribs posteriorly were
submitted for routine pathology.
After the anterior portion of the first rib had been divided at the costochondral junction, dissection along the superior border of
the first rib was performed down to the insertion on the spine to join the posterior dissection. The chest wall was retracted
inferiorly to display the subclavian artery and vein and the brachial plexus. [Additional statement: During the completion of
dissection along the brachial plexus, multiple frozen sections were obtained. The patient did [OR DID NOT]have residual
microscopic disease along the C8 nerve root. The tumor surrounded the T1 nerve root therefore it was resected. No area of
gross residual disease remained. Posteriorly, the paraspinous muscles were retracted to expose the transverse processes. At
this point, the neurosurgeon came to the operating room to complete the posterior aspect of this dissection along the spine.
The upper lobectomy and mediastinal lymph node dissections were completed next. An en bloc resection of the subcarinal and
paratracheal (or AP window) lymph nodes was performed and submitted for frozen section analysis. The upper lobe bronchus
was dissected free, ligated with a TA-30 4.8 mm stapler and then transected distally. The branches of the pulmonary artery to
the upper lobe were dissected free, ligated, and divided with the Endo-GIA vascular stapler. The superior pulmonary vein
branches were ligated with the Endo-GIA vascular stapler. The fissure was divided with Endo-GIA stapler to complete the
resection.
Finally, the chest was closed and reconstructed. Intercostal nerve blocks were performed with 0.5% Marcaine. Two 28
French chest tubes were inserted via separate inferior stab wounds and placed anteriorly and posteriorly in the pleural space.
The thoracotomy incision was then closed by reapproximating the fifth and sixth ribs with #2 Vicryl pericostal sutures. The
chest wall defect was repaired with 2 mm thickness Gore-Tex patch, which was secured in place with #0 Prolene sutures. The
sutures approximated the paraspinous muscles to the patch posteriorly and to the intercostals and chest wall muscles
anteriorly. The entire incision was closed in layers with #0 Vicryl to the chest wall muscles, #2-0 Vicryl to the subcutaneous
tissues, and #3-0 subcutaneous Monocryl for the skin closure. Dressings were applied.
The patient was returned to supine position and reintubated with a single lumen endotracheal tube. Toilet bronchoscopy was
performed. The patient was awoken from general anesthesia, extubated, and transferred to the recovery room.
18. Tracheostomy
Lara Schaheen, MD, and Jonathan D’Cunha, MD, PhD

1. Lines and Pulse Ox Monitoring
3. Time out and administer pre-operative antibiotics according to institutional standards
4. Pre-oxygenate with FiO2 at 100%
5. Neck hyperextension and shoulder roll placement
6. Perform flexible bronchoscopy for pulmonary toilet and evaluate anatomy
7. Arms tucked
8. Sterile prep and drape of the neck and entire chest including lateral aspect in case chest tube needed
9. Palpate cricoid and thyroid cartilages
10. Midline transverse incision one finger breadth above the sternal notch
11. Dissect in midline to the trachea
12. Retract the strap muscles laterally and thyroid isthmus superiorly
13. Palpate the tracheal rings
14. Insert tracheostomy hook if needed to elevate the trachea anteriorly by retracting superiorly.
15. Decrease FiO2 to room air to avoid airway fire (from cautery if required)
16. Have the anesthesiologist deflate the endotracheal tube balloon
17. Make a vertical incision between the second and third tracheal rings
18. Dilate the trachea with a tracheal spreader
19. Withdraw endotracheal tube under vision to just above the tracheotomy
20. Insert tracheostomy tube (typically #8 Shiley).
21. Connect tracheostomy tube to ventilatory circuit. Inflate tracheostomy balloon. Confirm placement with end-tidal
CO2.
22. Confirm placement with flexible bronchoscopy via tracheostomy tube and clear any residual secretions
23. Secure tracheostomy with tracheal sutures x 4 (#2-0 Prolene).
24. Place tracheostomy ties.
25. Perform flexible bronchoscopy via endotracheal tube to ensure good position of tracheostomy and no upper airway
bleeding.
26. Remove endotracheal tube.
27. Order chest x-ray post operatively.

1. Caution with hyperextension of the neck with history of cervical spine injury or fusion.
2. Overextension of the neck should be avoided. It narrows the airway and can lead to placement of the tracheostomy
too low (near the carina and innominate artery).
3. Have several sizes of tracheostomy tubes available. Including a tracheostomy tube that is the same size as the
endotracheal tube and one size smaller in event that placement is difficult.
4. Have reintubation supplies at the ready
5. Stay midline during dissection
6. If difficulty ventilating consider the potential for a pneumothorax
7. Bronchoscopy after placement should ensure that there is no membranous tracheal tear
8. Bleeding must be evaluated carefully
9. Tracheostomy malposition must be inspected for via the tracheostomy tube and via the endotracheal tube
10. Pre-oxygenate patient with 100% Fi02 to avoid hypoxia during tracheostomy placement.
11. Decrease FiO2 to room air prior to making a tracheotomy to avoid an airway fire.
Template Dictation
Preoperative Diagnosis:[INDICATION– e.g. Respiratory Failure, need for prolonged airway management, inability to
manage airway secretions, airway obstruction at or above the level of the larynx, ]
Postoperative Diagnosis:Same
Procedure(s)Performed :Tracheostomy, Flexible Bronchoscopy(DETAILS – e.g. type and size of tracheostomy placed)
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE]year old[GENDER]with[DURATION]history of [COMPLAINT– e.g. respiratory
failure, need for prolonged airway management, inability to manage airway secretions, airway obstruction at or above the level
of the larynx].
Description of Procedure:The patient was identified in the pre-operative holding area and taken to the operating
room on [DATE]. The patient’s identity and planned procedure verified, and the patient was placed on the operating
room table in the supine position. General anesthesia was obtained. A shoulder role was placed to assist in neck
hyperextension. The neck and anterior chest were then prepped and draped in sterile fashion. A time out was
performed prior to beginning the procedure. The patient was pre-oxiginated with 100% FiO2. The trachea, cricoid
cartilage, thyroid cartilage and sternal notch were palpated. A 4 cm midline transverse incision was made one
fingerbreadth above the suprasternal notch. The incision was carried down through the subcutaneous tissues using
cautery. The platysma was divided with cautery. The strap muscles were identified, divided in the midline, and
retracted laterally. The thyroid gland was retracted superiorly, and dissection continued down to the level of the
pretracheal fascia. Hemostasis was maintained. The second tracheal ring was identified. A tracheostomy hook was
placed between the first and second tracheal rings and the tracheal was retracted superiorly. The FiO2 was
decreased to room air. Anesthesia was instructed to deflate the endotracheal tube balloon prior to incising the
trachea. Using an #11 blade scalpel, a vertical incision was made in the trachea between the 2nd and 3rd tracheal
rings. The endotracheal tube was withdrawn so that its tip was immediately proximal to the tracheostomy site. A #
8 tracheostomy tube was successfully inserted and advanced into the trachea. The tracheostomy balloon was inflated
and the tracheostomy was connected to the ventilatory circuit. Placement was confirmed by return of end tidal C02.
Oxygen saturations were excellent. A flexible bronchoscope was placed through the tracheostomy tube to confirm
appropriate placement under direct vision. The tracheostomy tube was secured in place using a #2-0 Prolene sutures
in each of the four quadrants. A soft tracheostomy tie was placed around the patient’s neck leaving two
fingerbreadths space beneath the tape. Bronchoscopy was performed through the endotracheal and tracheostomy
tubes to ensure hemostasis and for pulmonary toilet. There were no immediate complications. Counts were correct x
2 at the end of the case. The patient tolerated the procedure well. A post-operative chest xray was ordered. The
attending surgeon was scrubbed and present for the critical portion of the procedure. The patient was subsequently
transferred to intensive care unit in stable condition.
Dr.[BLANK]was present and scrubbed for[BLANK]elements of this procedure.
19. Tracheal Resection and Reconstruction
Cameron T. Stock, MD and Douglas J. Mathisen, MD
Massachusetts General Hospital, Boston, MA

1. Careful radiologic evaluation
3. Preoperative bronchoscopic evaluation of the trachea by the operating surgeon
4. Dilation of the stenotic tracheal segment to secure the airway for resection or palliation until resection can be
safely performed
5. Careful dissection of the trachea from surrounding structures staying immediately on the tracheal surface to avoid
injury to the recurrent laryngeal nerve
6. Cross field ventilation
7. Placement of traction sutures in the midlateral position on the proximal and distal tracheal ends to gauge tension
on the anastomosis and to take tension off the anastomosis when tying the anastomotic sutures.
8. Placement of interrupted absorbable sutures in an organized and systematic fashion for the anastomosis
9. Coverage of the anastomosis with a pedicled muscle flap
10. Neck drainage / placement of a guardian stitch

1. Poor preoperative patient selection
2. Injury to the recurrent laryngeal nerve by electrocautery or sharp dissection
3. Excessive tension on the anastomosis when tying
4. Compromise of the tracheal blood supply by excessive dissection
5. Injury to the brachiocephalic artery during dissection inferiorly
6. Postoperative wound infection
7. Air leak/subcutaneous air
8. Anastomotic separation/dehiscence
Template Dictation
Preoperative Diagnosis: Tracheal stenosis, tracheal malignancy
Procedure(s) Performed: Tracheal resection and reconstruction, muscle flap coverage of the anastomosis
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [INDICATIONS, e.g., post-intubation tracheal stenosis,
tracheal mass, etc.] who presented with increasing dyspnea and audible stridor with exertion. Preoperative imaging showed
[CXR and CT findings] and bronchoscopy revealed [BRONCHOSCOPIC FINDINGS AND PATHOLOGY RESULTS ].
After discussing the risks and benefits of the procedure, the patient provided informed consent for a flexible bronchoscopy,
tracheal resection and reconstruction and muscle flap coverage of the anastomosis.
Description of Procedure: The patient was brought to the operating room on [DATE]. The patient was confirmed with two
unique identifiers and the correct procedure was verified. The patient was placed supine on the operating table and general
anesthesia was administered. After flexible bronchoscopy revealed healed, non-inflamed tracheal mucosa at the area of known
stenosis, the patient’s neck was extended by insufflating the thyroid bag placed under the patient’s shoulders, and the head was
supported with blankets. The patient’s neck and chest were prepped and draped in the usual fashion. A time out was
performed. A low transverse collar incision was made between the cricoid cartilage and the sternal notch. The incision was
carried through the dermis and subcutaneous fat to the platysma. The platysma was divided transversely and cutaneous sub-
platysmal flaps were raised to the level of the cricoid superiorly and the sternal notch inferiorly. Gelpi retractors were placed
at the lateral aspects of the incision for exposure. The midline of the trachea was identified and the overlying sternohyoid and
sternothyroid muscles were dissected off the surface of the trachea laterally for a short distance. The cricoid cartilage was
identified in the midline and the anterior surface of the trachea was dissected to the thyroid isthmus. The isthmus was divided
sharply and the ends were suture ligated. At the level of the sternal notch dissection of the pretracheal fascia was initiated
using finger dissection and the anterior surface of the trachea was dissected bluntly down to the carina. This maneuver was
employed to allow the distal trachea to slide cephalad with less tension when creating the anastomosis.
Sharp dissection of the affected tracheal segment was performed using scissors and short bursts of electrocautery. Care was
taken to stay immediately on the surface of the trachea to avoid injury to the recurrent laryngeal nerve. Circumferential
dissection of the trachea was completed only on the affected segment. The trachea was divided between cartilages distal to the
tracheal lesion and the trachea was retracted cephalad to facilitate posterior dissection. Care was taken to avoid injury to the
esophagus. Ventilation of the distal trachea was performed by intermittent cross field ventilation with sterile tubing and an
armored Tovell endotracheal tube. After careful dissection of the tracheal lesion was completed, it was divided sharply on the
proximal end of the affected segment and the specimen was passed off the field.
The tracheal ends were inspected and determined to be satisfactory to complete the anastomosis. Full thickness #2-0 Vicryl
traction sutures were placed around the cartilage 1.5 cm from the cut tracheal ends on the proximal and distal airway in the
midlateral position on both sides of the trachea. Next, the neck was flexed by deflating the thyroid bag and placing 2-3 folded
blankets under the patient’s head. The proximal and distal traction sutures were grasped on either side of the trachea and by
pulling them together it was determined there would not be excessive tension on the completed anastomosis. The anastomosis
was performed using interworked #4-0 Vicryl stitches. The first stitch was placed in the posterior membranous trachea at the 6
o’clock position such that the knot would was on the outside of the trachea. The ends were clipped to the drapes cephalad at
the 12 o’clock position. Subsequent stitches were placed on the posterior wall of the tracheal to level of the lateral traction
sutures and were clipped to the drapes in the caudal position. Each subsequent suture was affixed anterior to the proceeding
stitch on the drapes. Sutures were placed approximately 4 mm apart and 2-3 mm from the cut end of the trachea such that all
knots would lie on the outside. Cross field ventilation was performed between stitches. Next, stitches were placed from
traction suture to traction suture along the anterior wall of the trachea and the ends were clipped to a surgical towel placed
cephalad to the incision. After all the anastomotic stitches were placed the proximal and distal traction sutures were then tied
to each other, pulling the tracheal ends together. Next the #4-0 Vicryl stitches placed along the anterior wall were tied from
traction suture to traction suture. The stitches on the back wall were then tied, first on the left side followed by the right side.
The anastomosis was inspected and found to be satisfactory by deflating the cuff on the endotracheal tube, closing the nose and
mouth, and giving a breath to 20-40 cm of H20 pressure.
Next the right sternothyroid muscle was identified and dissected from the sternohyoid muscle. It was divided inferiorly and
rotated over the anastomosis and sutured in place over the anastomotic suture line using interrupted #4-0 Vicryl sutures in a
mattress fashion. The sternohyoid muscles were closed in the midline using interrupted sutures. A #10 flat Jackson-Pratt drain
was placed in the neck near the anastomosis and the platysma and skin were closed. All instrument, sponge and needle counts
were confirmed to be correct. A heavy #2 Vicryl “guardian” stitch was placed from the chin to the presternal skin to prevent
tension on the anastomosis. A sterile dressing was applied to the neck incision. The patient was extubated and brought to the
ICU in stable condition.
20. Esophageal Stent Placement
Thomas Caranasos, MD and Kfir Ben-David, MD
University of Florida, Gainesville, FL

1. Preoperative imaging to determine pathology (Malignant esophageal stricture, Begin esophageal stricture, Esophageal
perforation, Leak following esophageal or gastric surgery, Tracheoesophageal fistula)
2. Appropriate noninvasive monitoring
3. Conscious sedation or general endotracheal anesthesia.
4. Introduction of the scope into the esophagus to the pylorus or duodenum depending on pathology
5. Examination of the stomach and hiatus with retroflexion
6. Examination of the GE junction and esophagus
7. Recognition of pathology
8. Deployment of the stent
9. Examination of appropriate positioning
10. Safe withdrawal of the scope

1. Appropriate administration of sedation (avoiding over-sedation, hemodynamic instability, or aspiration)
2. Introduction of the scope within the esophagus
3. Careful advancement of the scope, especially in the face of stricture as to not cause perforation.
4. Appropriate examination of the entire stomach, possibly the duodenum, GE junction, and esophagus for underlying
pathology. Biopsy if needed.
5. Management of bleeding with clips or submucosal epinephrine injection
6. Deployment of stent bridging area of pathology
7. Anchoring the stent to prevent stent migration
8. Evaluation of placement of the stent for concern of perforation or mucosal injury
9. Appropriate timing of stent removal to avoid late complications (Perforation, Erosion, Migration, Bleeding)
Template Dictation
Preoperative Diagnosis: Esophageal Perforation
Procedure(s) Performed: EGD, Esophageal Stent Placement
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [Blank] is a 60 year old male who is post procedure day 2 from EGD for Achalasia. He returned
to the hospital with worsening mid-epigastric pain. Oral contrasted CT imaging showed evidence of distal esophageal leak.
The risks, benefits, and alternatives to the above procedure were discussed at length with the patient and he agreed to and
accepted the risks.
Description of Procedure: The patient was brought to the endoscopy suit. Noninvasive blood pressure and continuous heart
rate and pulse oximetry monitoring were utilized throughout the procedure. Versed and fentanyl were used for conscious
sedation. The endoscope was introduced through the bite block in the mouth and into the posterior oropharynx. The vocal
cords were visualized anteriorly and the scoped passed posterior to the left arytenoid and into the esophagus. Under direct
visualization the scope was carefully advanced. The proximal and middle esophagus appeared normal. A [Finding and
description - e.g. 10 mm mucosal laceration was noted at 38 cm from the incisors. The tear was located on the left anterior-
lateral portion of the esophagus. The lesion extended from 38-39 cm from the incisors]. The GE junction was measured at [X]
cm from the incisors. The scope is slowly advanced into the stomach and retroflexed to examine the GE junction. No evidence
of hiatal hernia or gastric perforation was visualized. The stomach and first portion of the duodenum were examined. No
abnormalities were noted. The scope was slowly withdrawn 10 cm proximal to the level of the [lesion to be stented]. Under
direct endoscopic visualization, a 0.97 mm guide wire was advanced into the stomach. A [dimensions X by X] [brand] stent
was deployed according to the manufacturer’s recommendation. The proximal end of the stent was positioned at [X] cm from
the incisors with the distal end bridging the GE junction and positioned in the stomach. The string at the proximal end of the
stent was clipped to the mucosa with two endo-clips to prevent migration. The scope was then passed back into the stomach to
confirm appropriate positioning and slowly withdrawn and removed. The bite block was removed and the patient transferred
to the endoscopy recovery room in stable condition.
21. Laparoscopic Nissen Fundoplication
Luis F. Alberton, MD and Sean Kwon, MD
North Shore Long Island Jewish Health System, New Hyde Park, NY

1. Lithotomy position or supine with foot rest to allow steep reverse Trendelenburg position
2. Foley catheter
3. Additional peripheral IVs +/- arterial line
4. Gain access to abdominal cavity with Veress needle or open Hassan technique
5. Inspect abdominal cavity and place additional ports
6. Place liver retractor to provide exposure of hiatus
7. Mobilize lesser curvature, divide gastrohepatic ligament
8. Dissect right crus
9. Mobilize greater curvature
10. Dissect left crus
11. Complete anterior portion of mediastinal dissection of the distal esophagus starting on the pericardium anteriorly and
then working from pleura to pleura
12. Take down retrogastric and retroesophageal attachments and identify the decussation of the right and left crus
13. Complete the mediastinal dissection in the posterior (periaortic plane) until the distal esophagus has been mobilized
circumferentially taking care to spare both vagal trunks
14. Dissect the GEJ fat pad to identify the true GEJ
15. Collis gastroplasty if there is inadequate length of intraabdominal esophagus
16. Place Bougie (i.e., 54 Fr)
17. Grasp fundus along the line of the short gastrics and pass from left to right in the retroesophageal window inside of
the vagus nerves
18. Shoe shine technique to assure the absence of rotational torsion
19. Place 2 to 3 sutures to secure the wrap around the esophagus
20. Remove Bougie
21. Close diaphragmatic hiatus
22. Remove liver retractor and ports under direct visualization
23. Close port sites
Special Equipment
1. 5 and/or 10 mm 30 or 45 degree laparoscopes
2. Endoscopic suturing instrument or pledged sutures
3. Self-retaining liver retractor
4. Electrocautery / ultrasonic dissector

1. Injury to abdominal viscera or blood vessels while entering the abdominal cavity.
2. Esophageal or gastric perforation
3. Tension pneumothorax
4. Hypotension secondary to CO2 insufflation
5. Injury to replaced left hepatic artery while dissecting gastrohepatic ligament
6. Spleen or splenic vascular injury
7. Bleeding secondary to injury to the short gastrics
8. Wrap or hiatal closure too tight or too loose
9. Injury to vagus nerves
10. When dissecting the GEJ fat pad, always work from right to left
11. Inadequate mobilization of the esophagus and failure to recognized a short esophagus
12. Constructing the wrap around the cardia
13. Denuding the peritoneum off the right or left crus
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. reflux disease unresponsive to medical therapy]
Procedure(s) Performed: Laparoscopic Nissen Fundoplication and hiatal hernia repair
Assistants: [BLANK]
Anesthesiologist: [BLANK]
Anesthesia: GETA IVF: [BLANK] EBL: [BLANK] UO: [BLANK]
Indication(s) for Procedure: [AGE]year old [GENDER]with [DURATION]history of gastroesophageal reflux disease
manifesting as [SYMPTOMS] that has failed to respond to maximal medical therapy. [HIS/HER] preoperative evaluation has
included a barium esophagram which revealed [FINDING S]. Esophageal manometry demonstrated [FINDING S]. A pH
study demonstrated a DeMeester score of [X]. A upper endoscopy was obtained which revealed a [X] cm hiatal hernia and
[OTHER FINDINGS, i.e., Barrett’s esophagus, esophagitis, etc]. After discussing the risks and benefits of the procedure,
the patient provided informed consent for a laparoscopic Nissen fundoplication and hiatal hernia repair.
procedure were verified, and the patient was placed on the operating room table in the supine position. Sequential
compression devices were placed in both legs for DVT prophylaxis. Following an uneventful induction of general anesthesia,
the patient was intubated without incident. A Foley catheter was inserted. [Patient was placed on lithotomy position]. The
abdomen was then prepped and draped in the usual sterile fashion. The camera and insufflation equipment were connected and
checked. A time out was then performed according to hospital policy.
Access to the abdominal cavity was obtained using [Hassan/Veress needle] technique. A camera port was placed in the
midline supraumbilical area, approximately 15cm from the xiphoid process. Pneumoperitoneum was established with carbon
dioxide to a pressure of 15 mmHg, paying close attention to the vital signs and flow and total volume of gas infused.
Inspection of abdominal cavity was performed and no abnormalities or injuries were identified. Four additional ports were
placed. A 10-mm trocar was placed below the left costal margin, 11 cm away from the xiphoid process. A 5-mm assistant's
port was placed a hand’s breadth lateral to the 10 mm trocar along the left costal margin. A 5-mm trocar for the liver retractor
was inserted just below the right costal margin in the lateral aspect of the right upper quadrant. A self-retaining liver retractor
was then used to elevate the left lateral segment of the liver to expose the esophageal hiatus. The retractor is stabilized with a
table-mounted mechanical arm. An additional 5-mm trocar was inserted just to the right side of the Falciform ligament and
angled toward the hiatus.
Once all the trocars were in place, the gastrohepatic ligament was divided directly over the caudate lobe using
[electrocautery / ultrasonic dissector]. The dissection was continued towards the base of the right crus. The medial border
of the right crus was defined, taking care to preserve its peritoneal lining. We began the lateral mediastinal portion of the
dissection, sweeping the pleura laterally. We then divided the peritoneum anteriorly and continued along the medial border of
the left crus, taking care to preserve its peritoneal lining. We then completed mobilization of the distal esophagus in the
anterior plane, working directly on the pericardium and then working from pleura to pleura, taking care to preserve the anterior
vagus nerve.
Attention was then directed to the greater curvature of the stomach. The gastrosplenic ligament was opened with the ultrasonic
dissector, and the short gastric vessels were divided to the level of the Angle of His. We then completed our dissection along
the medial border of the left crus.
Attention was then redirected to the lesser curvature of the stomach. The stomach was elevated. The retroesophageal and
retrogastric attachments were taken down. [A Penrose drain was passed around the esophagus and used for retraction.]
The distal esophagus was then mobilized posteriorly in the pre-aortic areolar soft tissue plane. The distal esophagus was then
circumferentially mobilized. Both vagal trunks were identified and were spared during the dissection. In order to identify the
true gastroesophageal junction, we mobilized the GEJ fat pad laterally off the esophagus, sparing both vagal trunks. We noted
approximately [x] cm of intraabdominal esophagus. [Variation: Collis gastroplasty may be performed if a short esophagus
(<2 cm of intra-abdominal length) is present]. The Penrose drain was removed.
The posterior aspect of esophageal hiatus was then closed with interrupted [SIZE and TYPE;e.g, non-absorbable, pledged]
sutures. The fundus of the stomach was then grasped and passed from left to right in the retroesophageal window between the
esophagus and the fat pad. The lines of the short gastrics on either side of the wrap were aligned with one another, thereby
forming a 360 degree wrap. A [SIZE] Bougie was advanced transorally down the esophagus and into the stomach under
direct vision. We performed a “shoeshine maneuver” to assured the absence of rotational torsion. The wrap was then sutured
in place using [TYPE AND NUMBER OF SUTURES ], taking a bite of the fundus on one side, the esophagus, and then the
fundus on the other side. The Bougie was removed. An NG tube was placed under and the liver retractor and ports then
removed under direct visualization. The abdominal cavity was again inspected and no bleeding or sites of injury were seen.
Pneumoperitoneum was then desufflated. The fascial incisions of the 10 mm ports were closed with [SUTURE].Finally the
skin was closed with [SUTURE / GLUE] and sterile dressings then applied.
subsequently transferred to the postanesthesia care unit in satisfactory condition.
22. Laparoscopic Paraesophageal Hernia Repair
Andrew B. Nguyen, MD and James D. Luketich, MD

1. Upper endoscopy.
2. Supine position (far right on operating bed), arms out 45 degrees, and foot board placement for steep reverse
Trendelenburg.
3. Place 10 mm port via open Hasson technique in the right paramedian line approximately one-third of the way from the
xiphoid to the umbilicus.
4. CO2 insufflation to 15 mmHg.
5. Confirm position within the peritoneal cavity and inspect abdomen with laparoscope.
6. Place additional ports under direct laparoscopic visualization. An 11 mm left paramedian port one hand’s breadth to
the left initial cutdown port. A 5 mm right and left subcostal port a hand’s breadth from the paramedian port sites. A
5 mm port in the lateral right upper quadrant directed along the lower edge of the liver.
7. Insert liver retractor to elevate the left lobe of the liver for exposure of the hiatus.
8. Place patient in steep reverse Trendelenburg position to facilitate visualization of the hiatus.
9. Reduce herniated content gently while avoiding placing traction on the stomach.
10. Evert and incise hernia sac anteriorly.
11. Complete the anterior portion of the dissection, beginning on the pericardium and then working from pleura to pleura.
12. Open the gastrohepatic omentum directly above the caudate lobe
13. Define the medial border of the right crus, while preserving its peritoneal lining.
14. Divide the short gastric vessels.
15. Define the medial border of the left crus, while preserving its peritoneal lining.
16. Medistinal dissection in areolar periaortic soft tissue plane
17. After mobilizing the esophagus circumferentially to the level of the inferior pulmonary veins, excise the hernia sac
18. For a Nissen-Fundoplication
1. Dissect gastric fat pad off stomach to precisely identify the gastroesophageal junction.
2. Develop a retroesophageal window between the esophagus and posterior vagus nerve.
3. Pass a 54-French bougie transorally into the stomach under direct laparoscopic visualization.
4. [Perform Collis gastroplasty if more intrabdominal esophageal length is required.]
5. Create a “floppy” Nissen wrap.
19. For a gastropexy:
1. Interrupted u-stitches between the line of the short gastrics and left hemidiaphragm
20. Close hiatus with interrupted sutures approximating crura posteriorly (and anteriorly if necessary).
21. Place NG tube
22. Close

1. Avoid upper overinsufflation during upper endoscopy which will increase the difficulty of a laparoscopic repair.
2. Trocar injuries.
3. Injury to esophagus.
4. Injury to stomach.
5. Injury to spleen.
6. Vagal nerve injury. Be cognizant of the location of both nerves during the dissection. Minimize the risk of anterior
vagal nerve injury by beginning the dissection anteriorly and dissecting in the areolar soft tissue plane. Dissect the fat
pad by working from left to right
7. Inadequate esophageal mobilization or failure to recognize a short esophagus can result in a recurrence. Many
patients with giant paraesophageal hernias require gastroplasties
8. A poorly planned gastroplasty can result in undue angulation of the stomach
9. An excessively tight hiatal repair can cause obstructive symptoms. An excessively loose repair can contribute to a
recurrence.
10. Hypercapnea from CO2 insufflation
11. Pneumothorax
Template Dictation
Preoperative Diagnosis: Paraesophageal hernia
Procedure(s) Performed: Laparoscopic paraesophageal hernia repair
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: This is a [AGE]-year-old male/female who presented with [SYMPTOMS AND SIGNS] . The
patient was found on [ESOPHAGRAM/UPPER ENDOSCOPY/COMPUTED TOMOGRAPHY SCAN] to have a type
[II/III/IV] paraesophageal hernia involving a large portion of the stomach/ +/- OTHER ABDOMINAL STRUCTURES]
The risks and benefits had been discussed with the patient regarding surgical repair. The patient provided informed consent
for an upper endoscopy, laparoscopic (possible open) paraesophageal hernia repair, and [NISSEN
FUNDOPLICATION/GASTROPEXY], [AND POSSIBLE COLLIS GASTROPLASTY].
Description of procedure: The patient was identified in the preoperative area, taken to the operating room, and placed supine
on the operating table. General anesthesia was induced. The patient was intubated with a single-lumen endotracheal tube.
[CEFAZOLIN/OTHER ANTIBIOTIC] was given for perioperative antibiotic prophylaxis. A Foley catheter was inserted.
Sequential compression devices were placed bilaterally in the lower extremities and a dose of 5000 units of subcutaneous
heparin was given for deep venous thrombosis prophylaxis. A proper time-out was conducted.
An upper endoscopy was first performed. A flexible endoscope was inserted transorally and advanced distally into the
esophagus. The esophagus appeared [DESCRIBE FEATURES, NORMAL, ESOPHAGITIS, BARRETT’S ESOPHAG
ETC]. The gastroesophageal junction was noted at about [LOCATION FROM INCISORS] cm and the crural pinch at
[LOCATION FROM INCISORS] cm from the incisors, consistent with a [SIZE] hiatal hernia. The endoscope was advanced
into the stomach, which had herniated in the chest. Care was taken to not over insufflate the stomach to avoid gastric and
intestinal distention. The scope was advanced through a patent pylorus into the duodenum, which appeared normal. The
duodenum, stomach, and esophagus were then desufflated as the endoscope was withdrawn.
The patient is positioned far right on the operating room table in preparation for the subhepatic liver retractor. A foot board
was placed for support during steep reverse Trendelenburg positioning. The patient’s arms were secured to the arm board,
carefully padded, and rotated 45 degrees away from the bed. The patient was then prepped and draped in the usual sterile
fashion.
The first port was placed using the open Hasson technique in the right paramedian line approximately one-third of the distance
from the xiphoid process to the umbilicus. The skin was incised and the subcutaneous tissue was bluntly dissected with S
retractors. The anterior sheath was opened vertically with electrocautery. The S retractors were used to separate the rectus
muscles in the direction of the fibers. The posterior sheath was then grasped with tonsils, elevated, and incised. The
peritoneal cavity was entered with S retractors and a 12-mm Hassan port was then placed, taken care to avoid dissecting into
the falciform ligament. The abdomen was insufflated to 15 mmHg and the 30-degree laparoscope was inserted to confirm
position within the peritoneal cavity and inspect the abdomen. The Hasson port was then secured to the skin with Vicryl
sutures. Additional ports were then placed under direct laparoscopic visualization. A left paramedian port was placed
approximately one hands breadth to the left and slightly lower to the initial cutdown port. Bilateral 5 mm subcostal ports were
placed a hand’s breadth from the paramedian ports. A 5 mm port was placed in the lateral aspect of the right upper quadrant
and in-line with the lower edge of the liver for insertion of the liver retractor. Under direct laparoscopic visualization, the
liver retractor was inserted and used to elevate the left lobe of the liver for exposure of the hiatus.
The patient was placed in steep reverse Trendelenburg position to facilitate visualization of the hiatus. The herniated content
was then reduced gently. The herniated sac was then grasped near the 12’oclock position and everted. Using the harmonic
scalpel, the sac was opened, exposing the areolar plane between the hernia sac and the mediastinum. The sac was sharply and
bluntly dissected from the pleura laterally on both sides, the pericardium anteriorly, and the aorta posteriorly with the use of
the harmonic scalpel. The anterior and posterior vagus nerves were identified during the mediastinum dissection and
preserved.
Attention was then turned to opening the gastrohepatic omentum directly over the caudate lobe. The dissection was continued
towards the base of the right crus.
After the division of the gastrohepatic omentum, the esophagus was mobilized first by dissecting out the right crus and taking
down the phrenoesophageal ligament, making sure to preserve the peritoneal lining of the right crus. The areolar plane
between the esophagus and the right crus was entered. Extensive, circumferential mobilization of the esophagus was then
performed high in the mediastinum to the level of the inferior pulmonary veins to help re-establish adequate intraabdominal
esophageal length of 2-3 cm. Again, the vagus nerves were identified and preserved. The left crus and base of the crura were
also dissected during the mobilization of the esophagus.
Attention was then turned to the mobilization of the fundus and the division of the short gastric vessels. With the traction of
gastrosplenic omentum and countertraction of the stomach, the short gastric vessels were ligated with a harmonic scalpel along
the upper third of the greater curve of the stomach. Care was taken as the superior pole of the spleen was approached to avoid
injury to the spleen. Gastrosplenic attachments were carefully ligated. Retrogastric attachments were also taken down, and a
window was created into the lesser sac. Division of the short gastric vessels provided exposure to the left crus and angle of
His, which was further dissected to help facilitate retroesophageal mobilization.
To help facilitate precise identification of the gastroesophageal junction, the gastric fat pad was dissected anteriorly off the
stomach and distal esophagus, taking care to preserve the anterior vagus nerve. A retroesophageal window was then
developed between the esophagus and posterior vagus nerve through which a Nissen fundoplication would be performed.
[Collis Gastroplasty] Despite extensive esophageal mobilization, additional esophageal length was required, which was
achieved through laparoscopic wedge Collis gastroplasty. A 54-French bougie was placed transorally into the stomach under
direct laparoscopic visualization to allow for safe passage. The stomach was then grasped just proximal to the planned initial
staple site. Using a 4.8 mm green load/3.5mm blue load cutting endostapler, serial fires were taken perpendicular to the
bougie to divide the stomach toward the bougie. With gentle traction of the partially stapled gastric wedge, additional serial
firings of the endostapler were placed parallel to the bougie to complete the creation of the neoesophagus.
In preparation for a “floppy” Nissen fundoplication, a 54-French bougie is placed transorally into the stomach under direct
laparoscopic visualization to allow for safe passage. A grasper was then passed through the retroesophageal window. The
fundus was grasped at the level the divided short gastric vessels along the greater curvature and pulled through the window to
the right side. A “shoe-shine” maneuver was then performed with the created wrap to ensure adequate mobility without twists
or tension. The “floppy” Nissen fundoplication was then secured with two #2-0 Surgidac sutures with the use of the Endo
Stitch suturing device. Each stich incorporated full thickness of the stomach and partial thickness of the esophagus, spaced 2
cm apart to prevent slippage of the wrap.
[Gastropexy] Due to concerns for the patient’s intraoperative instability/age/co-morbidities/viability of the
stomach/preoperative symptoms and esophageal dysmotility, a gastropexy was performed. With an Endo Stitch suturing
device, multiple serial interrupted horizontal mattress of #0 Surgidac sutures were placed between the stomach and the anterior
abdominal wall over a distance of about 10 cm, spaced 2 cm apart.
Attention was then turn to performing a tension-free hiatal closure. The bougie was removed and the crura were assessed for
adequate tissue integrity and mobility. [Due to the enlarged hiatus and significant tension with the approximation of the crura,
left pneumothorax was induced with a placement of the pigtail catheter in the left pleural space under direct laparoscopic view
of the diaphragm. The diaphragm was noted to become relaxed and bulged into the peritoneal cavity. The pigtail catheter was
then secured to the skin and placed to drainage after the closure of the hiatus.] The crura were reapproximated with 2 (or 3)
posterior interrupted sutures of #0 Surgidac using the Endo Stich suturing device. [After approximating the crura posteriorly,
the hiatus was re-evaluated and noted to have a patulous anterior space. A single stitched was then placed anteriorly in the
upper aspect of crura.] Care was taken to avoid artificially creating an angulation of the esophagus at the hiatus. At the
completion of the hiatal closure, a grasper was easily passed through the hiatus and the closure did not appear tight.
A nasogastric tube was then placed under direct laparoscopic vision to confirm placement in the stomach.
After ensuring adequate hemostasis, the right paramedian port placed via open Hasson technique was removed under direct
laparoscopic visualization. The fascial defect was closed with a single #0 Vicryl suture using a Carter-Thomason device. The
other ports were removed under direct laparoscopic visualization. The abdomen was desufflated. The camera port was then
removed. All skin incisions were closed and sterile dressings were applied.
The patient tolerated the procedure well and was transferred to the postanesthesia care unit in stable condition.
23. Transhiatal Esophagectomy
Michelle C. Ellis, MD & Jules Lin, MD
University of Michigan, Ann Arbor, MI

1. Lines and monitoring (arterial line, large bore IV)
2. Consider epidural catheter placement
4. Intraoperative esophagoscopy
5. Laparotomy
6. Assess for resectability, conduit choice
7. Gastric mobilization
8. Kocher maneuver
9. Pyloromyotomy/pyloroplasty
10. Placement of feeding jejunostomy
11. Hiatal dissection and lower esophagus mobilization with mediastinal lymphadenectomy
12. Cervical incision and upper esophagus mobilization
13. Transhiatal mobilization of entire esophagus
14. Division of cervical esophagus
15. Packing of the mediastinum and chest tube placement (if needed)
16. Preparation of gastric conduit
17. Gastric conduit pull through and positioning
18. Reapproximation of the diaphragmatic crus
19. Maturation of feeding jejunostomy
20. Abdominal closure
21. Cervical anastomosis
22. Placement of cervical drain and wound closure

1. Unrecognized progression of disease
2. Unrecognized replaced left hepatic artery
3. Splenic injury
4. Inadequate/unhealthy conduit (ischemic, traumatized, or narrowed), need for alternate conduit (colon, jejunum)
5. Control of left gastric artery
6. Inadequate duodenal mobilization
7. Inadvertent pyloric mucosal injury
8. Mediastinal bleeding (azygous vein injury)
9. Injury to the membranous trachea
10. Recurrent laryngeal nerve injury
11. Torsion of conduit
12. Tension free cervical anastomosis
Template Dictation
Preoperative diagnosis: [INDICATION– high grade dysplasia, esophageal squamous or adenocarcinoma] [with or without
neoadjuvant chemoradiation therapy]
Postoperative diagnosis: same
1. Flexible esophagoscopy
2. Transhiatal esophagectomy
3. Cervical esophagogastric anastomosis
4. Pyloromyotomy
5. Jejunostomy tube placement
6. +/- chest tube placement
Assistants: [BLANK]
Anesthesia: [BLANK]
Estimated blood loss: [BLANK]
Specimens: Esophagus and proximal stomach, proximal esophageal margin
Drains: Nasogastric tube, cervical Penrose drain, jejunostomy tube, +/- chest tube
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT-dysphagia, reflux].
Preoperative workup reveals [TESTING performed and FINDINGS]. I have discussed with the patient the risks and benefits
of a transhiatal esophagectomy including the risks of an anastomotic leak, stricture, damage to surrounding structures including
the recurrent laryngeal nerve resulting in hoarseness, the airway, blood vessels, spleen resulting in a splenectomy, thoracic
duct resulting in a chylothorax, cancer recurrence, heart attack, stroke, and death. She/He asked appropriate questions and
would like to proceed.
Description of Procedure: The patient was taken to the operating room on [DATE]. A time-out was completed verifying
correct patient, procedure, site, positioning, and implant(s) or special equipment. After induction of satisfactory general
endotracheal anesthesia, the flexible esophagoscope was introduced through the cricopharyngeus sphincter without difficulty.
The squamocolumnar epithelial junction was located at X cm and the gastroesophageal junction at X cm. The tumor extended
from X cm to X cm. There [was X cm of/no] extension onto the stomach. The gastroscope was advanced into the stomach and
retroflexed. [FINDINGS ON EXAMINATION OF STOMACH]. The esophagoscope was then removed without difficulty.
The patient was positioned supine with a folded blanket under the shoulders. The head was turned to the right and supported on
a head ring. The arms were padded and tucked at the sides. The skin of the neck, chest and abdomen was prepped and draped.
A second time-out was completed verifying correct patient, procedure, site, positioning, planned operation and site.
The peritoneal cavity was entered through a supraumbilical midline incision. The triangular ligament of the liver was divided
with cautery, and the left lobe of the liver was padded and retracted to the right. An upper hand self-retaining table mounted
retractor was inserted. Exploration of the upper abdomen revealed no evidence of metastatic disease and no palpable mass in
the stomach. After identifying the course of the right gastroepiploic artery, and beginning at the midpoint of the greater
curvature of the stomach, the greater omentum was separated from the stomach to the level of the pylorus between right-angled
clamps applied at least 1-2 cm below this vessel using #2-0 silk ties. The left gastroepiploic artery and short gastric vessels
were divided between right-angled clamps using #2-0 silk ties. Care was taken to avoid injury to the spleen. The peritoneum
overlying the esophageal hiatus was incised. The gastrohepatic omentum was incised, preserving the right gastric artery. The
left gastric vein was divided between right angle clamps and ligated with a #2-0 silk. The left gastric artery was dissected,
doubly ligated with #2-0 silk and divided.
A generous Kocher maneuver was performed. A 2 cm long pyloromyotomy was carried out, beginning 1.5 cm on the stomach
and extending onto the duodenum for 0.5-1 cm. This was performed using the cutting current of a needle tipped electrocautery
and a fine tipped mosquito clamp. The duodenal mucosa [WAS/WAS NOT] entered during this dissection. [Due to a mucosal
injury, a pyloroplasty was performed opening the pylorus longitudinally. The pyloroplasty was closed transversely in 2 layers
reapproximating the mucosa with a running #4-0 PDS suture and a second layer of interrupted Lembert #4-0 PDS sutures. The
pylorus was marked with silver clips for future radiographic identification.
A #14 French rubber jejunostomy tube was inserted 4-6 inches beyond the ligament of Treitz and was secured in place with
two #4-0 Prolene purse-string sutures and then a 4 cm long Witzel maneuver. Attention was then turned to the mobilization of
the esophagus. With downward traction on the Penrose drain encircling the esophagogastric junction, the diaphragmatic hiatus
was progressively dilated until the hand could be inserted into the posterior mediastinum through the diaphragmatic hiatus. The
following findings relative to the esophagus were encountered: [FINDINGS: e.g., There were moderate mediastinal
adhesions. There was a palpable distal esophageal mass.]. Dissection of the distal 5-10 cm of the esophagus was performed
using electrocautery and a long right-angled clamp and then more superiorly keeping the fingers closely applied to the
esophagus. Narrow retractors placed into the hiatus allowed visualization, division, and ligation of the lateral attachments of
the distal half of the esophagus. Accessible paraesophageal, left gastric, and celiac axis lymph nodes were mobilized for
resection with the esophagus and proximal stomach. During the mediastinal dissection, arterial blood pressure was monitored
with a radial arterial line to avoid prolonged hypotension due to displacement of the heart. The dissection was carried to the
level of the carina. Attention was then turned to the neck.
Through an oblique left cervical incision paralleling the anterior border of the sternocleidomastoid muscle, the platysma
muscle was divided. The carotid sheath and its contents were retracted laterally, the trachea and thyroid gland medially, and
the prevertebral fascia identified. Care was taken throughout the cervical dissection to avoid direct pressure on the recurrent
laryngeal nerve in the tracheoesophageal groove. The cervical esophagus was encircled with a one inch Penrose drain, and
with gentle upward traction, blunt mobilization of the upper thoracic esophagus from the superior mediastinum was performed.
Working upward from the diaphragmatic hiatus and downward through the cervical incision, mobilization of the esophagus
was completed using a combination of finger dissection and dissection with a sponge stick. Blood was evacuated from the
mediastinum with a #28 French Argyle Saratoga sump catheter. Once the entire intrathoracic esophagus was free from the
mediastinum, the nasogastric tube was withdrawn into the cervical esophagus. The upper esophagus was delivered into the
neck wound and divided with a 3.8 mm GIA surgical stapler. The stomach and esophagus were delivered out of the abdominal
wound. Narrow retractors were inserted into the diaphragmatic hiatus, and the mediastinum inspected for bleeding. No
significant mediastinal bleeding was encountered. Both sides of the mediastinal pleura were inspected for injury. Entry into
both pleura [WAS/WAS NOT] identified [28F straight chest tubes were placed bilaterally, secured to the skin with #2-0
vicryl, and attached to Pleurovacs].
The esophagus and proximal stomach were then separated from the remaining stomach by applying the 3.8 mm GIA surgical
stapler several times along the lesser curvature of the stomach 4-5 cm distal to the esophagogastric junction. The thoracic
esophagus and proximal stomach were then removed from the field. The gastric staple suture line was oversewn with a running
#4-0 Prolene Lambert suture. The stomach was then gently manipulated through the hiatus and advanced manually upward
through the posterior mediastinum until the gastric fundus could be visualized at the base of the neck wound and drawn into the
field. The position of the stomach in the neck wound was maintained by packing a small moistened gauze into the thoracic inlet
alongside the stomach to prevent it from retracting down into the mediastinum. Care was taken to be certain that the stomach
was not twisted within the mediastinum. The abdomen was then inspected for hemostasis. The diaphragmatic hiatus was
narrowed to three fingerbreadths with [X] interrupted #1 silk sutures and was then loosely tacked to the adjacent stomach with
one interrupted #3-0 silk suture. The left lobe of the liver was returned to its normal location and reapproximated to the
diaphragm with a #3-0 silk suture.
The jejunostomy tube was brought out through a separate left upper quadrant incision and sutured to the adjacent peritoneum
with interrupted #3-0 silk sutures. The tube was secured to the skin with a #2-0 Prolene suture. The abdomen was closed using
a running #1 looped PDS suture on the muscle fascia, running #2-0 vicryl on the subcutaneous tissue and a #4-0 monocryl
subcuticular suture on the skin.
After closure of the abdomen, the cervical esophagogastric anastomosis was performed. A 1.5 cm anterior gastrotomy was
made and the stapled end of the cervical esophagus amputated. A side to side anastomosis between the cervical esophagus and
gastric fundus was performed using the 3.8 mm Endo-30 GIA stapler. Two lateral suspension sutures of #4-0 Vicryl were
placed between the cervical esophagus and the stomach on either side of the anastomosis. A 16 Fr nasogastric tube guided
across the anastomosis and into the intrathoracic stomach. The anterior esophagotomy and gastrotomy were closed in 2 layers
with running and then interrupted #4-0 PDS sutures. A silver hemoclip was placed on either side of the anastomosis for future
radiographic identification. The neck was irrigated with warm water, and a 1/4 inch Penrose drain was placed next to the
anastomosis. Muscle fascia was loosely reapproximated with interrupted #3-0 Vicryl, and the skin edges were reapproximated
with a #4-0 monocryl subcuticular suture. Dry sterile dressings were applied to all incisions.
The sponge and needle counts were correct.
A postoperative chest radiograph obtained in the operating room demonstrated [CORRECT/INCORRECT] placement of
chest tubes with no pneumothorax or effusion.
The patient tolerated the procedure well and left the operating room extubated and in satisfactory condition.
24. Open Modified Mckeown Esophagectomy
Zarrish S. Khan, MD and Subroto Paul, MD

1. Preoperative workup-staging, neoadjuvant treatment, cardiopulmonary workup.
2. General anesthesia, endotracheal tube, lines and monitoring
4. Esophagogastroduodenoscopy
5. Double lumen endotracheal tube
6. Left lateral decubitus position, right posterolateral thoracotomy.
7. Divide inferior pulmonary ligament, open mediastinal pleura, divide Azygous vein.
8. Dissect esophagus (from the hiatus to the thoracic inlet) en bloc with lymph nodes. Penrose drains looped around the
esophagus and knotted. One is tucked in thoracic inlet, and one is tucked in hiatus.
9. Ligate thoracic duct
10. Confirm hemostasis and place chest tube
11. Close thoracotomy in layers
12. Turn patient supine.
13. Midline laparotomy. Look for ascites. Examine and palpate abdominal cavity and liver for metastases.
14. Mobilize left lobe of liver. Place retractors
15. Divide lesser omentum in avascular plane.
16. The transverse colon mobilized from the greater omentum
17. Greater omentum resected, leaving the gastroepiploic arcade.
18. The greater curvature of the stomach grasped protecting the right gastroepiploic arcade. Lesser sac entered.
Beginning inferiorly travelling along the greater curvature, tissues and short gastric vessels were divided outside of
the right gastroepiploic arcade to completely free greater curvature.
19. Dissect gastroesophageal junction. Previously placed Penrose drain is grasped and used for retraction.
20. Divide left gastric vessels
21. Take down remaining retrogastric attachments
22. Widely Kocherize the duodenum.
23. Pyloromyotomy/pyloroplasty
24. Jejunostomy tube inserted 40 cm distal to ligament of Treitz; Witzle, secured to abdominal fascia, and brought out
abdominal wall.
25. Incision along medial aspect of left sternocleidomastoid muscle. Divide omohyoid.
26. Bluntly retract sternocleidomastoid and carotid sheath laterally. Bluntly dissect down to prevertebral fascia, identify
and grasp the previously placed Penrose drain at the thoracic inlet.
27. Esophagus is divided at the level of the clavicle and then withdrawn from the abdomen through the esophageal hiatus
28. Construct a 4cm wide gastric conduit based on the line of the short gastric vessels, beginning at level of Crow’s foot
and extending to Angle of His. Oversew the staple line.
29. Deliver the gastric conduit preserving appropriate orientation (staple line facing patient’s right side) through the
mediastinum into the cervical incision.
30. End-to-end two layer handsewn anastomosis using interrupted 3-0 Vicryl for the inner layer and 3-0 PDS for the
outer layer
31. Nasogastric tube passed distally through the conduit.
32. #10 flat Jackson-Pratt placed into the neck incision,
33. Neck incision closed in layers.
34. Redundancy in the conduit is reduced and conduit is tacked to hiatus to prevent herniation
35. Abdominal fascia and incision closed in layers
36. Exchange double lumen for single lumen endotracheal tube
37. Toilet bronchoscopy and assess airways for thermal injury.

Procedure Specific Complications:
1. Anastomotic complications (i.e., leak/dehiscence and strictures)
2. Gastric conduit necrosis
3. Recurrent nerve injury, resulting in aspiration and impaired ability to swallow.
4. Chylothorax from thoracic duct injury
5. Gastric outlet obstruction
6. Tracheobronchial tree injury with or without tracheoesophageal fistula
7. Diaphragmatic herniation of abdominal contents
General Complications of Abdominal and Chest Surgery:
1. Bleeding requiring transfusion and reoperation.
2. Cardiovascular complications including arrhythmias and myocardial infarction
3. Thromboembolic complications including deep venous thrombosis with pulmonary embolism.
4. Respiratory complications including pneumonia, pneumothorax, empyema, and atelectasis.
5. Infectious complications including urinary tract infection and line infections.
6. Wound complications including infection and dehiscence.
7. Gastrointestinal complications including ileus, colitis, perforation, volvulus, and obstruction.
Template Dictation
Preoperative Diagnosis: [Indication stage, location and type of esophageal cancer]
Postoperative Diagnosis: Same.
2. Esophagogastroduodenoscopy and
3. Modified McKeown Esophagectomy and creation of gastric conduit
Assistants: [BLANK]
Anesthesia: [BLANK]
Estimated Blood Loss:
Complications:
Drains: 28 Fr right chest tube, #10 Jackston-Pratt drain, 14 Fr red rubber feeding jejeunostomy tube
Fluids: [CRYSTALLOID, COLLOID, BLOOD PRODUCTS]
Indication(s) for Procedure: The patient is a [AGE] year old [GENDER] with history of [PAST MEDICAL HISTORY]
who was found to have esophageal mass during endoscopy as part of workup for [BLANK]. The biopsy of the mass was
positive for [ADENOCARCINOMA/SQUAMOUS CELL CARCINOMA] , which was subsequently staged as a [TxNxMx]
tumor by EUS and PET/CT. The patient had a favorable response to neoadjuvant chemoradiaiton therapy was deemed an
appropriate candidate for esophagectomy.
In preparation for surgery, the patient underwent a cardiopulmonary evaluation which included a negative stress test and
normal PFTs. He is able to walk 5 city blocks without any symptoms (Exercise capacity). He was advised to undergo the
aforementioned procedure. The risks, benefits and alternatives were explained to the patient and family including the risk of
pain, infection, bleeding, need for further surgery, pneumothorax, prolonged air leak, damage to surrounding structures,
recurrent laryngeal nerve injury, chylous effusion, anastomotic leak, bowel obstruction, empyema, arrhythmia, myocardial
infarction, stroke and venous thrombosis with pulmonary embolism, and the potential need for anastomotic dilatation.
[HE/SHE] and [HIS/HER] family expressed understanding and agreed to proceed.
BRONCHOSCOPY AND ESOPHAGOGASTRODUODENOSCOPY
After general anesthesia via endotracheal tube was induced, flexible bronchoscopy was carried out through the endotracheal
tube. The trachea was normal. The carina was sharp. Examination of the right and left mainstem bronchi and all lobar and
segmental bronchi bilaterally down to the level of the subsegments failed to reveal any endobronchial abnormalities such as
blood, tumor or frankly purulent secretions. A moderate-to-large amount of mucopurulent secretions was suctioned from the
airways bilaterally. The normal anatomy was otherwise present. The flexible bronchoscope was withdrawn.
Next, the adult flexible gastroscope was advanced through the oropharynx, beyond the cricopharyngeus, and into the
esophagus. The proximal and mid-thoracic esophagus were normal. Beginning at 38 cm and extending to the gastroesophageal
junction (at 40cm), there was a partially obstructing mass. The gastroscope could be advanced through the gastroesophageal
junction without difficulty. The endoscope was advanced through the pylorus without difficulty. The first and second portions
of the duodenum were normal. The endoscope was then pulled back, and the stomach and esophagus were examined. The
gastric antrum and fundus were normal. The incisura was sharp; the stomach distended normally. The gastroscope was
retroflexed. There was no hiatal hernia. There was no evidence of tumor invasion onto the cardia. The stomach appeared
endoscopically suitable for use as a conduit. The stomach was completely decompressed of air. The gastroscope was pulled
back into the esophagus. Proximal to the tumor, the esophagus appeared normal. The gastroscope was then withdrawn. A
nasogastric tube was passed by anesthesia into the stomach without difficulty.
Next, the patient's single-lumen endotracheal tube was exchanged for a double lumen endotracheal tube by anesthesia, and
appropriate positioning was confirmed by bronchoscopy.
THORACIC DISSECTION
The patient was placed in the left lateral decubitus position, and the right chest was prepped and draped in the usual sterile
fashion. The right lung was isolated. We performed a limited serratus-sparing posterolateral thoracotomy and entered the
right hemithorax via the fifth intercostal space without incident. The sixth rib was shingled. Palpation of the lung revealed no
abnormalities. The inferior pulmonary ligament was divided to the level of the inferior pulmonary vein using electrocautery. A
station 9 lymph node was sampled and sent to pathology as a permanent specimen. The lung was retracted anteriorly. The
mediastinal pleura anterior to the esophagus was divided between the inferior pulmonary vein and azygous vein. An
avascular window was created around the azygous vein, and the vein divided with a endo-GIA vascular load stapler. The
pleura was divided posterior to the esophagus between the inferior pulmonary vein and the azygous vein. Just inferior to the
level of azygos vein, the esophagus was circumferentially dissected free from the surrounding soft tissues. A Penrose drain
was passed around the esophagus and tied to facilitate retraction and further dissection.
We then turned our attention back to the lower thoracic esophagus and completed the anterior portion of the dissection. The
periesopheal lymphatics were dissected off the pericardium. The dissection was continued cephalad, dissecting the
periesophageal lymphatics off the bronchus intermedius. The subcarinal lymph node packet was removed en bloc with the
esophagus. The periesophageal tissues were then dissected off the right mainstem to the level of the azygous vein. We then
turned our attention to the posterior dissection plane and took down the periesophageal lymphatics from the level of the
esophageal hiatus to the azygous vein. Branch lymphatic vessels and aortoesophageal vessels were divided between clips.
The esophagus was completely mobilized circumferentially.
The dissection was continued inferiorly to and below the level of the hemidiaphragm. At the hiatus, the muscle fibers of the
crura were identified. Dissection was continued until nearly circumferential intraperitoneal access was achieved. The
thoracic duct was ligated with a figure-of-eight #0 Ethibond suture. The previously placed Penrose drain was tucked through
the hiatus and into the peritoneal cavity.
A second Penrose drain was passed around the esophagus and tied. We then completed the mobilization of the proximal
esophagus. Staying directly on the wall of esophagus, the esophagus was circumferentially mobilized from the surrounding soft
tissues to the level of the thoracic inlet. During the dissection, the vagus nerves were divided directly on the esophagus to
minimize the risk of recurrent laryngeal nerve injury. The Penrose drain was tucked into the thoracic inlet to facilitate
identification of the proper dissection plane from the cervical dissection.
The right hemithorax was copiously irrigated with sterile water followed by sterile saline. After a final check for hemostasis
was made, a #28 French chest tube (with extra drainage holes cut into it) was inserted through a small incision in the anterior
axillary line at approximately the 7th intercostal space. The chest tube was positioned posteriorly to the apex and secured in
place using a #0 silk suture. The right hemithorax was then copiously irrigated with antibiotic irrigation. Number 2 Vicryl
pericostal sutures were inserted to reapproximate the ribs. After a final check for hemostasis, the right lung was re-expanded
under direct vision. Once complete reinflation was confirmed, the pericostal sutures were secured. The remainder of the
incision was closed anatomically in layers. Steri-Strips and sterile dressings were applied.
ABDOMINAL DISSECTION
The patient was then placed in the supine position. The neck was slightly extended, and the head turned towards the right. The
neck, chest and entire abdomen were prepped and draped in the usual sterile fashion. A midline incision from the xiphoid to
the supraumbilical area was used to gain access atraumatically to the peritoneal cavity. The xiphoid process was resected at
the commencement of the laparotomy incision using Mayo scissors.
The abdomen was explored. There was no ascities. There were no liver, peritoneal or omental lesions. There was no celiac
adenopathy. The stomach was inspected. There was no evidence of T4 disease.
The Penrose drain was readily identified. The triangular ligament was divided using electrocautery. This allowed insertion of
an upper hand retractor. The left lobe of the liver was gently folded on itself, covered with a moist laparotomy pad, and a
liver retractor was placed. The lesser omentum was divided in an avascular plane above the caudate lobe of the liver using
electrocautery. The peritoneum overlying the gastroesophageal junction was divided and the previously placed Penrose drain
was grasped and used for retraction purposes.
The transverse colon was mobilized from the greater omentum using a combination of electrocautery and the ligasure device in
an avascular plane. The portion of the greater omentum to the left of midline and extending to the splenic flexure was resected,
taking care to leave the gastroepiploic arcade, which was readily palpable, undisturbed. This omentectomy specimen was sent
to pathology.
The greater curvature of the stomach was cautiously grasped with a gauze sponge, being certain that the right gastroepiploic
arcade was protected at all times. The lesser sac was taken entered, and the short gastrics were taken down all the way to the
Angle of His using a Ligasure. The remaining retrogastric and retroesophageal attachments were taken down. The left gastric
vessels were left intact. We then completed the caudal dissection along the greater curvature of the stomach. The antropyloric
attachments were taken down. The pylorus was identified. The duodenum was widely Kocherized.
Next, a pyloromyotomy [OR PYLOROPLASTY]was performed. Electrocautery was used to begin to divide the muscle
fibers of the pylorus longitudinally. As the fibers were divided, blunt dissection using a Schnidt clamp was performed to
further disrupt the circular fibers of the pylorus. The pyloromyotomy was extended a few centimeters onto the distal antrum.
The duodenum was not injured. At the end of the pyloromyotomy, the pylorus was inspected and noted to be widely patent.
Next, the transverse colon was elevated, and the ligament of Treitz was identified. Approximately 40 cm distal to the ligament
of Treitz, a freely mobile loop of jejunum was chosen for jejunostomy tube insertion. Concentric pursestring sutures of 3-0
Vicryl were passed through the antimesenteric aspect of the jejunum, and an enterotomy was created in the center of the
pursestrings using electrocautery. A #14 French whistle-tip jejunostomy tube was inserted through the jejunotomy and
advanced distally into the jejunum. The pursestring sutures were secured. The jejunostomy tube was Witzled at the
jejeunostomy entrance site using interrupted 3-0 Vicryl sutures. The jejunostomy tube was brought out through a stab incision
in the left abdomen lateral to the umbilicus. The jejunum at the jejunostomy tube site was approximated to the anterior
abdominal wall in four quadrants using interrupted 3-0 Vicryl sutures. The jejunostomy tube was sutured at its skin exit site
using an #0 Ethibond suture. Antiobstruction stitches were placed 5 cm proximal and 5 cm distal to the jejeunostomy using 3-0
Vicryl sutures. After assuring that it flushed easily, the jejeunostomy was capped.
NECK DISSECTION AND ANASTOMOSIS
An oblique incision was made in the neck paralleling the anterior aspect of the left sternocleidomastoid muscle. The incision
was carried down through the subcutaneous tissues. The platysma was divided. The omohyoid was isolated, tied in continuity
with #0 Vicryl ties and then divided using electrocautery. The sternocleidomastoid and carotid sheath were retracted laterally,
and the thyroid was retracted medially. The middle thyroid vein was divided. The dissection was continued down to the
prevertebral fascia. The previously placed Penrose drain at the thoracic inlet was grasped and brought up into the wound.
Staying directly on the esophagus, the esophagus was mobilized off the trachea to the level of the cricopharyngeus using
bipolar cautery.
An ampule of glucagon was then administered by Anesthesia. Palpation through the esophageal hiatus confirmed dilation to
four fingers width. After adequate circulation time of glucagon, the nasogastric tube was withdrawn by anesthesia to just
proximal to the neck incision. The esophagus was divided at the level of the clavicle using an endo GIA purple load stapler.
A #2 silk suture was passed through the staple line of the distal end of the divided esophagus. The esophagus was then
withdrawn from the abdomen, thereby pulling the silk suture through the mediastinum. An Allis clamp was placed on the
proximal esophagus to maintain appropriate orientation. The suture in the abdomen was disconnected from the specimen. The
left gastric vessels were divided at their takeoff with an endo GIA vascular load stapler. Beginning on the cardia and
continuing caudally parallel to the line of the short gastrics, a 3 cm wide gastric conduit was constructed using multiple firings
of an endo GIA purple load stapler. At approximately the level of the 3rd arcarde along the lesser curvature, the staple firings
were angled towards the lesser curvature. The lesser curvature vessels were divided using an endo GIA vascular load
stapler. The esophagogastrectomy specimen was inspected. The margins were grossly negative. The specimen was sent to
pathology, and frozen sections confirmed microscopically negative margins for metaplasia, dysplasia, and carcinoma. The
entire staple line of the newly created gastric conduit was oversewn using running 3-0 Vicryl sutures. The end of a silk suture
passed through the mediastinum into the abdomen was connected to a Foley catheter with 30 mL balloon inflated to
approximately 20 mL. An arthroscopy bag was placed around the Foley and tied proximally to the balloon. The bag was cut to
an appropriate length. At this point, the gastric conduit was inserted into the arthroscopy bag. Proper orientation was
maintained on the gastric conduit. The Foley catheter was placed to suction and the arthroscopy bag sealed down around the
gastric conduit. While maintaining continuous suction, the bag was carefully advanced through the mediastinum, thereby
atraumatically delivering the gastric conduit in appropriate orientation through the mediastinum and out through the cervical
incision. The arthroscopy bag was removed. The conduit appeared pink and healthy.
The staple lines from the remnant esophagus and gastric conduit were resected. An end-to-end two layer handsewn
anastomosis was then completed using interrupted 3-0 PDS sutures for the inner (mucosal) layer and 3-0 interrupted Vicryl
sutures for the outer (muscular) layer. An 18 French nasogastric tube was advanced through the esophageal conduit prior to
completion of the cervical anastomosis and positioned with its tip just proximal to the pyloromyotomy. The cervical
anastomosis was completed and allowed to fall into the mediastinum. A #10 flat Jackson-Pratt drain was inserted through a
separate stab incision in the neck, positioned posterior to the anastomosis, and secured to the skin using a 3-0 nylon suture.
The neck incision was then copiously irrigated. The omohyoid was reapproximated using a figure of 8-0 Vicryl sutures and
then the remainder of the incision was closed anatomically in layers. Steri-Strips and sterile dressings were applied.
The redundant portion of the conduit was pulled back into the abdomen. The conduit was tacked to the hiatus using 3-0 silk
suture. The abdomen was copiously irrigated with antibiotic-containing saline. After a final check for hemostasis was made,
the abdominal incision was closed. The fascia was closed using a running #2 Prolene suture. The subcutaneous tissues were
copiously irrigated. The subdermal tissues were closed using a running 2-0 Vicryl suture. The skin was closed using a 4-0
Vicryl subcuticular suture. Steri-Strips and sterile dressings were applied. The double-lumen endotracheal tube was
exchanged for a single-lumen endotracheal tube by anesthesia, and completion bronchoscopy was carried out through the
endotracheal tube. A moderate to large amount of mucopurulent secretions was again suctioned from the airways bilaterally.
There was no evidence of airway injury. The flexible bronchoscope was withdrawn.
Sponge and needle counts were reported as correct. The patient was transported to Thoracic Surgical Intensive Care Unit,
intubated and in stable condition
25. Open Ivor-Lewis Esophagectomy
Jordy C. Cox, MD, David M. Jablons, MD

1. Lines, monitoring (+/- epidural analgesia).
2. General endotracheal anesthesia - double lumen endotracheal tube.
3. Prophylactic antibiotics, urinary catheter and SCDs.
4. Upper endoscopy & bronchoscopy. Place nasogastric tube.
Abdominal Phase
5. Upper midline laparotomy
6. Explore abdomen: look for ascities; look for liver, peritoneal or omental implants; feel the primary tumor and feel for
surrounding adenopathy.
7. Gastric mobilization
1. Divide Falciform and left triangular ligaments & retract left lateral segment
2. Expose right crus- incise pars flaccida overlying caudate lobe
3. Dissect periesophageal tissue circumferentially.
4. Encircle with Penrose drain for traction.
5. Widen esophageal hiatus:
6. (If required) Ligate and divide the phrenic vein and divide crural fibers vertically towards the central tendon.
7. Mobilize the distal esophagus in the mediastinum.
8. Enter the lesser sac and mobilize greater curvature of the stomach. Divide the omentum towards the fundus 1-2
cm lateral to the right gastroepiploic arcade. Stay wide and preserve vascularized omentum to serve as a buttress
for the anastomosis.
9. Divide vasa brevia 1 cm off the stomach.
10. Divide posterior gastric attachments.
11. Open gastrohepatic ligament. Retract stomach cephalad and isolate and divide the left gastric vessels. Include
all left gastric lymph nodes within the specimen..
8. Kocher maneuver.
9. Pyloroplasty or pyloromyotomy
10. Feeding Weitzel jejunostomy: 16 French catheter placed 40cm distal to the ligament of Treitz
11. Close laparotomy.
Chest Phase
12. Reposition, prep and drape for right thoracotomy. Re-confirm ETT position.
13. Posterolateral thoracotomy: 5th intercostal space.
14. Open mediastinal pleura over the entire length of the thoracic esophagus: from hiatus to 5-10 cm above the azygos
vein.
15. Mobilize esophagus circumferentially & encircle with Penrose drain. Control all vessels and lymphatics with clips
or energy devices (i.e. Ligasure)
16. Divide azygos vein and preserve supreme intercostal vein.
17. Manually deliver stomach into the chest.
18. Place esophageal traction sutures at proximal margin of resection.
19. Withdraw nasogastric tube. Complete transection of the esophagus and tubularize the gastric conduit (4cm diameter).
20. Systematically sample mediastinal lymph node stations 2R, 4R, 7, 8, 9.
21. Construct a stapled (or alternatively, a hand-sewn) anastomosis at approximately the level of the azygous vein
1. 25-28 mm EEA stapler
2. Place the anvil directly into esophagus and secure it with a purse-string suture
3. Insert the EEA stapler through a gastrotomy. Advance the pin through the posterior wall of the greater curve and
engage the anvil.
4. Complete the anastomosis, remove the EEA and check the anastomotic rings.
5. Reinforce the anastomosis with additional Lembert sutures.
6. Send the anastomotic doughnuts for frozen section analysis.
7. Close the gastrotomy and oversew staple lines with running Prolene.
8. Advance NG tube through the anastomosis and secure it just below the diaphragm.
9. Check final margins for metaplasia, dysplasia or carcinoma
22. Cover the anastomosis with omentum, or a pedicled-flap of parietal pleura.
23. Place a chest tube. Add additional holes with a double-action Rongeur to increase drainage capacity.
24. Irrigate and check for hemostasis
25. Multilevel intercostal block
26. Close thoracotomy in layers

1. Preoperative considerations:
1. Pretreatment staging includes a barium contrast study, CT scan, PET scan and upper endoscopy with endoscopic
ultrasound.
2. Consider doing a diagnostic laparoscopy initially to rule out disseminated abdominal disease and evaluate for
resectability.
3. Timing between induction chemo-radiation and surgery should be 4-6 weeks. In general, allow enough time for
recovery of the patient’s performance status and nutritional markers.
4. Placement of a feeding jejunostomy tube prior to neoadjuvant therapy should be considered in some cases,
especially if there is severe dysphagia and/or a history of weight loss.
5. Repeat PET scan preoperatively to asses for response to induction therapy and evaluate for distant metastatic
disease.
6. Preoperative workup should include pulmonary function testing, echocardiogram and nutritional parameters.
2. Bronchoscopy in the operating room to asses for double lumen ETT positioning and rule out malignant invasion of the
airway
3. Upper endoscopy in the operating room to asses for tumor burden, location, extension, associated stricture or
Barrett’s metaplasia.
4. Technical considerations:
1. Avoid entering the pericardial space when widening the hiatus.
2. Wide Kocher maneuver. To assure adequate mobilization, the pylorus should easily reach the level of the
caudate lobe to assure that a tension-free intrathoracic anastomosis can be constructed.
3. Narrow gastric conduits are better for emptying. Wide are better for perfusion. It should be approximately 4cm
in diameter.
4. Take care to avoid thoracic duct injuries when mobilizing the esophagus.
5. Avoid thermal injuries to the airways when mobilizing the esophagus.
6. Carefully preserve the orientation of the gastric conduit when hand-delivering it into the chest. The lesser curve
staple line should face upwards (towards the thoracotomy)
7. Dividing the esophagus with a TA stapler allows for a 90-degree angle of transection even high in the chest
8. Cover anastomosis with omentum, pleura or a portion of redundant stomach.
9. If gentle ventilation or CPAP of the right lung is required for oxygenation, pack the lung out of the operative field
with moist towels.
Template Dictation
Preoperative Diagnosis: [indications] – e.g.GE Junction Adenocarcinoma, High-grade Barrett’s dysplasia, distal esophageal
stricture.
Procedure(s) Performed: Flexible bronchoscopy, flexible upper endoscopy, Ivor-Lewis esophagogastrectomy, and feeding
jejeunostomy tube placement
Assistants: [BLANK]
Anesthesia: General with a double lumen ETT tube.
Fluids:
Estimated Blood Loss:
Drains:
Disposition: To ICU
Complications:
Indication(s) for Procedure: [age] year old [gender] w i th [duration] history of [chief complaint] (e.g. progressive
dysphagia). Upper endoscopy demonstrated a mass at the GE junction. Biopsies confirmed adenocarcinoma. EUS was used for
staging. The patient underwent induction chemo-radiation with excellent clinical response. Repeat PET scan confirmed the
absence of distant metastatic disease. He presents for possible esophago-gastrectomy.
Description of Procedure: The patient was taken to the operating room on [DATE]. A time out was done, and the patient’s
identity and planned procedure were verified by the surgical and anesthesia teams.
An epidural catheter was placed prior to induction.
General anesthesia was induced, and the patient was intubated with a double lumen endotracheal tube without difficulty. The
position of this tube was confirmed by flexible bronchoscopy.
The patient was placed in a supine position with adequate padding of all bony prominences and received prophylactic
antibiotics per protocol. A Foley catheter and a nasogastric tube were placed.
We performed an upper endoscopy that demonstrated [FINDINGS].
The abdomen was prepped and draped in usual sterile fashion. An upper midline incision was performed and carried down
through the fascia. The abdomen was entered. A self-retaining retractor was used to achieve adequate exposure.
The abdomen was thoroughly explored and no evidence of macroscopic metastatic disease was found.
The falciform and left triangular ligaments were divided and the left lateral segment of the liver was retracted towards the right
upper quadrant
We began mobilization of the stomach and the distal esophagus at the hiatus. The right and left crus were exposed. The distal
esophagus was mobilized circumferentially and encircled with a Penrose drain. The hiatus was enlarged and blunt dissection
was used to free the distal esophagus.
We then entered the lesser sac and divided the greater omentum, paying close attention to preserving the right gastroepiploic
arcade. The short gastric vessels were doubly ligated and divided. All adhesions to the posterior gastric wall were divided
sharply.
We directed our attention to the gastro-hepatic ligament, and divided it sharply. The left gastric vessels were identified, triply
ligated and divided. There was no evidence of an accessory left hepatic artery. Any noticeable lympahdenopathy was included
in the specimen or dissected individually.
A wide Kocher maneuver was done to provide adequate mobilization of the gastric conduit. The stomach and distal esophagus
were now free.
Next, we performed a pyloroplasty. The pylorus was identified and elevated. Two traction sutures were placed laterally and a
full-thickness longitudinal duodenotomy was done. This was closed transversely in two layers of #3-0 [TYPE] suture. The
repair was palpated and felt to be widely patent. A small tongue of omentum was draped over the closure to provide additional
buttressing.
We directed our attention to the small bowel. We measured 40cm distal to the ligament of Treitz and identified a portion of
jejunum that would accommodate a feeding tube and easily reach the abdominal wall. Two concentric purse-string sutures
were placed on the anti-mesenteric border of the bowel and a small enterotomy was made in the center of the pursestring
sutures. A 16 French feeding tube was advanced through the enterotomy. A Weitzel tunnel was fashioned with interrupted #3-0
[TYPE] suture. The catheter was brought out through a separate stab incision in the left upper quadrant. The small bowel was
tacked to the underside of the abdominal wall and the catheter was secured to the skin with additional sutures.
The abdomen was re-examined. Hemostasis was felt to be adequate and the conduit was clearly viable. The bowel was
returned to the abdomen in an anatomical position and the fascia was closed with running [SIZE AND TYPE]suture. The skin
was closed after irrigation of the subcutaneous tissues. Sterile dressings were applied.
We now proceeded with the thoracic portion of the procedure. The patient was placed in lateral decubitus and the position of
the endotracheal tube was re-confirmed with the bronchoscope. Single lung ventilation was initiated. The chest was prepped
and draped.
We made a limited muscle-sparing postero-lateral thoracotomy. The latissimus dorsi was divided sharply for the length of the
incision, and the serratus was retracted anteriorly. The chest was entered in the 5th intercostal space. There was minimal rib
spreading and no shingling was required.
The right lung was retracted anteriorly. The mediastinal pleura was incised, and the esophagus was dissected free of
surrounding structures from the hiatus to just above the azygos vein. The azygous vein was also dissected free and divided with
and endo-GIA vascular load stapler.
The stomach was delivered into the chest, paying close attention to maintaining an adequate orientation and avoiding torsion.
Two traction sutures were placed laterally on the esophagus, the nasogastric tube was removed and the esophagus was divided
proximally with a single firing of a TA stapler.
The gastric conduit was then fashioned with multiple firings of an endo-GIA thick-tissue stapler beginning at a point low on the
lesser curve and directed towards the fundus in order to construct a 4 cm tubularized gastric conduit. The specimen was sent
to Pathology. Frozen sections demonstrated that the proximal and distal margins were negative for metaplasia, dysplasia and
carcinoma.
A systematic lymph node dissection was done in the posterior mediastinum and the peri-esophageal region. Hemostasis was
optimized with cautery and surgical clips.
We now performed a [SIZE] mm EEA esophago-gastrostomy. Dr [NAME] scrubbed out at this point to place the Orovil. The
anvil was advanced into the proximal esophageal pouch. The stapler was placed in the gastric conduit through a gastrotomy
and the anastomosis was completed after adequate coupling of the device. The anastomotic doughnuts were inspected and
found to be satisfactory. They were sent for frozen section analysis.
The gastrotomy was closed with additional firings on the endo-GIA stapler and the staple line was oversewn with a running
[TYPE] suture.
The anastomosis was inspected and found to be tension-free, widely patent and clearly viable. Additional sutures were placed
at the anastomosis to minimize traction injuries and a nasogastric tube was re-inserted under direct vision through the
anastomosis and secured just below the diaphragm.
A portion of viable omentum was draped over the anastomosis and the right chest was irrigated with warm saline.
A [SIZE] French chest tube was placed through a separate stab incision and secured to the skin. The right lung was re-inflated
under direct vision and a sustained Valsalva ensured adequate recruitment. Intercostal blocks were done with 0.25%
bupivacaine.
Pericostal sutures were used to approximate the ribs and the thoracotomy was closed in layers with [SIZE and TYPE]
suture.Sterile dressings were applied and the patient was returned to the supine position.
All sponge, needle and instrument counts were confirmed to be correct at the end of the case.
The patient was extubated in the operating room and transferred with physician escort to the cardiac surgical intensive care
unit in [type] condition.
There were no immediate complications. The patient tolerated the procedure well.
26. Minimally Invasive Ivor-Lewis Esophagectomy
David D. Odell, MD, MMSc and James D. Luketich, MD

Laparoscopic Phase
1. Upper endoscopy to assess tumor location and extent of stomach involvement.
2. Supine position (far right on operating bed), arms out 45 degrees, and foot board placement for steep reverse
Trendelenburg. Double lumen endotracheal intubation.
3. Place 10 mm port via open Hasson technique in the right paramedian line approximately one-third of the way from the
xiphoid to the umbilicus.
4. CO2 insufflation to 15 mmHg.
5. Confirm position within the peritoneal cavity and inspect abdomen with laparoscope to assess for any injury or
evidence of advanced disease.
6. Place additional ports under direct laparoscopic visualization. An 11 mm left paramedian port one hand’s breadth to
the left initial cutdown port. A 5 mm right and left subcostal port a hand’s breadth from the paramedian port sites. A
5 mm port in the lateral right upper quadrant directed along the lower edge of the liver. An 11 mm port in the right
lower quadrant.
7. Insert liver retractor to elevate the left lobe of the liver for exposure of the hiatus.
8. Place patient in steep reverse Trendelenburg position to facilitate visualization of the hiatus.
9. Open the gastrohepatic ligament and dissect the right crus.
10. Complete the anterior portion of the dissection, beginning on the pericardium and then working from pleura to pleura.
11. Complete dissection of tissue from the left crus.
12. Divide the short gastric vessels preserving 5-10 mm of fatty tissue along the stomach border.
13. Posterior medistinal dissection in areolar pre-aortic soft tissue plane
14. Isolate and divide the left gastric artery and vein, sweeping all nodal tissue up towards the stomach
15. Complete retrogastric dissection to the level of the pylorus.
16. Divide the gastrocolic omentum in the filmy portion (taking care to avoid the gastroepiploic arcade)
17. Mini-Kocher maneuver to mobilize the 1st and 2nd portions of the duodenum. Mobilization is adequate when the
pylorus reaches the caudate lobe.
18. Create a narrow gastric conduit (3-4 cm in width) using serial firings of the Endo-GIA stapling device. Staple line
begins at the first branch of the right gastric artery on the lesser curvature and follows the arc of the greater curvature.
19. Laparoscopically place a feeding jejunostomy (Seldinger technique using a needle jejunostomy kit)
20. Pyloroplasty – full-thickness incision across the pylorus closed transversely in a Heineke-Mickulicz fashion
21. Orient the gastric conduit and suture to the end of the specimen for delivery into the chest during the thoracoscopic
phase of the operation.
22. Close the right paramedian cutdown port with a #0 Vicryl suture using a Carter Thompson Suture passing device.
Thoracoscopic Phase
1. Left lateral decubitus position with the arm out and supported at a 90 degree angle and parallel to the floor.
2. Initial 10 mm camera port placed via cutdown through the 9th intercostal space at the level of the posterior axillary
line.
3. Additional ports are place under direct vision. A 10 mm surgeon’s working port in the 9 th intercostal space in the
line of the scapular tip. A 5 mm assistant port in the midaxillary line at the 6 th interspace. A 5 mm port for the
surgeon’s left hand at the scapular tip. A 10 mm port for lung retraction in the 4 th intercostal space at the posterior
axillary line.
4. Complete lung mobilization and lysis of any adhesions.
5. Division of inferior pulmonary ligament
6. Dissection along lateral pericardium.
7. Dissection along posterior border of bronchus intermedius and subcarinal lymphadenectomy.
8. Division of the Azygous vein
9. Dissection along the esophagus above the Azygous to the level of the thoracic inlet
10. Dissection of the posterior aortic plane. Multiple clips are used for hemostasis and to prevent delayed lymphatic
leak.
11. Cirumferential mobilization of the esophagus.
12. Conduit is brought into the chest, maintaining proper orientation, and the specimen is divided at or above the level of
the Azygous.
13. Minithoracotomy (4 cm) is made in the 6th intercostal space and protected with a wound protector. The specimen is
withdrawn and sent to pathology for margins.
14. EEA (usually a #28) anvil is sewn into the cut end of the proximal esophagus with 2 pursestring sutures.
15. The gastric conduit is opened along the staple line. And the EEA stapler inserted. The spike is advanced through the
greater curve side once the appropriate length of conduit is determined. The stapler is docked to the anvil and fired.
Rings are evaluated for completeness.
16. The excess conduit is resected using an endo-GIA stapler.
17. An NG tube is advanced beyond the anastomosis under direct vision.
18. A 10 French flat Jackson-Pratt drain is positioned behind the anastomosis.
19. A 28 French chest tube is positioned posteriorly toward the apex.
20. A multilevel intercostal nerve block is performed.
21. The thoracotomy incision is closed in layers.
22. The mouth and nasopharynx are irrigated and suctioned free of debris and the double lumen endotracheal tube is
exchanged for a single lumen endotracheal tube. A completion bronchoscopy is performed to toilet secretions and
assess for airway injury.

1. Avoid upper overinsufflation during upper endoscopy which will increase the difficulty of laparoscopic dissection.
2. Extension of tumor onto the stomach, compromising the planned conduit – requires alternative conduit choice (i.e.
colon interposition).
3. Injury to the gastroepiploic arcade during dissection – requires alternative conduit choice (i.e. colon interposition).
4. Tumor involvement of other organs – requires intraoperative decision regarding resectability en bloc.
5. Hypercapnea from CO2 insufflation
6. Pneumothorax
7. Failure to achieve adequate lung isolation or inability to tolerate single lung ventilation
8. Loss of proper orientation of the conduit (spiraling) as it is brought into the chest (the staple line should face the
lateral chest wall – towards the camera).
9. Anastomotic leak
10. Airway injury (from excessive use of energy adjacent to the airway)
11. Aspiration events during endotracheal tube manipulation
Template Dictation
Preoperative Diagnosis: [esophageal cancer, end-stage achalasia, etc.]
1. Flexible Bronchoscopy.
2. Flexible Esophagogastroscopy with Biopsies.
3. Laparoscopic Thoracoscopy Minimally Invasive Ivor-Lewis Esophagectomy.
4. Laparoscopic Creation of Gastric Tube.
5. Laparoscopic Pyloroplasty.
6. Laparoscopic Insertion Of #10 French Feeding Jejunostomy Tube.
7. Right Video-Assisted Thoracoscopic Immobilization of the Esophagus.
8. Right Vats #28 Eea Esophagogastric Anastomosis.
9. Multilevel Intercostal Nerve Block.
10. Omental Pedicle Flap Covering of the Esophagogastric Anastomosis.
Attending surgeon: [BLANK]
Resident surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: General endotracheal through a double lumen endotracheal tube.
Complications: None.
Estimated Blood Loss: [Blank]
Specimens:
1. Esophageal biopsies at [Blank]
2. Esophagogastrectomy
3. EEA rings (final esophageal margin and final gastric margin)
Tubes and Drains:
1. #12 French feeding jejunostomy tube.
2. #28 French chest tube posteriorly directed towards the apex.
3. #10 French Jackson-Pratt drain in the posterior esophageal bed draining the anastomosis.
Indication(s) for Procedure: [DESCRIBE THE SALIENT DETAILS OF THE INDIVIDUAL PATIE
PRESENTATION AND ANY RELEVANT TREATMENT UNDERTAKEN PRIOR TO SURGERY (FOR EXAM
CHEMOTHERAPY AND RADIATION). ] The patient was counseled regarding the risks, benefits, and alternatives to
minimally invasive esophagectomy and was agreeable to proceed. An informed consent was signed by the patient.
Description of Procedure: The patient was identified in the preoperative holding area and the operative site marked. The
patient was then taken to the operating room by Anesthesia. (S)He was placed supine on the operating room table. Bilateral
lower extremity sequential compression devices placed and 5000 units of subcutaneous heparin were administered prior to
induction of anesthesia. A Foley catheter was inserted and adequate intravenous access assured. [Appropriate intravenous
antibiotics and dose] were administered within an hour of the skin incision and re-dosed as needed throughout the operation.
The patient was successfully intubated with a double lumen endotracheal tube.
A time-out was observed to identify patient and intended procedure. The flexible bronchoscope was then passed through the
endotracheal tube. Complete examination of the airway was performed through the proximal trachea to the carina into the
subsegmental airways bilaterally. Endobronchial anatomy was normal, there were no endobronchial lesions. The position of
the endotracheal tube was judged to be appropriate. The bronchoscope was then withdrawn. The flexible esophagoscope was
passed posterior to the posterior arytenoid and into the esophagus under direct vision. The proximal and mid esophagus were
normal in appearance. At approximately [Blank] cm from the incisors tumor seen extending to [Blank]. The stomach
distended normally without evidence of linitis plastica. The incisura was sharp. The gastric cardia was free of disease. The
proximal portion of the duodenum was visually normal. The stomach was desufflated and the scope withdrawn.
The abdomen was then sterilely prepped and draped in the usual surgical fashion. A Hasson cut-down incision was made 1/3
of the distance between the umbilicus and the xiphoid just to the right of midline. The anterior rectus fascia was scored with
Bovie and the posterior sheath grasped between tonsils and sharply incised and the peritoneal cavity entered. A Hasson trocar
was then placed and the abdomen insufflated with 15 mmHg of carbon dioxide insufflation. The 10 mm 30 degree laparoscope
was inserted and the abdomen visually examined. There was no evidence of injury at the abdominal entry site. Five additional
laparoscope port sites were placed. A left subcostal 5 mm port, a left upper quadrant 5/11 port, right subcostal 5 mm port and
a right flank 5 mm port and right lower quadrant 5/11 port. All port sites were hemostatic.
Laparoscopic exploration was then performed. There was no evidence of omental, peritoneal or hepatic metastasis noted. The
left lateral segment of the liver was elevated with a flexible liver retractor to facilitate exposure of the hiatus. The
gastrohepatic ligament was then incised along its filmy portion towards the right crus. The peritoneal lining along the right
crus was identified and preserved and the loose areolar plane of the mediastinum entered along the right crus. A
circumferential mediastinal mobilization of the intrathoracic esophagus along the lower third was performed from the
pericardium anteriorly to the periaortic plane posteriorly and from the right pleura to the left pleura.
Attention was returned to the abdomen, and the phrenoesophageal membrane was divided anteriorly and dissection continued
onto the left crus. The peritoneal lining along the left crus was identified and preserved. The upper portion of the gastric
cardia and fundus was slowly mobilized with the attachments to the diaphragm being divided. The left gastric artery and vein
pedicle were identified and all lymphatic and fatty tissues were swept along this vascular pedicle towards the specimen. Once
circumferentially mobilized, the pedicle was divided at its base with a vascular load of the Endo GIA stapler. We next
worked along the greater curvature of the stomach, entering the lesser sac. The upper short gastric vessels were divided,
meeting the plane of dissection along the left crus. The lesser sac was entered and division of the omentum was continued
along the greater curve between the transverse colon and the Right gastroepiploic arcade taking care to preserve the vessel and
surrounding tissue. We next mobilized and divided the retrogastric attachments to the superior border of the pancreas down to
the level of the pylorus. We then performed an antropyloric mobilization maneuver, and a limited Kocher maneuver,
mobilizing the first and second portion of the duodenum.
At this point the pylorus readily reached the base of the caudate lobe. We placed 2 stay sutures in the pylorus, 1 inferiorly and
1 superiorly. We then removed all of the underlying tubes and devices from the esophagus and proceeded to fashion a
neurogastric tube. We started this with vascular load along the lesser curvature vascular and fatty tissues just above the takeoff
of the right gastric artery. This was done so as to preserve the first few branches of this vessel feeding the antrum of the
stomach. After the initial vascular load we then used serial purple loads of the Endo GIA stapler to fashion the 3.5-4 cm
neurogastric tube. We preserved the proper orientation of the tube because we made it to prevent any spiraling. We then
opened the pylorus longitudinally and with the ultrasonic scalpel and proceeded to close it transversely in a Heineke-Mikulicz
fashion so as to fashion our pyloroplasty. The incision was closed with #2-0 Surgidac sutures using the EndoStitch device
with a total of 6 sutures being placed. We then checked for hemostasis along the lesser curvature and staple line, which was
found to be free of any active bleeding.
The transverse colon was then elevated and the ligament of Treitz identified. The freely mobile loop of jejunum was identified
approximately 40 cm distal to the ligament of Treitz. The appropriate site in the left lower abdominal wall was identified for
placement of the feeding jejunostomy tube. The jejunum was tacked along its antimesenteric border to the anterior abdominal
wall with #2-0 Surgidac EndoStitch and the finder needle inserted, followed by the feeding jejunostomy kit needle. This
needle was brought in through the subserosal plane in a Witzel type fashion and then the lumen of the bowel entered. An air
insufflation test was performed to confirm the intraluminal placement. Surgidac #2-0 Witzel type stitch was placed and the
guidewire passed through the needle distally into the bowel under direct laparoscopic vision. A nick was made in the skin at
its wire site with an 11 blade and utilizing a Seldinger technique the dilator sheath complex was centered over the wire and
into the bowel lumen under direct laparoscopic vision. The feeding jejunostomy tube, a #12 French, catheter was inserted
through the peel away sheath under direct vision and the tube secured with a #2-0 silk suture at the insertion site. The loop of
jejunum was then circumferentially tacked to the anterior abdominal wall with a #2-0 Surgidac purse-string suture. We then
placed an anti-obstruction suture approximately 3 cm distal again using #2-0 Surgidac Endo Stitch. Intraluminal placement
was again confirmed with air insufflation and the tube secured to the skin with 2-0 silk sutures.
We tacked the omental flap previously fashioned at the gastric tube in 2 locations with #2-0 Surgidac Endo Stitches such that
our omental pedicle would come up with the tube. We tacked the tube using a mattress type suture to the esophagogastrectomy
specimen again with 2-0 Surgidac Endo Stitches. The specimen was then delivered along with the gastric tube and omental
flap through the hiatus and pushed superiorly into the chest as able. Hemostasis was again insured and the liver retractor
removed under direct vision. The Hasson trocar site was closed with an #0 Vicryl suture on a Carter-Thompson suture passing
device. The wounds were irrigated and stapled shut with Band-Aids applied.
The patient was then re-positioned in the lateral decubitus position. The position of the double lumen endotracheal tube was
re-confirmed using a pediatric bronchoscope. This was found to be adequate. All pressure points were padded and the
axillary roll was placed. The lung was isolated and the right chest sterilely prepped and draped in the usual surgical fashion.
An incision was made over the 9th rib in the posterior axillary line and the chest cavity entered above the diaphragm.
Additional thoracoscopic ports were placed under direct vision including an infrascapular 5 mm port, 10 mm surgeon's
working port over the 10th rib in a line parallel to the scapular tip, and a 5 mm port in the 6th interspace in the mid anterior
axillary line along with a 10 mm port in the 4th interspace in the posterior axillary line. All port sites were hemostatic. A
thoracoscopic exploration was then performed. There was no pleural pericardial or diaphragm metastasis noted. The inferior
pulmonary ligament was mobilized using the ultrasonic scalpel. An #0 Surgidac suture was placed in the diaphragm for
retraction purposes and brought out through the right flank and secured to the chest wall with a snap. The esophagus was
mobilized with a video-assisted thoracoscopic approach. The anterior pericardial plane was followed along its avascular
line. An en bloc subcarinal lymphadenectomy was then performed using a combination of ligature and ultrasonic scalpel. The
anatomic strictures, including the right mainstem bronchus, main carina bronchus intermedius, left mainstem bronchus and
subcarinal space were all identified and preserved in their entirety. All lymph nodes were swept towards the esophagectomy
specimen. The azygos vein was identified, mobilized and divided with a surgical stapler using a single load of the vascular
Endo GIA. The vagus nerve was identified and divided at the level of the azygos vein and swept aside so as to avoid traction
injury on the recurrent laryngeal nerve.
Above the level of the azygos vein we carried our dissection towards the esophagus and mobilized the esophagus upwards
towards the thoracic inlet. In the posterior plane the plane along the esophagus was similarly identified and maintained with
all aorto-esophageal vascular and lymphatic branches controlled with clips and divided using ultrasonic scalpel. This
technique of dissection was utilized to mobilize the entire length of the esophagus from the diaphragm to the thoracic inlet. We
then brought the specimen, along with the attached gastric tube, into the chest taking care to preserve the orientation of the
gastric tube. The gastric tube was then tacked to the diaphragm with a #2-0 Surgidac to prevent slippage into the abdomen or a
loss of orientation. The posterior dissection was then completed using clips to control aortoesophageal and lymphatic
branches.
We next made an access incision through a mini thoracotomy one interspace above our surgeon's working port by dividing the
latissimus and intercostal muscles with electrocautery. An Alexis wound retractor was placed and brought into position.
Using an endoscopic guidance, we transected the esophagus approximately [Blank] cm below the level of the thoracic inlet
roughly [Blank] cm from the incisors by endoscopy. We removed the specimen and passed it off the table for margins. All
frozen section margins were negative. A #28 EEA Anvil was sewn into the cut end of the proximal esophagus with 2
concentric #2-0 Surgidac purse-string sutures. The first was a baseball type stitch and the second a series of horizontal bites.
We then opened the conduit along the right side of the staple line using an ultrasonic scalpel and delivered the EEA stapler,
#28 size, into the conduit. Preserving the proper orientation, we fashioned the #28 EEA esophagogastric anastomosis. Two
complete staple rings were noted subsequent to completion of this anastomosis. These were passed off the table for permanent
pathology. The redundant portion of the gastric tube was retracted superiorly with and resected with 2 purple loads of the
Endo GIA stapler.
The omental pedicle flap was then secured in place with #2-0 Surgidac Endo Stitches taking care to incorporate the
anastomosis in the area of coverage. A #2-0 Surgidac was placed in the diaphragm and attached to the tube along the right
crus. A #10 French flat Jackson-Pratt drain was placed in the posterior medistinal bed during the anastomosis. Antibiotic
irrigation consisting of 2 liters of water was used to irrigate the chest and was suctioned free. A #28 French chest tube was
then posteriorly directed towards the apex and secured at the skin with a #0 silk suture. The JP was secured with 3
independent #2-0 silk sutures. The lung was aerated and seemed to expand well. All port sites were examined for hemostasis
and found to be adequate. The mini thoracotomy access incision was closed with #0 Vicryl in a running fashion. All port sites
were closed with interrupted #2-0 Polysorb in an inverted subcuticular fashion. The wounds were irrigated and staples were
used to close the skin incisions. Sterile dressings were applied. The JP was hooked to bulb suction on the chest tube to 20 cm
of water Pleur-Evac suction. The patient was then returned to the supine position and nasopharyngeal/oropharyngeal
pulmonary toilet performed. The double lumen endotracheal tube was exchanged for a single lumen tube by Anesthesia under
direct vision without the use of a tube changer. A pulmonary toilet bronchoscopy was then performed. There was some
evidence of ecchymosis of the level of the carina and the right mainstem bronchus. There was no obvious airway injury noted.
There was a moderate amount of secretions, which were toileted free without difficulty.
At the completion of the operation all sponge and needle counts were correct. The patient tolerated the procedure well and
was transferred to the Surgical Intensive Care Unit, extubated and in stable condition. There were no immediate
complications.
27. Lung Volume Reduction Surgery
Desmond M. D’Souza, MD and David P. Mason, MD
Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio

1. Lines and Monitoring.
3. Double lumen endotracheal tube
4. Approach: Median sternotomy versus bilateral video-assisted thoracoscopic (VATS)
5. VATS: 3 port incisions
6. Proceed anterior to posterior over the apex of the upper lobe
7. Start in the anterior segment of the upper lobe – above the minor fissure on the right and the lingual on the left
8. Use a buttressed staple fire for the entire resection
9. Gentle handling of the lung is paramount to preventing air leaks; avoid contact with the remnant lung.
10. Extract resected specimen through the large utility port
11. Two well placed chest tubes
13. Sternotomy or port site closure
14. Chest tubes to waterseal. Do not connect to suction.

1. For open approach: stay midline during sternotomy
2. Staple misfire, buttress failure, or inadvertent lung injury can result in a difficult airleak.
Template Dictation
Preoperative Diagnosis: INDICATION – Emphysema.
Procedure(s) Performed: Bilateral Video assisted thoracoscopic (VATS) Lung Volume Reduction Surgery (LVRS)
Assistant Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT –e.g. progressive
shortness of breath, emphysema with predominant upper lobe disease and low exercise capacity.]
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity, and the planned
procedure were confirmed. The patient was placed on the operating room table in a supine position. General anesthesia with a
double lumen endo-tracheal tube was obtained. An arterial line and central venous catheter were placed. Proper positioning
of the double lumen endotracheal tube was confirmed bronchoscopically, administration of pre-operative antibiotics and DVT
prophylaxis were confirmed with the anesthesiologist and operating team.
The patient was repositioned in the left lateral decubitus position. The chest was prepped and draped in the usual sterile
fashion. A 2 cm incision was made in the ninth intercostal space in the anterior axillary line. A 30-degree thoracoscope was
inserted, and the lung was inspected. Two secondary ports were then placed in the sixth intercostal space in the mid-clavicular
line, and the fourth intercostal space in the posterior axillary line.
The thoracoscope was then directed anteriorly with the 30-degree lens pointed superiorly. A ring forceps was used through
the posterior port to retract the lung and align the parenchyma of the right upper lobe in the direction of the anterior port. A
biological, buttressed purple load stapler was then inserted via the anterior port. Caution was taken while inserting the stapler
to avoid inadvertent injury to the friable parenchyma. Multiple staple loads were fired across the apex of the right upper lobe
in an anterior to posterior fashion. The thoracoscope was switched to the anterior port, and an endo-catch bag was inserted
through the large utility port. The specimen was placed into the endo-catch bag and removed.
The pleural cavity was filled with saline, and the anesthesiologist was asked to ventilate the right lung. The staple line and lung
were inspected. There were no air leaks. Multilevel rib blocks with 0.5% marcaine was performed. One 28 French chest
tube was placed anteriorly, and one 28 French chest tube was placed posteriorly. The ports were removed, and the port sites
were inspected for hemostasis. The lung was re-expanded under direct vision. Prior to closure all instrument, sponge and
needle counts were confirmed correct. The port sites were closed using a #2-0 vicryl suture for the fascia and a #4-0 vicryl
suture on the skin. The chest tubes are connected to waterseal with no suction.
The patient was then repositioned in the right lateral decubitus position to proceed with the left sided procedure in a similar
fashion.
Estimated blood loss was [X] cc. There were no intra-operative adverse events. The patient was extubated in the operating
room and subsequently transferred to the postoperative thoracic surgery unit.
28. VATS Wedge Resection
John R. Spratt, MA, MD and Eitan Podgaetz, MD, MPH
University of Minnesota, Minneapolis, MN

1. Availability of relevant imaging in OR
2. Operative-side-up lateral decubitus jackknife positioning with reverse Trendelenberg allowing chest wall to be
parallel to the floor
3. General endotracheal anesthesia with double lumen endotracheal tube and single-lung ventilation
4. Double lumen tube position must be confirmed by flexible bronchoscopy
5. Surgeon stands on anterior side of patient, assistants posterior
6. Placement of camera port low in the chest (7th-8th intercostal space, midaxillary or anterior axillary line)
7. CO2 insufflation can be considered to allow better lung collapse
8. First working port in 4-5th intercostal space in anterior axillary line
9. Inspection of lung and hilum with finger/ ring foreceps to determine placement of remaining incision(s) if needed
10. Placement of utility thoracotomy (2 – 4 cm) in 4th or 5th intercostal space between anterior border of latissimus dorsi
and lateral border of pectoralis major (anterior axillary line)
11. Retraction of soft tissue over utility thoracotomy for easy chest access. [Self-retaining plastic (i.e., Alexis) wound
protector]
12. Identification of target lesion and control with ring or Duval forceps proximal to lesion
13. Resection of target lesion with endoscopic stapler
14. Removal of specimen using endoscopic retrieval bag or through wound protector
15. Assess staple line integrity and hemostasis
17. Port closure

1. Incomplete flexion of patient during positioning
1. May compress intercostal spaces
2. Ipsilateral hip may limit freedom of thoracoscope
2. Patient intolerance of single-lung ventilation, requiring CPAP or intermittent ventilation of operative-side lung. Can
infuse ipsilateral lung with oxygen.
3. Improper endotracheal tube placement leading to hypoxemia or poor lung isolation
4. Failure to appropriately triangulate camera and working incisions around target tissue (good rule of thumb is to leave
a hand’s breadth between ports)
5. Failure to retract soft tissues over utility thoracotomy may result in lung re-expansion during intrathoracic suctioning.
This is especially true in obese patients.
6. Failure to remove sample using retrieval bag may lead to tumor spillage and port site recurrence
7. Avoid crushing the lesion with the ring forceps.
Template Dictation
Date of Service: [DATE]
Preoperative Diagnosis: [INDICATION]
Procedure(s) Performed: [L or R] VATS wedge resection
Assistants: [BLANK]
Anesthesia: [BLANK]
Specimens: [BLANK]
Fluids: [BLANK]
EBL: [BLANK]
Complications: [BLANK]
Drains: [BLANK]
Disposition: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with a [SIZE] peripheral lung nodule discovered by [IMAGING
RESULTS]. The decision was made to perform VATS wedge resection of the lesion for pathologic diagnosis. The risks and
benefits of the procedure were described to the patient, who verbalized good understanding, and informed consent was
obtained.
Description of Procedure: The patient was taken to the operating room from the preoperative holding area. The patient’s
identity and planned procedure were verified and the patient was then placed on the operating room table in the supine
position. General endotracheal anesthesia was induced, and the patient was intubated with a double lumen endotracheal tube
[OR SINGLE LUMEN ENDOTRACHEAL TUBE AND SUBSEQUENT PLACEMENT OF A BRONCH
BLOCKER]. Tube position was confirmed by flexible bronchoscopy, allowing selective ventilation of the lung on the non-
operative side. Once this was completed, the patient was then moved into the [NONOPERATIVE SIDE] -lateral decubitus
position ensuring his bony prominences were well padded. The upper extremity was not on any undue stretch. The operating
table was maximally flexed at the level of the patient’s hip. Appropriate endotracheal tube placement was again confirmed
with a pediatric bronchoscope. The [SIDE] chest was then prepped widely from the axilla to inferior to the costal margin
longitudinally and from the midclavicular line to the tip of the scapula transversely. A surgical time out was performed to
identify patient and intended procedure.
The [SIDE] lung was isolated. Rib blocks with [VOLUME AND TYPE OF LOCAL ANESTHESIA] were made prior to
th
each incision. The 8 intercostal space was identified and a 2 cm skin incision was made [LOCATION]. Dissection down to
the parietal pleura was performed with electrocautery. The chest was entered sharply and the absence of adjacent adhesions
or adherent lung tissue was confirmed by finger palpation. A 10 mm trocar was placed, and the chest cavity was inspected with
a 10 mm 30-degree thoracoscope. [FINDINGS]. The chest was then insufflated with CO2 via the trocar to facilitate lung
collapse.
After determining that it was safe to proceed, a second port was placed in the 6th intercostal space in the midaxillary line using
the same technique as above. An endoscopic alligator grasper was used to retract the lung and inspect the pleura and the
anterior hilum, as well as to identify the lesion. A third and final incision, 3-4 cm in length, was made between the anterior
border of the latissimus dorsi and the anterior axillary line at the level of the 4th intercostal space, after instillation of local
anesthesia. A small wound protector was placed.
The target lesion was identified at [LOCATION] by visualization and direct finger palpation. The lesion and surrounding
lung parenchyma were grasped atraumatically using a Duval clamp. The lesion was elevated and resected with serial firings
of a [SIZE, COLOR, STAPLER TYPE] endoscopic stapler. The staple line was noted to be hemostatic. The stapler was
removed and a specimen retrieved through the wound protector.
Additional rib blocks were given under direct vision using [VOLUME AND TYPE OF LOCAL ANESTHESIA] and a
thoracoscopic aspiration needle. A [SIZE] chest tube was then placed through the camera port, tunneled anteriorly, and
directed posteriorly and towards the apex. Chest tube position was confirmed by thoracoscopic visualization. All the ports
were removed and the lung was reinflating with Valsalva maneuvers obliterating the pleural space and reversing atelectasis.
Each of the ports were closed in layers with absorbable suture.
The sponge, instrument, and needle counts were said to be correct at the conclusion of the procedure. The patient was then
extubated without incident and taken to the post-anesthesia care unit in [CONDITION].
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
29. VATS Sympathectomy
John R Spratt, MA, MD and Eitan Podgaetz, MD, MPH

1. Semi-Fowler position with reverse Trendelenburg, arms abducted beyond 90° bilaterally, and entire chest prepped
into the field
2. General endotracheal anesthesia with double lumen endotracheal tube and single-lung ventilation
3. Double lumen tube position confirmed by flexible bronchoscopy
4. Surgeon stands on ipsilateral side
5. 1 cm incisions over 5th intercostal space at lateral border of pectoralis major and 4th intercostal space in anterior
axillary line with placement of 5 mm trocars in each
6. CO2 insufflation to facilitate better lung collapse (pressure 6 to 10 mmHg)
7. Inspection of chest cavity and identification of sympathetic chain crossing rib heads posteriorly
8. Meticulous counting of ribs to determine proper level; 2nd rib is most superior rib visible from within pleural cavity,
T2 ganglion located between heads of 2nd and 3rd ribs
9. Use hook cautery to dissect parietal pleura above and below isolating the sympathetic chain at the levels desired
1. T2-T3 transection is best for palmar hyperhidrosis
2. T3-T4 transection is best for axillary hyperhidrosis
3. May extend as low as T5 for lower-extremity symptoms
4. T1-T3 for reflex sympathetic dystrophy
5. T4-T10 for chronic pancreatic pain
10. Cautery or clips may be used to transect/ clip sympathetic chain. (Clips are believed to be reversible in cases of
severe compensatory hyperhidrosis)
11. Lung is re-inflated under direct vision, may use small chest tube through one of the working incisions to evacuate
residual gas
12. Removal of chest tube following closure of subcutaneous layer, followed by skin closure
13. Procedure is then repeated on contralateral side
14. Chest radiograph in PACU

1. Meticulous identification of proper level of transection is mandatory
1. Landmarks:
1. 2nd rib is most superior rib visible from within the chest
2. Azygos vein lies at 5th interspace
3. Aortic arch reaches 4th interspace
2. Named ganglia located inferior to corresponding rib (e.g. T2 ganglion is located between heads of 2nd and 3rd
ribs)
2. Bleeding complications rare, but may result from damage to intercostal vasculature or great vessels, hemothorax from
port site bleeding also possible
3. Clinically insignificant postop pneumothoraces are common
4. Horner’s syndrome may result from misidentification of level of transection
5. Compensatory sweating of the torso, thighs, and legs may result, can be as severe as original palmar/ axillary
hyperhidrosis in some cases
6. Patients must have documented proof of at least two medical treatments (topicals, iontophoresis, Botox, etc.) to be
considered for surgical intervention.
Template Dictation
Procedure(s) Performed: [L or R] [LEVEL] VATS sympathectomy
Assistants: [BLANK]
Anesthesia: [BLANK]
Specimens: [BLANK]
Fluids: [BLANK]
EBL: [BLANK]
Drains: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [INDICATION]. The patient has failed maximal medical
management of this condition, which included [MEDICAL THERAPY], and the decision was made to perform thoracoscopic
sympathectomy. The risks and benefits of the procedure were described to the patient, who verbalized good understanding,
and informed consent was obtained.
Description of Procedure: The patient was taken to the operating room from the preoperative holding area. The patient’s
identity and planned procedure were verified and the patient was then placed on the operating room table in the supine
position. General endotracheal anesthesia was induced with the use of [SINGLE LUNG VENTILATION – double lumen
endotracheal tube, bronchial blocker, endobronchial intubation, etc.]; tube position was confirmed by flexible bronchoscopy,
allowing selective ventilation of the lung on the non-operative side. Once this was completed, the patient was moved into a
Semi-Fowler position with both arms abducted beyond 90 degrees. All bony prominences were padded, and it was ensured
that the patient’s upper extremities were not under undue stretch. The chest was prepped bilaterally from the clavicle to below
the costal margin longitudinally and to out to the tip of the scapulae transversely. The patient was draped appropriately and a
surgical time out was performed.
The [SIDE] lung was isolated. The fifth intercostal space was identified at the lateral border of the pectoralis muscle. A rib
block was performed with [VOLUME AND TYPE OF LOCAL ANESTHESIA] , after which a 5mm skin incision was
made. Ventilation was held. A 5 mm trocar was placed and the chest was inspected with a 5 mm 30 degree thoracoscope.
The lung was noted to be deflated. [FINDINGS]. The chest was then insufflated with CO2 via the trocar to facilitate lung
collapse to a pressure of 10 mmHg. After determining that it was safe to proceed, a second 5 mm port was placed in the 4th
intercostal space in the anterior axillary line using the same technique described previously.
The second rib was identified high in the chest cavity and this was used as a landmark to identify the location of the
[TARGET GANGLIA] ganglia along the visualized sympathetic chain. Hook cautery was used to open the parietal pleura at
[LEVELS]. The exposed sympathetic chain was dissected from the parietal pleura. Surgical clips were placed at the
proximal and distal level. A 14 French chest tube was then placed through the working trocar; the trocar was then removed
over the tube. Suction was applied to the chest tube. The lung was then re-inflated under direct vision and the subcutaneous
tissues were then closed after the final trocar and camera were withdrawn. The chest tube was removed under Valsalva
maneuver and the skin was closed in a subcuticular fashion with absorbable suture.
[PROCEDURE IS REPEATED ON CONTRALATERAL SIDE]
The sponge, instrument, and needle counts were said to be correct at the conclusion of the procedure. The patient was then
awoken from anesthesia, extubated in the OR, and then taken to the PACU in[CONDITION], where a chest radiograph is
pending at the time of this dictation.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
30. VATS Thymectomy
Manu S. Sancheti, MD and Allan Pickens, MD
Emory University, Atlanta, GA

2. General double lumen endotracheal tube anesthesia
3. Partial right lateral decubitus positioning
4. Prep and drape entire chest
5. Single lung ventilation
6. Thoracoscopic guided trocar placement
7. CO2 insufflation 6 mmHg to 15 mmHg as tolerated
8. Additional left trocars placement
9. Open mediastinal pleura anterior to phrenic nerve
10. Isolate and divide left inferior horn
11. Free thymus from pericardium moving superiorly to thoracic inlet
12. Free thymus anteriorly from sternum along IMA/IMV
13. Enter right pleural space
14. Right trocars placement and move camera/ultrasonic coagulator to right
15. Isolate and divide right inferior horn
16. Free thymus from pericardium moving superior to thoracic inlet
17. Divide attachments to innominate vein
18. Isolate and divide right superior horn
19. Move camera and instruments back to left
20. Divide attachments to innominate vein
21. Isolate and divide left superior horn
22. Place thymus in endoscopic bag and remove
23. Examine specimen
24. Hemostasis
25. Ensure no residual thymic tissue present
26. Place chest tube transmediastinally
27. Observe lung re-expansion
28. Closure

1. Improper double lumen endotracheal tube placement
2. Improper positioning and poor padding of pressure points/traction on shoulder or elbow
3. Improper trocar positions
4. Lung injury with initial thoracoscopic guided trocar placement
5. Hemodynamic compromise with insufflation
6. Injury or division of phrenic nerve
7. Bleeding from thymic vessels at horns due to inadequate coagulation or clipping
8. Injury to IMA/IMV
9. Injury to right lung when entering right pleural space
10. Injury to innominate vein or inadequate control of vein branches from innominate vein
11. Poor hemostasis
12. Residual thymic tissue left at end of case
13. Chest tube not placed transmediastinally
14. Poor lung re-expansion
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g Myasthenia Gravis, Thymoma, Thymic cyst, Thymic carcinoma]
Procedure(s) Performed: Thoracoscopic thymectomy
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT –e.g. chest pain,
muscle weakness, incidental finding]. Preoperative imaging revealed [RADIOLOGY RESULTS]. Patient was evaluated in
Thoracic Surgery Clinic and recommended to undergo thymectomy via bilateral thoracoscopy. Risks/alternatives discussed,
questions answered and patient agrees to proceed.
obtained and the patient was intubated with a double lumen endotracheal tube. Proper position was confirmed with flexible
bronchoscopy. A Foley catheter was inserted under sterile conditions. [PREOPERATIVE ANTIBIOTIC AND DOSE ] was
administered within 1 hour of skin incision. Bilateral lower extremity sequential compression devices were placed for DVT
prophylaxis. A warming blanket was placed for intraoperative hypothermia.
The patient was placed in a partial right lateral decubitus position with a bump placed under the patient’s left side. The left
arm was placed in a sling above the head. All pressure points were padded well and no traction was placed on the shoulder or
elbow. Hair removal was performed with clippers. The entire chest was prepped and draped in sterile fashion. The right lung
was selectively ventilated. A time out was performed.
LOCAL ANESTHETIC MEDICATION AND DOSE ] was used to infiltrate each trocar site prior to incision. A 12 mm
th
incision was made in the 7 intercostal space in the mid-axillary line. A 12 mm thoracoscopic port was placed into the left
pleural space under direct thoracoscopic guidance using a 10 mm 30-degree thoracoscope. Upon entrance into the pleural
space, insufflation was started up to 15 mmHg as tolerated. Two 5 mm thoracoscopic ports were then placed under direct
visualization: one in the left 4th intercostal space at the anterior axillary line and one in the left 6th intercostal space at the
anterior axillary line.
The dissection was started by opening the mediastinal pleura with a grasper and ultrasonic coagulator approximately 1-2 cm
anterior to the phrenic nerve. This was followed inferior to the diaphragm. The left inferior pole of the thymus gland was freed
from its attachments inferiorly. The thymus was then dissected free from the pericardium moving superiorly toward the thoracic
inlet. The thymus was then mobilized from the sternum anteromedially along the length of the internal mammary artery/vein.
The right pleura was then opened and carried inferiorly. Next, two 5 mm thoracoscopic ports were placed under direct
visualization in the right inframammary fold approximately 8 cm apart. The thoracoscope was moved to one of these ports and
the ultrasonic coagulator in the other. The thymus was grasped from a left sided port and retracted towards the left. The right
inferior horn was isolated and divided. The thymus was then freed from the pericardium moving superiorly toward the thoracic
inlet being careful to stay at least 1-2 cm anterior to the phrenic nerve. Superiorly, the thymus was freed from its attachments to
the innominate vein using coagulation and clips. The right superior horn was then isolated and divided assisted by inferior
retraction of the gland. The camera was then moved back to the left-sided 5 mm port. The left superior horn was then isolated
and divided in a similar fashion. A 10 mm endoscopic bag was then placed through the 12 mm port. The thymus gland was
extracted in the bag from this port. The gland was examined on the back table and finding include [FINDINGS e.g. mass, cyst,
normal, etc]. The specimen was sent to pathology.
The entire chest cavity was inspected. Hemostasis was achieved. No evidence of residual thymus was visualized. A 19 French
Blake drain was placed through one of the right-sided 5 mm ports and crossed transmediastinally to the left. All ports were
removed except the camera port. Insufflation was removed and the lung was observed to expand fully. The final port was
removed. The 12 mm port site fascia was closed with #2-0 Vicryl. All skin incisions were closed with running #4-0 Monocryl
in a subcuticular fashion and Dermabond was placed on the skin. The chest tube was secured with #0 silk suture.
extubated and taken to the Post-Operative Recovery Unit in stable condition.
31. Transcervical Thymectomy
J. Matthew Reinersman, MD, and Stephen D. Cassivi, MD, MSc

1. Patient Selection
1. Partnering with an experienced neurologist specializing in myasthenia gravis and similar motor disorders is
essential to preoperatively confirm the diagnosis of myasthenia gravis.
2. Patients with suitable body habitus for this procedure are those patients who can adequately extend their neck
and do not have limiting osteoarthritis of the cervical spine or significant osteophytes.
3. Patients presenting with a presumed thymoma visible on imaging are not preferred for this approach and should
be considered for thoracoscopic thymectomy.
4. This approach can also be used to resect a thymus gland containing an active ectopic parathyroid gland.
1. Standard peripheral venous access is usually sufficient along with standard non-invasive intraoperative
monitoring. When possible, venous access should be obtained from the right upper extremity.
3. Patient Positioning and Preparation
1. The patient is positioned supine with an inflatable pillow placed behind the shoulders to assist with neck
extension.
2. The operative table is shifted away from the usual anesthetic equipment so that the head of the bed accessible to
the surgeon and surgical assistant.
3. The patient is prepped and draped from the chin to just above the umbilicus to allow for possible conversion to
median sternotomy.
4. General endotracheal anesthesia without use of neuromuscular blockade
5. Low collar incision
6. Create superior and inferior subplatysmal flaps
7. Divide midline strap muscles
8. Dissect upper poles of thymus gland from underneath the strap muscles on each side and divide between suture
ligatures, leaving the ligatures on the thymus side long as means of retraction
9. Just behind the sternal notch, bluntly dissect the plane posterior to sternum, place Cooper retractor, let down
inflatable shoulder pillow
10. Retract thymus forward and upward to display veins draining into innominate vein. Ligate and divide the draining
thymic veins
11. Carry dissection along posterior aspect of thymus into mediastinum along anterior pericardium
12. Utilize 5-mm, 30-degree thoracoscope to improve visualization
13. Dissection carried on the right side laterally and then the left side laterally.
14. Continue dissection anteriorly to divide the attachments of the anterior thymus to the retrosternal surface
15. Remove the specimen intact, weigh it, take to pathology
16. Re-examine thymectomy space for any residual thymus or fatty tissue and assess hemostasis
17. Reapproximate midline strap muscles, close platysma and skin

1. Patient selection is critical - nonthymomatous myasthenia. This approach should not be utilized for patients with
thymoma or thymic carcinoma. Other relative contraindications include previous median sternotomy, severe
osteoarthritis or previous cervical spine surgery, or previous thyroid surgery.
2. Prep and drape entire neck and anterior chest, have sternal saw immediately available and be prepared to perform
sternotomy if difficult visualization, bleeding, or other problems occur.
3. Completing the posterior dissection between the thymus and the pericardium first prior to dissecting anteriorly
between the thymus and sternum is highly recommended as it allows for better visualization. Maintaining the anterior
attachments between the sternum and the thymus help to keep this tissue retracted anteriorly while the posterior
dissection is completed down to the pericardiophrenic angles.
4. Avoid injury to phrenic nerves; Use of electrocautery in the deep lateral extent can put the phrenic nerves at risk; use
low power in a patient free of muscle relaxants.
5. Entry into the pleural space can occur but is usually inconsequential and does not require a formal chest tube drainage
if the lung has not been injured. Evacuation of the pleural space air can be accomplished at the end of the procedure
by placing a drainage tube to underwater seal into the pleural space via the cervical incision. Sustained positive
pressure breaths are obtained and the tube is pulled when the pleural air has been sufficiently cleared prior to closure
of the incision.
6. If necessary, arterial monitoring line should be placed in the left upper extremity due to possible intermittent
compression of the innominate artery throughout the operation may lead to false determinations of a low blood
pressure. Venous lines should be placed in the right upper extremity.
7. Utilization of a 5-mm, 30-degree thoracoscope assists with visualization
8. Muscle relaxants are avoided in myasthenia gravis cases to reduce the postoperative complications due to
exacerbated motor nerve disturbances, especially respiratory muscle weakness.
Template Dictation
Preoperative Diagnosis: Nonthymomatous myasthenia gravis
Procedure(s) performed: Transcervical Thymectomy
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with a history of [SYMPTOMS] and a diagnosis of
[DIAGNOSIS] presents for transcervical thymectomy.
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient's identity and planned
procedure were verified, and the patient was placed on the operating room table in the supine position. Following induction of
general anesthesia without the use of muscle relaxants, the patient was intubated with a single-lumen endotracheal tube. The
patient's arms were tucked at the side and an inflatable pillow was placed behind the shoulders and inflated to allow extension
of the neck. The entire neck and anterior chest were then prepped and draped.
A 4 cm incision was made one fingerbreadth above the sternal notch in a curvilinear transverse fashion. The platysma was
incised and superior and inferior subplatysmal flaps were then created, extending to the level of the sternal notch inferiorly and
to the inferior border of the thyroid superiorly. The midline between the strap muscles was then incised along the midline
raphae and the upper poles of the thymus gland were detected behind these structures. The left upper pole of the thymus gland
was identified, isolated, and then ligated underneath the sternohyoid and sternothyroid muscles. The pedicle was controlled
between two #2-0 silk ligatures and then divided. The silk ligatures on the thymus were left long for traction purposes.
Similarly the right superior pole was dissected under the right side strap muscles. The upper pole ligatures were then used to
allow gentle retraction during the remainder of the procedure. Dissection was then carried down to the level of the innominate
vein, posterior to the superior portions of the thymus gland. A space was cleared in the plane between the posterior sternal
notch and the anterior thymus gland for placement of the Cooper retractor. With the Cooper retractor in place, the sternum was
elevated anteriorly and the inflatable cushion was deflated allowing the mediastinal contents to fall away from the sternum.
The thymus was then carefully dissected off of the innominate vein. Multiple small venous branches of the innominate vein
were carefully ligated and divided. A 5-mm, 30-degree thoracoscope was then inserted through our incision to aid in
visualization and dissection. The dissection was then continued along the anterior pericardium all of the way down to the
diaphragm. The right side was then dissected free laterally, followed by the left side. We then carried our dissection
anteriorly to divide the attachments of the anterior thymus to the retrosternal surface. The thymus was then able to be
completely delivered through the cervical incision. It was removed intact within its capsule. It weighed [WEIGHT] grams.
Pathology revealed [PATHOLOGY DIAGNOSIS]. At this point after sending the specimen off, we reinserted the
thoracoscope and reinspected the mediastinum for any further thymic or fatty tissue. We assured hemostasis. Once we were
satisfied, the Cooper retractor was removed, the strap muscles were reapproximated with two interrupted Vicryl sutures. The
platysma was then closed with a running Vicryl suture. The incision was then irrigated and the skin was closed with #4-0
Monocryl suture. The incision was washed, dried, and dressed. The patient was recovered from anesthesia, extubated and
brought to the recovery room in stable condition. At the end of the case, both sponge and instrument counts were correct, and
the estimated blood loss was [BLOOD LOSS].
32. Trans-Sternal Thymectomy
Geoffrey T. Lam, MD, and Jessica S. Donington, MD
NYU School of Medicine, New York, NY

2. General endotracheal anesthesia with double-lumen tube: preferable but not essential
3. Bronchoscopy: to confirm placement of double-lumen tube
4. Median sternotomy
5. Thymectomy
6. Preservation of phrenic nerve
8. Sternotomy closure

1. Straying off midline during sternotomy
2. Injury to innominate vein
3. Injury to phrenic nerve
4. Failure to remove the entire thymus
5. Inadequate hemostasis prior to sternotomy closure
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. mediastinal mass, thymoma, thymic carcinoma]
Procedure(s) Performed: Trans-sternal thymectomy, fiberoptic bronchoscopy
Assistants: [BLANK]
Anesthesia: [BLANK]
Fluids: [BLANK]
EBL: [BLANK]
Specimens: [BLANK]
Drains: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [THYMOMA/THYMIC CARCINOMA]
. Preoperative
imaging revealed [FINDINGS].
Description of Procedure: Informed consent for surgery was obtained from the patient, including a discussion of risks,
benefits and alternatives, and the form was documented in the chart. The patient was taken to the operating room on [DATE]
and placed on the operating room table in supine position. Anesthesia inserted appropriate intravascular access and
hemodynamic monitoring lines. Preoperative IV antibiotics were administered. A time out was called to identify the correct
patient, procedure and anatomic location. Following the induction of teneral endotracheal anesthesia, the patient was intubated
with a double-lumen endotracheal tube. Bronchoscopy was performed. Proper placement of the endotracheal tube was
confirmed. The airways were examined. Normal endobronchial anatomy was noted. There were no endobronchial
abnormalities. The patient was left in the supine position, a transverse shoulder roll was placed, and the arms were tucked. A
lower Bair Hugger was applied and all pressure points were padded. The neck and chest were prepped and draped in sterile
fashion.
The endotracheal tube was disconnected from the ventilator. A median sternotomy was performed. Mechanical ventilation
was resumed. Hemostasis of the sternum was obtained, and a sternotomy retractor was placed. The [RIGHT/LEFT] side
was approached first. The ipsilateral lung was isolated, the sternal table was elevated and the pleural space was widely
opened. Dissection was started inferiorly and care taken to identify and preserve the phrenic nerve. Small thymic branches
were doubly clipped with medium clips and divided using Bovie electrocautery. The mass was elevated off the pericardium
[THE PERICARDIUM WAS RESECTED EN BLOC IF ADHERENT] and dissection continued over the pericardial
surface, superiorly up to the level of the innominate vein and laterally out to the phrenic nerve. Attention was turned to the
superior horn, which was dissected free, clipped superiorly and brought inferiorly to the level of the innominate vein. Prior to
beginning dissection on the contralateral side, a 28-French straight chest tube was placed into the pleural space via a separate
lateral stab incision, directed anteriorly and superiorly and secured to the skin using #1 silk. Anesthesia then switched the lung
isolation. The sternal table was elevated and the contralateral pleural space was opened widely. The dissection was started
inferiorly and carried in a superior direction, taking care to identify and preserve the phrenic nerve. All thymic tissue and
mediastinal fat between the phrenic nerves was dissected free up to the level of the innominate vein. The second superior horn
was dissected free and clipped at its highest point and then dissected inferiorly down to the level of the innominate vein. The
thymus was dissected off the innominate vein, and the draining vein was identified, clipped and divided. The thymus was
passed off the field.
Hemostasis was achieved using Bovie electrocautery. A 28-French straight chest tube was placed into the contralateral
pleural space via a separate lateral stab incision, directed anteriorly and superiorly and secured to the skin using #1 silk. The
lung was reinflated and the patient left on two-lung ventilation. The sternum was reapproximated using [NUMBER] #5
stainless steel wires. The sternotomy incision was closed in layers, using #0 PDS for the fascia, #2-0 PDS for the deep dermal
layer and a running #3-0 Monocryl subcuticular stitch for the skin. Sterile dry dressings were applied. The chest tubes were
connected to Pleur-Evac drainage.
The patient tolerated the procedure well. The patient was extubated in the operating room and transferred in stable condition
to the recovery room. At the end of the case, the sponge, needle and instrument counts were correct x2.
33. Open Lobectomies
Erin Gillaspie, MD and K. Robert Shen, MD
Note: There are a variety of surgical options for managing the pulmonary vasculature and the bronchus. Different methods are
described throughout the chapter.
Right Upper Lobectomy

1. Place an arterial line and Foley catheter.
2. General endotracheal anesthesia and thoracic epidural catheter.
3. Flexible bronchoscopy to assess airway for secretions, pus, blood, bronchial anatomical abnormalities and
endobronchial lesions.
4. Exchange single lumen for dual lumen tube or place bronchial blocker.
5. Confirm tube positioning with bronchoscopy.
6. Place patient in lateral decubitus positioning with table flexed cephalad to xiphoid process.
7. Perform muscle sparing postero-lateral thoracotomy dividing the latissimus dorsi but sparing the serratus anterior
muscle which is reflected anteriorly. Chest is entered in the 4th or 5th intercostal space.
8. Divide inferior pulmonary ligament up to the inferior pulmonary vein.
9. Open mediastinal pleural circumferentially around the hilum.
10. Open fissure to expose the pulmonary artery at the junction of the major and minor fissure.
11. Transect superior pulmonary vein after verifying that there is a separate inferior pulmonary vein.
12. Transect the truncus anterior artery and posterior ascending artery.
13. Transect bronchus after test clamping the right upper lobe and having the anesthesia team reinflate the right lung to
verify that the bronchi to the middle and lower lobes have unobstructed flow.
14. Complete fissure posteriorly and complete parenchymal division anteriorly.
15. Perform thoracic lymphadenectomy with sampling or removal of lymph nodes from stations 4, 7, 8, 9 as well as
peribronchial nodes around the bronchus of the right upper lobe.
16. Test bronchial stump for pneumostasis.
17. Check for hemostasis.
18. Tack right middle lobe to lower lobe to prevent middle lobe torsion.
19. Place chest tubes.
20. Close thoracotomy.

1. Traditionally, the pulmonary vein is transected first. However, if exposure is difficult, the artery or bronchus may be
transected initially to provide adequate exposure to complete the lobectomy safely.
2. If the bronchus is divided first, the vein and artery are at risk for injury due to the lack the structural support of the
bronchus; special care must be taken.
3. Prior to dividing any venous branches, verification of a separate inferior pulmonary vein is mandatory
4. The right upper lobe artery anatomy is variable. The posterior ascending artery typically originates from the main PA
just opposite to the middle lobe artery. It may also originate from the superior segment to the right lower lobe.
5. The venous anatomy is also variable. The middle lobe vein may be a tributary of either (or both) the superior or
inferior pulmonary vein. Special attention must be taken when performing a middle lobectomy to assure that the
middle lobe vein isn’t sacrificed.
6. Removal of the “sump node” (level 11R node), which resides between the right upper lobe bronchus and bronchus
intermedius, is helpful to expose the posterior ascending artery.
7. Avoid devascularization of the whole bronchus as this impairs healing and results in higher rates of broncho-pleural
fistula formation.
Template Dictation
Procedure(s) Performed: Right upper lobectomy
Assistants: [BLANK]
Anesthesia: [GENERAL ENDOTRACHEAL, THORACIC EPIDURAL]
Indication(s) for Procedure: [AGE] year old [GENDER] who presented with [DURATION] history of [COMPLAINT].
Workup included [CXR, CT, PET] which demonstrated [WORKUP FINDINGS]. Pulmonary functions tests demonstrated
patient to be a candidate for lobectomy.
procedure were confirmed. The patient was transferred to the operating room table and placed in supine position. General
endotracheal anesthesia was induced. Flexible bronchoscopy was performed. There were no secretions, pus, blood,
bronchial anatomical abnormalities, or endobronchial lesions. The single lumen tube was exchanged for a dual lumen
endotracheal tube. Tube position was verified with bronchoscopy. A radial arterial line and additional peripheral IVs were
placed.
The patient was placed in the left lateral decubitus position and prepped and draped in the usual sterile fashion. A time out
was performed. All members of the surgical team were present and were in agreement.
The right lung was isolated. A serratus-sparing right posterolateral thoracotomy was performed. The chest was entered. The
[FIFTH/SIXTH] rib was shingled posteriorly. The inferior pulmonary ligament was divided to the level of the inferior
pulmonary vein. A station 9 lymph node was sampled. The lung and pleura were examined; the lesion was identified in the
upper lobe. The lung was retracted posteriorly and the mediastinal pleural opened circumferentially around the hilum. The
sump node (station 11R) was removed. The horizontal fissure was opened using electrocautery and completed with the GIA
stapler to expose the underlying pulmonary artery. The superior pulmonary vein was identified and the apical, anterior and
posterior branches were skeletonized, ligated proximally and distally with [TIE/SUTURE/STAPLE] and divided. The
truncus anterior and posterior ascending branches of the pulmonary artery were skeletonized, ligated proximally and distally
with [TIE/SUTURE/STAPLE] and divided. The upper lobe was retracted superiorly and posteriorly to identify the right
upper lobe bronchus. The bronchus was exposed circumferentially with lymphatic tissue being swept up towards the
specimen. The upper lobe bronchus was occluded just distal to the takeoff from the mainstem bronchus with a curved clamp.
The middle and lower lobe expanded, thereby confirming unobstructed flow. The bronchus was transected and over-sewn
with #3-0 PDS [SUTURE MATERIAL]. The upper was sent to Pathology. Frozen sections demonstrated negative bronchial
margins
Mediastinal lymph nodes from stations 2R, 4R, 7, 8, 9, 10R, and 11R were sampled during the dissection.
The bronchial stump was submerged under water, the lung was inflated to 40 cm water pressure and the stump was found to be
pneumostatic. The right middle lobe was sutured to the right lower lobe to prevent torsion. The chest was re-evaluated for
bleeding and excellent hemostasis was assured.
Two 28 french chest tubes were placed in the pleural cavity and sutured into place.
The lung was allowed to re-expand under direct vision.
The ribs were re-approximated with figure of 8 peri-costal sutures. The serratus anterior layer was re-approximated with
running suture. The latissimus dorsi was closed in two layers with running suture. The subcutaneous tissue and skin were
closed in running fashion.
Right Middle Lobectomy

4. Exchange single lumen for dual lumen tube or place bronchial blocker.
7. Perform a muscle sparing posterolateral thoracotomy, dividing the latissimus dorsi but sparing the serratus anterior
muscle, which is reflected anteriorly. Chest is entered in the 4th or 5th intercostal space.
10. Open horizontal fissure.
11. Transect venous branch to the middle lobe.
12. Transect artery (or arteries). There may be one or two middle lobe arterial branches.
13. Transect the bronchus after test clamping the right middle lobe and having the anesthesia team reinflate the right lung
to verify that the bronchi to the upper and lower lobes have unobstructed flow.
14. Complete the horizontal and oblique fissures.
15. Perform thoracic lymphadenectomy with sampling or removal of lymph nodes from stations 4R, 7, 8, 9 as well as
peribronchial nodes around the bronchus of the right middle lobe.

1. There may be one or two arterial branches to the middle lobe. The posterior ascending branch to the RUL should not
be confused with a second branch.
2. Venous anatomy is variable. The middle lobe vein can be a tributary of the superior or inferior pulmonary vein and at
times both.
fistula formation.
Template Dictation
Procedure(s) Performed: Right middle lobectomy
Assistants: [BLANK]
Workup included [CXR, CT, PET] which demonstrated [WORKUP FINDINGS]. The patient’s pulmonary function tests
indicate that a lobectomy could be safely performed.
placed.
[FIFTH/SIXTH] rib was shingled posteriorly. The inferior pulmonary ligament was divided to the level of the inferior
pulmonary vein. A station 9 lymph node was sampled. The lung and pleura were examined; the lesion was identified in the
upper lobe. The lung was retracted posteriorly and the mediastinal pleural was opened circumferentially around the hilum.
The horizontal fissure was opened and completed with a GIA stapler to expose underlying pulmonary artery branches. The
lung was rotated posteriorly and middle lobe vein identified from its takeoff from the [SUPERIOR/INFERIOR] pulmonary
vein. The vein was skeletonized and transected with vascular load stapler. The [ONE/TWO] arterial branches to the right
middle lobe were identified, skeletonized and divided with a vascular load stapler. The oblique fissure was completed using
serial applications of GIA stapler. Finally, the middle lobe was rotated superiorly to expose the right middle lobe bronchus at
the origin of the bronchus intermedius. The bronchus was exposed circumferentially. All lymphatic tissue was swept up
towards the specimen. A 4.8 mm TA stapler applied to the right middle lobe bronchus. The lung allowed to re-inflate.
Unobstructed airflow to the right upper and lower lobes was confirmed. The bronchus was transected, and the specimen was
removed from the chest. Frozen sections demonstrated negative bronchial margins.
Station 2R, 4R, 7, 8, 9 and 10R lymph nodes were sampled.
The bronchial stump was submerged under water, the lung was inflated to 40 cm water pressure, and the stump was found to be
pneumostatic. The chest was irrigated. Hemostasis was assured.
Two 28 French chest tubes were placed in the pleural cavity.
The lung was allowed to re-expand.
The ribs were re-approximated with figure of 8 peri-costal sutures. The serratus anterior layer was re-approximated with
running suture. The latissimus dorsi was closed in two layers with running suture. Subcutaneous tissue and skin were closed
in a running fashion.
Right Lower Lobectomy

4. Exchange single lumen for dual lumen tube or place bronchial blocker
7. Perform muscle sparing posterolateral thoracotomy, dividing the latissimus dorsi and sparing the serratus anterior
muscle, which is reflected anteriorly. The chest is entered in the 4th or 5th intercostal space.
8. Divide the inferior pulmonary ligament up to the inferior pulmonary vein.
10. Open the fissure.
11. Transect inferior pulmonary vein after verifying that there is a separate superior pulmonary vein.
12. Transect superior segmental artery and basial arterial branches.
13. Transect the bronchus after test clamping the right lower lobe and having the anesthesia team reinflate the right lung
to verify that the bronchi to the right upper and middle lobes have unobstructed flow.
14. Complete the fissure posteriorly and complete parenchymal division anteriorly.
15. Perform thoracic lymphadenectomy with sampling or removal of lymph nodes from stations 4R, 7, 8, 9, and 10R as
well as peribronchial nodes around the bronchus of the right lower lobe.

1. The right middle lobe bronchus is at risk when completing the fissure between the right middle lobe and lower lobe
posteriorly. Care needs to be taken to ensure that the right middle lobe bronchus is not inadvertently divided or
narrowed during this step.
2. Furthermore, when preparing the divide the bronchus to the right lower lobe, it is critical to ensure that the bronchus
to the right middle lobe is not kinked or narrowed by the stapler since it comes off the bronchus at close to a 90
degree angle just proximal to the take-off for the right lower lobe.
fistula formation.
Template Dictation
Procedure(s) Performed: Right lower lobectomy
Assistants: [BLANK]
placed.
sixth rib was shingled posteriorly. The inferior pulmonary ligament was divided to the level of the inferior pulmonary vein. A
station 9 lymph node was sampled. The lung and pleura were examined; the lesion was identified in the upper lobe. The lung
was retracted posteriorly and the mediastinal pleural was opened circumferentially around the hilum. The oblique fissure was
opened using electrocautery and completed with serial GIA stapler application. The inferior pulmonary vein was encircled as
it exits the pericardium and divided using a vascular load stapler. The superior and basilar segmental arterial branches to the
right lower lobe were identified, encircled and ligated with a vascular load stapler. The lower lobe was rotated anteriorly;
the bronchus intermedius was identified. The branch to the right middle lobe and right lower lobe were identified and the
lower lobe branch exposed circumferentially with lymphatic tissue being swept up towards the specimen. A 4.8 mm TA
stapler applied to the right lower lobe bronchus. The remaining was lung allowed to re-inflate to confirm unobstructed
airflow. The stapler was fired, the bronchus was transected, and the specimen was removed from the chest.
Mediastinal lymph nodes from stations 4R, 7, 8, 9, and 10R and 11R were sampled.
pneumostatic. Chest was irrigated. Hemostasis was assured.
Two 28 french chest tubes were placed in the pleural cavity.
The lung was reinsufflated under direct vision.
Ribs were re-approximated with figure of 8 peri-costal sutures. The serratus anterior layer was re-approximated with running
suture. The latissimus dorsi was closed in two layers with running suture. Subcutaneous tissue and skin were closed in a
running fashion.
Left Upper Lobectomy

1. Place an arterial line and Foley catheter
4. Exchange single lumen for dual lumen tube or place bronchial blocker. Generally, a left-sided double lumen
endotracheal tube is used for most situations because it is considered technically easier to place. However, in some
circumstances, such as a left pneumonectomy or a left sleeve lobectomy, a right-sided double lumen tube may be
preferable and should be discussed with the anesthesia team.
5. Confirm endotracheal tube positioning with bronchoscopy.
7. Perform muscle sparing postero-lateral thoracotomy, dividing the latissimus dorsi and sparing the serratus anterior
muscle, which is reflected anteriorly. The chest is entered in the 4th or 5th intercostal space.
8. Divide the inferior pulmonary ligament up to the inferior pulmonary vein.
9. Open the mediastinal pleural circumferentially around the hilum.
10. Open the fissure anteriorly and posteriorly.
11. Transect the superior pulmonary vein after verifying that there is a separate inferior pulmonary vein.
12. Transect apico-anterior, posterior and lingular arterial branches.
13. Transect bronchus after test clamping the left upper lobe and having the anesthesia team reinflate the left lung to
verify that the bronchus to the lower lobe has unobstructed flow.
14. Complete the fissure.
15. Perform thoracic lymphadenectomy with sampling or removal of lymph nodes from stations 4L, 5, 6, 7, 8, 9, 10L as
well as peribronchial nodes around the bronchus of the left upper lobe.

1. The left upper-lobe pulmonary artery anatomy is the most variable among the lobes. Usually, there are three
branches– apico-anterior, posterior and lingular. A left upper lobectomy is the most technically challenging
lobectomy in part due to this variability in the segmental arterial anatomy. In addition, the segmental arteries are quite
small, and easily injured. In particular the most proximal segmental artery needs to be handled with care since an
inadvertent injury can rapidly propagate into a left main pulmonary artery tear and be very difficult to control.
fistula formation.
Template Dictation
Procedure(s) Performed: Left upper lobectomy
Assistants: [BLANK]
procedure were confirmed. The patient was transferred to the operating room table and placed in the supine position. General
endotracheal anesthesia was induced, and the patient was intubated with a single lumen endotracheal tube. Flexible
bronchoscopy was performed. There were no secretions, pus, blood, bronchial anatomical abnormalities, or endobronchial
lesions. The single lumen tube was exchanged for a dual lumen endotracheal tube. Tube position was verified with
bronchoscopy. A radial arterial line and additional peripheral IVs were placed.
The left lung was isolated. A serratus-sparing left posterolateral thoracotomy was performed. The chest was entered. The
sixth rib was shingled posteriorly. The inferior pulmonary ligament was divided to the level of the inferior pulmonary vein.
The lung was retracted posteriorly and the mediastinal pleural opened circumferentially around the hilum. The fissure was
opened using sharp dissection and electrocautery. The fissure was completed with serial GIA stapler applications. The
superior pulmonary vein was encircled, ligated with [TIE/SUTURE], and divided. The left upper lobe pulmonary artery
branches were identified, skeletonized, individually ligated proximally and distally with [TIE/SUTURE] and divided. The
upper lobe was retracted anteriorly to identify the left upper lobe bronchus. The bronchus was exposed circumferentially. All
lymphatic tissue was swept upwards. A curved clamp was applied to the bronchus, and the lower lobe was allowed to
reinflate, thereby confirming unobstructed flow. The bronchus was transected and over-sewn with [SUTURE MATERIAL].
Mediastinal lymph node stations 4L, 5, 6, 7, 9, 10L and 11L were sampled.
Lung was allowed to re-expand.
suture. The latissimus dorsi was closed in two layers with running suture. Subcutaneous tissue and skin were closed in
running fashion.
Left Lower Lobectomy

4. Exchange single lumen for dual lumen tube or place bronchial blocker. Generally, a left-sided double lumen
endotracheal tube is used for most situations because it is considered technically easier to place. However, in some
circumstances, such as a left pneumonectomy or a left sleeve lobectomy, a right sided double lumen tube may be
preferable and should be considered or discussed with the anesthesia team.
7. Perform muscle sparing postero-lateral thoracotomy dividing the latissimus dorsi but sparing the serratus anterior
muscle which is reflected anteriorly. Chest is entered in the 5th intercostal space.
10. Open fissure anteriorly and posteriorly.
11. Transect inferior pulmonary vein after verifying that there is a separate superior pulmonary vein.
12. Transect superior segmental (one or two branches) and basilar segmental arterial branches.
13. Transect bronchus after test clamping the left lower lobe and having the anesthesia team reinflate the left lung to
verify that the bronchus to the upper lobe has unobstructed flow.
14. Complete the fissure.
15. Perform thoracic lymphadenectomy with sampling or removal of lymph nodes from stations 4, 5, 6, 7, 8, 9 as well as
peribronchial nodes around the bronchus of the left lower lobe.

1. Must be careful not to compromise the pulmonary artery branch to the lingula, which originates just proximally to the
lower lobe branches.
fistula formation.
Template Dictation
Procedure(s) Performed: Left lower lobectomy
Assistants: [BLANK]
procedure were confirmed. The patient was transferred to the operating room table and placed in the supine position. General
endotracheal anesthesia was induced, and the patient was intubated with a single lumen endotracheal tube. Flexible
bronchoscopy was performed. There were no secretions, pus, blood, bronchial anatomical abnormalities, or endobronchial
lesions. The single lumen tube was exchanged for a dual lumen endotracheal tube. Tube position was verified with
bronchoscopy. A radial arterial line and additional peripheral IVs were placed.
The left lung was isolated. A serratus-sparing left posterolateral thoracotomy was performed. The chest was entered. The
sixth rib was shingled posteriorly. The inferior pulmonary ligament was divided to the level of the inferior pulmonary vein.
The lung was retracted posteriorly and the mediastinal pleural opened circumferentially around the hilum. The fissure was
opened using sharp dissection and electrocautery. The fissure was completed with serial GIA stapler applications. The
inferior pulmonary vein was isolated and divided with a vascular load stapler. The left lower lobe pulmonary artery branches
were identified, skeletonized and ligated with a vascular load stapler. The lower lobe was retracted anteriorly to identify the
lower lobe bronchus. The bronchus was exposed circumferentially; all lymphatic tissue was swept up towards the specimen.
A 4.8 mm TA stapler was applied to the bronchus, and the remaining lung was allowed to re-inflate. The stapler was fired, the
bronchus transected sharply and the specimen removed from the chest.
Mediastinal lymph node stations 4L, 5, 6, 7, 9, 10L and 11L were sampled.
The lung was re-expanded under direct vision.
suture. The latissimus dorsi was closed in two layers with running suture. Subcutaneous tissue and skin were closed in
running fashion.
34. Segmentectomy
James E. Wiseman, MD and Samuel S. Kim, MD
University of Arizona, Tucson, AZ

1. Pre-operative work up including PFT with DLCO. In patients with limited lung function, quantitative V/Q scan and/or
cardiopulmonary exercise test is warranted.
2. Preoperative bronchoscopy for secretion clearance and visualization of anatomy
3. Double-lumen intubation
4. Positioning (lateral decubitus, with flexion of the bed at the hips)
5. Examine hemithorax for signs of other nodules/metastases prior to performing resection
6. Location and palpation of target lesion
7. Division of inferior pulmonary ligament (for mobilization in upper lobe segmentectomy, exposure of the vein in lower
lobe segmentectomy)
8. Mediastinal lymph node dissection
1. Right-sided tumors: 4R, 7, 9, 10R, 11R
2. Left-sided tumors: 5, 6, 9, 10L, 11L
9. Correct identification of vascular and bronchial anatomy
10. Inflation test to verify isolation of target segment
11. Verification of negative surgical margins prior to closure
12. Placement of chest tubes
13. Visualization of full lung expansion at the end of the operation, including recruitment maneuvers performed by
anesthesiologist

1. Distortion of lung anatomy by tumor or inflammation can interfere with identification of the target segment The
bronchus is the most reliable structural component; initial identification, dissection, and division of the bronchus may
facilitate the operation.
2. Identification and separation of the intersegmental plane is performed by differential inflation after occluding the
target bronchus and ventilating the lung. Intersegmental veins travel along this plane, and meticulous dissection along
this plane to define routes of venous drainage is imperative. The presence of significant collateral ventilation can
make deciphering this plane difficult. In these cases, the entire lung can be inflated initially, the target bronchus
occluded, and the lung deflated. The target segment is identified as the portion of lung that remains expanded.
3. The identification and division of correct segmental vein is essential.
4. Meticulous dissection and careful handling of the tissues are essential, especially in patients with pre-existing
emphysema, to avoid significant air leak which can complicate the post-operative course. Traditional dissection of
the intersegmetal plane using scissors or cautery increases the risk of postoperative airleak and bleeding. Surgical
staplers, while less prone to these complications, are limited by the thickness of the lung parenchyma, and thus
vulnerable to staple line disruption. This risk can be reduced by careful reinforcement of the staple line with
interrupted, vertical mattress sutures.
5. Right upper anterior segmentectomy is difficult to perform due to inaccessibility of the anterior segmental bronchus
from a posterior approach. Formal lobectomy is a safer approach to lesions in this anatomical division.
Template Dictation
Thoracotomy
Preoperative Diagnosis: [INDICATION for operation; typically neoplasm, but may be done for lesions with infectious or
benign etiology, particularly if diagnostic uncertainty is present]
Postoperative Diagnosis: specific diagnosis (i.e. cancer histology, if not known preoperatively and if frozen section
performed), other intraoperative findings
1. Thoracotomy (with laterality)
2. Segmentectomy (specify segment removed)
3. Mediastinal lymph node dissection (if done for malignancy)
Assistants: [BLANK]
Operative Findings: [Include results of frozen section specimens, anatomic variants, surgical margins]
Specimens: [Include an accurate description of all specimens sent. Typically will include mediastinal lymph nodes and
levels, tissue biopsies sent to rule out metastatic disease, and the target lung segment.]
Indication(s) for Procedure: This is a [AGE] year-old [ G E N D E R ]who presented with history of
[COMPLAINT/DURATION]. The patient was noted on diagnostic [CHEST RADIOGRAPHY] to have a [SIZE] nodule in
the [SIDE, LOBE, AND SEGMENT] . A CT-guided biopsy was performed, which was noted to be suspicious for [TISSUE
DIAGNOSIS]. (If no biopsy was performed—e.g. recent history of other malignancy with high suspicion for lung metastasis
—this should be stated here.) [MEDIASTINOSCOPY/ENDOBRONCHIAL ULTRASOUND] (if performed) did not show
mediastinal lymph node involvement. Based upon the patient’s presentation and preoperative workup, it was determined that
(he/she) would benefit from [SIDE, LOBE, AND SEGMENT]segmentectomy [with mediastinal lymph node dissection if
performed for malignancy]. The patient was informed of the risks and benefits of proceeding, including, but not limited to:
pain, bleeding, scarring, poor cosmetic outcome, inadvertent injury to adjacent structures necessitating a more complex
operation for repair, infection, either at the incision sites or elsewhere, persistent air leak from the lung or bronchus,
recurrence of the cancer (if appropriate), as well as those risks associated with the induction of general anesthesia, up to and
including death. All questions were answered to the satisfaction of the patient and family, including all alternatives to
operative intervention. The patient agreed with the need for the procedure, and informed consent was obtained.
Description of procedure: The patient was taken to the operating room and placed supine on the operating table. Following
induction of general anesthesia and intubation with a single-lumen endotracheal tube, a “time out” was performed, verifying
correct patient, correct procedure, and correct site. Antibiotics were then given to ensure delivery within one hour of
incision. Bronchoscopy was then performed; all segments were identified bilaterally, and all visible secretions were cleared.
[FINDINGS].The single-lumen endotracheal tube was then exchanged for a double-lumen tube with bronchoscopic guidance
to ensure total lung isolation.
The patient was then placed in the [SIDE] lateral decubitus position. All vulnerable pressure points were appropriately
padded, the bed flexed to extend the intercostal spaces, the up arm was extended cephalad to expose the axilla and secured into
place, and the patient secured to the operating table using a belt and cloth tape. After positioning was completed, correct
placement of the double-lumen endotracheal tube was again bronchoscopically confirmed, and the operative lung excluded.
The patient was then prepped and draped in the usual sterile fashion. A standard, posterolateral thoracotomy skin incision was
made overlying the fifth intercostal space, just inferior to the tip of the scapula. Using electrocautery, subcutaneous flaps were
created superiorly and inferiorly, and the dissection was carried down to the level of the latissimus dorsi, which was then
divided in hemostatic fashion. The serratus anterior muscle was encountered and mobilized from the chest wall by incising its
soft tissue attachments along the free edge of the muscle. The sixth rib was identified by palpation, and the 5th intercostal
muscle opened anteriorly and posteriorly to the paraspinous muscles using electrocautery while staying flush with the top of the
sixth rib. The pleura was then sharply incised, and digital palpation used to confirm the absence of adhesions. The fifth rib
was then shingled by removing a 0.5 cm segment of the rib at the level of the paraspinal muscles.
The entire lung was then mobilized using a combination of electrocautery and sharp dissection to divide attachments to the
chest wall. All lung parenchyma was visualized and palpated to rule out the presence of metastatic disease. The target nodule
was then palpated. Using monopolar cautery, the inferior pulmonary ligament was divided to a point just caudal to the inferior
pulmonary vein. During this maneuver, the level IX lymph node basin was identified. The overlying pleura incised, and all
nodes removed after ligation of the lymphatic pedicle. We then turned our attention to dissection of the mediastinal lymph node
basins. Using [ALLISON RETRACTORS/SPONGE STICKS/DUVAL GRASPERS/RING FORCEPS] , the lung was
retracted inferiorly, exposing the superior mediastinal structures.
For Right Lung Segmentectomies
The pleura immediately cephalad to the azygous vein was sharply incised, the level III and IVR lymph nodes were bluntly
skeletonized and retrieved following ligation of their lymphatic pedicles. These were sent to pathology for identification and
microscopic analysis.
The lung was then retracted anteriorly and the mainstem bronchus identified. The pleura overlying the hilum was sharply
incised, and the soft tissue immediately caudal to the bronchus was bluntly dissected. The level VII nodes were encountered
and retrieved after ligation of their lymphatic pedicles. These were sent to pathology for identification and microscopic
analysis.
For Right Upper Lobe Segmentectomies
Apical Segment: The superior venous trunk was identified and dissection continued until the apical segmental branch could be
identified and isolated using a blunt clamp. The dissection was then continued over the main pulmonary artery distally,
exposing its segmental branches. The apical segmental branch was identified as the first division of the main pulmonary artery.
This was circumferentially dissected and divided using an endoscopic stapler with a 45-millimeter vascular load. The apical
segmental branch of the superior pulmonary vein was then ligated and divided in a similar fashion. The lung was then
retracted medially, allowing identification of the upper lobe bronchus. Dissection was then carried distally along the bronchus
until the bifurcation of the apical and the posterior segmental divisions were visualized. The apical segmental division was
then isolated and divided using an endoscopic stapler.
Posterior Segment: The superior venous trunk was identified and dissection continued until the posterior segmental branch
could be identified and isolated using a blunt clamp. The dissection was then continued over the main pulmonary artery
distally, exposing its segmental branches. The posterior segmental branch was identified, circumferentially dissected, and
divided using an endoscopic stapler with a 45-millimeter vascular load. The posterior segmental branch of the superior
pulmonary vein was then ligated and divided in a similar fashion. The lung was then retracted medially, allowing
identification of the upper lobe bronchus. Dissection was then carried distally along the bronchus until the bifurcation of the
apical and the posterior segmental divisions were visualized. The posterior segmental division was then isolated and divided
using an endoscopic stapler.
For Right Lower Lobe Segmentectomies
Superior Segment: The oblique fissure was bluntly opened, exposing the interlobar pulmonary artery. Dissection was
carried out distally along the Plane of Leriche, and the overlying lung parenchymal divided with an endoscopic stapler using
successive 60-millimeter parenchymal loads. The superior segmental artery(ies) were identified and divided using vascular
loads following circumferential dissection. Dissection was then carried along the inferior pulmonary vein distally until the
superior segmental branch was identified as the most superior branch. This was divided in a similar fashion as the segmental
artery. The bronchus intermedius was then identified and dissection carried distally until the superior segmental division was
encountered. This was skeletonized and divided in similar fashion using an endoscopic stapler.
Basilar Segment: The oblique fissure was bluntly opened to expose the interlobar pulmonary artery. Dissection was
continued distally along the artery, exposing the basilar segmental branch. The basilar segmental pulmonary artery was then
circumferentially dissected and divided using an endoscopic stapler, taking care to preserve the branch to the middle lobe.
Dissection was then carried along the inferior pulmonary vein distally until the basilar segmental branch was identified. This
was divided in a similar fashion, taking care to preserve the superior pulmonary vein. The basilar division of the lower lobe
bronchus was then identified and divided using an endoscopic stapler.
The intersegmental boundaries were demarcated by gentle ventilation of the lung. Successive 60 millimeter stapler loads were
then used to completely divide the lung parenchyma along the line of demarcation. The lung segment was then delivered
through the thoracotomy incision, the surgical margin marked with a sterile marker, and the specimen sent to pathology for
identification and margin analysis.
The thoracic cavity was copiously irrigated with sterile water and hemostasis achieved. Two 28-french straight chest tubes
were brought through the chest wall using stab incisions immediately inferior to the thoracotomy incision anterior to the
midaxillary line. The medial chest tube was positioned posteriorly, the lateral chest tube was positioned anteriorly, and both
tubes were secured to the chest wall using 0-silk sutures. These were both connected to continuous suction at 20 cm H2O
pressure prior to closure of the chest wall. The lung was then inflated using recruitment maneuvers to confirm full expansion.
Following confirmation of negative surgical margins, the ribs were loosely reapproximated using interrupted pericardial
sutures in a figure-of-eight fashion. The serratus muscle was reattached to the chest wall using a single, 0-vicryl running
suture, and the latissimus dorsi was reapproximated in 2 layers using running 0-vicryl stitches. The subdermal tissue was
closed using a running, 2-0 vicryl stitch, and the skin reapproximated using 4-0 monocryl in a running, subcuticular fashion. At
the end of the operation, all sponge, needle, and instrument counts were correct. The patient was placed back in supine
position and bronchoscopic clearance of all secretions was performed prior to extubation.
For All Left Lung Segmentectomies
The aortopulmonary window was identified overlying the aortic arch. The pleura overlying this area was incised sharply, the
level V and VI lymph nodes were bluntly skeletonized and retrieved following ligation of their lymphatic pedicles. These
were sent to pathology for identification and microscopic analysis.
For Left Upper Lobe Segmentectomies
Apicoposterior Segment: The superior venous trunk was identified and dissected circumferentially using a blunt clamp. This
was then divided using an endoscopic stapler with a 45-millimeter vascular load. The dissection was then continued over the
main pulmonary artery distally, exposing the segmental branches. The oblique fissure was then opened, allowing identification
of the lingular branch of the pulmonary artery. All branches to the apicoposterior segment were then sequentially divided using
a 45-millimeter vascular load after circumferential dissection. The segmental division of the apicoposterior segmental
bronchus was then identified and divided using an endoscopic stapler.
Lingula: The oblique fissure was bluntly opened and the interlobar pulmonary artery identified. The lingular branch(es) were
identified and dissected circumferentially. These were then divided using a 45-millimeter vascular load on an endoscopic
stapler. The lingular bronchus was then identified and divided in a similar fashion. Attention was then turned to identification
of the superior pulmonary vein from a medial approach. Dissection was continued along the vein until the lingular branch
could be identified, at which point it was bluntly skeletonized and ligated using an endoscopic stapler.
For Left Lower Lobe Segmentectomies
Superior Segment: The oblique fissure was bluntly opened and dissection performed on areolar plane distally until the
superior segmental artery could be positively identified, taking care to also identify the lingular and basilar branches. This was
circumferentially dissected and divided. The superior segmental vein was then identified as the most superior branch of the
inferior vein. This was divided in a similar fashion as the segmental artery. The bronchus intermedius was then identified and
dissection carried distally until the superior segmental division was encountered. This was skeletonized and divided in
similar fashion using an endoscopic stapler.
Basilar Segment: The oblique fissure was bluntly opened and dissection continued until all branches of the pulmonary artery
could be identified. The basilar segmental pulmonary artery was then circumferentially dissected and divided. The basilar
segmental vein was then identified at its origin from the inferior pulmonary vein. This was divided in a similar fashion, taking
care to preserve the superior pulmonary vein. The basilar division of the lower lobe bronchus was then identified and divided
using an endoscopic stapler.
Video-Assisted Thoracoscopic Surgery

Preoperative Diagnosis: [INDICATION for operation; typically neoplasm, but may be done for lesions with infectious or
benign etiology, particularly if diagnostic uncertainty is present]
Postoperative Diagnosis: specific diagnosis (i.e. cancer histology, if not known preoperatively and if frozen section
performed), other intraoperative findings
1. Thoracotomy (with laterality)
2. Segmentectomy (specify segment removed)
3. Mediastinal lymph node dissection (if done for malignancy)
Assistants: [BLANK]
Operative Findings: [Include results of frozen section specimens, anatomic variants, surgical margins]
Specimens: [Include an accurate description of all specimens sent. Typically will include mediastinal lymph nodes and
levels, tissue biopsies sent to rule out metastatic disease, and the target lung segment.]
Indication(s) for Procedure: This is a [AGE] year-old [ G E N D E R ]who presented with history of
[COMPLAINT/DURATION]. The patient was noted on diagnostic [CHEST RADIOGRAPHY] to have a [SIZE] nodule in
the [SIDE, LOBE, AND SEGMENT] . A CT-guided biopsy was performed, which was noted to be suspicious for [TISSUE
DIAGNOSIS]. (If no biopsy was performed—e.g. recent history of other malignancy with high suspicion for lung metastasis
—this should be stated here.) [MEDIASTINOSCOPY/ENDOBRONCHIAL ULTRASOUND] (if performed) did not show
mediastinal lymph node involvement. Based upon the patient’s presentation and preoperative workup, it was determined that
(he/she) would benefit from [SIDE, LOBE, AND SEGMENT]segmentectomy with mediastinal lymph node dissection (if
performed for malignancy). The patient was informed of the risks and benefits of proceeding, including, but not limited to:
pain, bleeding, scarring, poor cosmetic outcome, inadvertent injury to adjacent structures necessitating a more complex
operation for repair, infection, either at the incision sites or elsewhere, persistent air leak from the lung or bronchus,
recurrence of the cancer (if appropriate), inability to complete the operation thoracoscopically requiring conversion to an open
operation, as well as those risks associated with the induction of general anesthesia, up to and including death. All questions
were answered to the satisfaction of the patient and family, including all alternatives to operative intervention. The patient
agreed with the need for the procedure, and informed consent was obtained.
Description of procedure: The patient was taken to the operating room and placed supine on the operating table. Following
induction of general anesthesia and intubation with a single-lumen endotracheal tube, a “time out” was performed, verifying
correct patient, correct procedure, and correct site. Antibiotics were then given to ensure delivery within one hour of
incision. Bronchoscopy was then performed; all segments were identified bilaterally, and all visible secretions were cleared.
The single-lumen endotracheal tube was then exchanged for a double-lumen tube with bronchoscopic guidance to ensure total
lung isolation. The patient was then placed in the [SIDE] lateral decubitus position. All vulnerable pressure points were
appropriately padded, the bed flexed to extend the intercostal spaces, the up arm was extended cephalad to expose the axilla
and secured into place, and the patient secured to the operating table using a belt and cloth tape. After positioning was
completed, correct placement of the double-lumen endotracheal tube was again bronchoscopically confirmed, and the
operative lung excluded. The patient was then prepped and draped in the usual sterile fashion. A 1-centimeter incision was
made overlying the 7th rib along the mid-axillary line. The port is placed, and a 10 millimeter, 30-degree thoracoscope was
then advanced through an endoport inserted into the intercostal space, and the thoracic cavity was assessed visually. Under
direct visualization, the utility port (4 cm in length) is created in anterior axillary line at the level of hilum (usually 4th
intercostal space for upperlobe disease and 5th for lower lobe disease). Additional traction port is created at posterior
axillary line about one hand breath away from the camera port.
The dissection and pulmonary resection is essentially identical to open operation.
35. Carinal Pneumonectomy
Lloyd M. Felmly, Walter F. DeNino, MD, and Chadrick E. Denlinger, MD
Medical University of South Carolina, Charleston, SC

(Written for right pneumonectomy, but steps that differ in action or laterality during left pneumonectomy are noted)
1. Supine positioning
3. General endotracheal anesthesia (can use double lumen tube or single lumen tube advanced into the left main stem
bronchus prior to accessing the pleural cavity)
4. Mediastinoscopy and node sampling
5. Positioning in the left lateral decubitus position (right lateral decubitus for left pneumonectomy)
6. Right posterolateral thoracotomy (left thoracotomy if left pneumonectomy)
7. Takedown of the ipsilateral inferior pulmonary ligament and mobilization of the lung
8. Encircle and ligate ipsilateral pulmonary veins and arteries
9. Right: Divide the azygos vein
10. Left: Mobilize and retract aortic arch laterally and cephalad (division of ligamentum arteriosum)
11. Lymphadenectomy and mobilization of the airway
12. Dissection and encircling of trachea, right main bronchus, and left main bronchus
13. Right: If SVC has been invaded by tumor, then heparinize, clamp the vessel proximally and distally, excise the
invaded portion, and replace with appropriate available graft material
14. Withdraw endotracheal tube to the distal cervical trachea (after pre-oxygenation and hyperventilation)
15. Incise trachea (guided by flexible bronchoscopy, send frozen section for tumor-free margins)
16. Incise left main bronchus (frozen section for tumor-free margins; right main bronchus if left pneumonectomy)
17. Remove right lung and carina (or appropriate lobes; left lung if left pneumonectomy)
18. Insert small catheter into left main bronchus for ventilation (right bronchus for left pneumonectomy)
19. Contralateral node dissection
20. Traction sutures to approximate distal trachea and left main bronchus (takedown of contralateral pulmonary ligament
if excess tension between apposed airways; right main bronchus if left pneumonectomy)
21. Running sutures to parachute trachea and bronchus
22. Interrupted sutures to complete end-to-end anastomosis (avoid placing sutures on the cartilage-membranous angle or
through membranous trachea)
23. Terminate cross-field ventilation and re-advance endotracheal tube
24. Test anastomosis for air leaks (ventilate up to 40cm of pressure)
25. If desired, reinforce with pedicled flap
26. Right: End-to-side anastomosis if residual right lung lobes are left In place (at least 2cm from previous anastomotic
suture line)
30. A guardian or “Grillo” stitch can be placed between chin and sternum (decreases airway tension)
31. Extubate in the OR

1. Appropriate pre-operative evaluation including PFTs
2. Mediastinoscopy should be performed in the same OR session to avoid healing and subsequent pre-tracheal scarring
3. Injury to the left recurrent laryngeal nerve during dissection
4. Injury to the thoracic duct during aortic mobilization
5. Improper deairing if SVC is resected and grafted
6. Excessive lateral dissection along the airway resulting in inadequate blood supply to the anastomosis
7. No attempt should be made to crimp or wedge the edges of the anastomosis to correct the size discrepancy between
the trachea and bronchus, as this can predispose the anastomosis to development of a fistula
8. Size discrepancy between the trachea and the right main stem bronchus is common and should be corrected
progressively with each suture
9. Tension on the airways leading to failure of the anastomosis
10. Tearing of the anastomosis at the cartilage-membranous angle
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. Centrally located right middle lobe nonsquamous-cell lung cancer, NSCLC
invading carina]
1. Cervical mediastinoscopy
2. Right/Left posterolateral thoracotomy with right/left-sided carinal pneumonectomy
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: The patient is a [AGE] [GENDER], who presented to us in the clinic with a concerning lesion
on the [RIGHT/LEFT SIDE] , was [LOCATION], which demonstrated on biopsy to be consistent with [FINDINGS].
Preoperative assessment of the mediastinum including [TESTS/SCANS ORDERED] [FINDINGS] . Pre-operative PFTS
included FEV1 of [VALUE] and FVC of [VALUE] with a DLCO of[VALUE]. As such, the patient was consented for
mediastinoscopy, a [RIGHT/LEFT]-sided thoracotomy and pneumonectomy given [RELEVANT PREOPERATIVE
EVALULATION].
Description of Procedure: The patient was brought to the operating room and placed in the supine position. Monitoring lines
were positioned, and a single lumen endotracheal tube was placed after the induction of general anesthesia, a time-out
confirmed the correct procedure for the correct patient and site. The patient was treated with 2G Ancef and 5000 units of
subcutaneous heparin.
The patient was prepared for mediastinoscopy by positioning him/her with the head at the top of the OR table. A shoulder roll
was placed behind the shoulders and the neck was maximally extended. The neck and anterior chest were prepped and draped
below the level of the xiphoid process to achieve a sterile field that would allow a sternotomy if necessary. The procedure
was commenced with a 2-cm incision in a horizontal fashion one fingerbreadth cranial to the suprasternal notch. The platysma
was divided transversely with electrocautery and the strap muscles were divided in the midline to expose the anterior surface
of the trachea. Using Metzenbaum scissors, the anterior tracheal fascia was incised, and with the fingers bluntly, a plane
anterior to the trachea was developed into the thoracic inlet.
The mediastinoscope was advanced into the pretracheal plane to the level of the carina. The proximal right and left main
bronchi were bluntly dissected. The azygos vein was identified cranial to the right main bronchus and the right pulmonary
artery was visualized crossing over the right bronchus. Lymph node biopsies were taken from the subcarinal region and were
sent for frozen section analysis labeled as level 7 lymph nodes. Additional lymph nodes were removed from above the right
bronchus and were sent for analysis labeled as level 4R lymph nodes. Hemostasis was achieved in both the level 4R and 7
regions using electrocautery. Additional lymph nodes were taken just above the left main bronchus and these were sent labeled
as level 4L lymph nodes. The use of electrocautery was minimized while sampling the level 4L lymph nodes in order to avoid
injury to the recurrent laryngeal nerve. Frozen section analysis of the resected lymph nodes did not show any evidence of
metastatic disease. [FINDINGS].
The mediastinoscope was withdrawn after hemostasis was achieved and Surgicel was placed. The incision was closed in
three layers. Interrupted Vicryl sutures were used to reapproximate the strap muscles. The platysma was also closed with
interrupted Vicryl sutures and the skin was closed with a running subcuticular Vicryl. The skin was sealed with topical glue.
The patient was then repositioned to a left lateral decubitus position and the right chest was prepped and draped in the usual
manner.
After a standard right posterolateral thoracotomy incision, electrocautery was utilized to divide the subcutaneous tissues and
latissimus dorsi and enter the chest cavity at the fifth intercostal space. The serratus anterior muscle was spared in this
dissection. The sixth rib was divided posteriorly to help facilitate exposure. The right lung was deflated by advancing the
endotracheal tube into the left bronchus using a bronchoscope for guidance. A Finochietto retractor was used to spread the ribs
and a Tuffier retractor was positioned at a right angle to the Finochietto to retract the soft tissues. The chest was visually and
manually explored and there were no additional lung or pleural nodules noted.
The right inferior pulmonary ligament was divided with electrocautery to the level of the inferior pulmonary vein. Lymph
nodes in the inferior pulmonary ligament were sent for pathological evaluation labeled as level 9 lymph nodes. The lung was
then retracted anteriorly while the pleura overlying the posterior aspect of the hilum was divided with cautery. This provided
exposure to the inferior pulmonary vein, the bronchus intermedius, upper lobe bronchus and right main bronchus. The
subcarinal lymph nodes were resected and sent for evaluation labeled as level 7 lymph nodes. The carina as well as the
proximal left main bronchus was identified. The azygos vein was divided and the mediastinal pleura overlying the trachea was
divided as well. The lung was then retracted posteriorly while the pleura overlying the anterior aspect of the hilum was
divided sharply with a Metzenbaum scissors in order to avoid thermal injury to the phrenic nerve. This provided exposure to
the anterior surface of the superior and inferior pulmonary veins as well as the upper aspect of the right pulmonary artery.
The inferior pulmonary vein was then dissected circumferentially using blunt dissection. An endo-GIA stapler with a vascular
load was then used to divide the vein. The superior pulmonary vein was then circumferentially dissected bluntly prior to its
division with the endo-GIA stapler using a second vascular load. The proximal right main pulmonary artery was then carefully
dissected away from the right bronchus. The pulmonary artery was stapled twice with a linear stapler prior to its division was
a #15 blade knife.
At this point a sterile ventilation circuit was passed off the field and prepared for the use of cross-field ventilation. After
adequate pre-oxygenation, the ventilator was turned off and the endotracheal tube was withdrawn to the midlevel of the
trachea. The left main bronchus was divided sharply with a #10 blade knife in an area that was as close to the carina as
possible, but also free of gross tumor involvement. The transected bronchial lumen was then visually inspected to ensure that
there was no gross evidence of disease. Two 2-0 silk sutures were then placed in the left main bronchus at the junction
between the cartilaginous and membranous portions as traction sutures. An 8-0 armored endotracheal tube was then advanced
into the transected bronchus to ventilate the left lung using the sterile circuit which had been passed off the field to the
anesthesiologists. The trachea was then transected above the tumor. At this point the lung was completely free from the
mediastinal structures and it was passed off the field and sent for pathological evaluation. The tracheal and left bronchial
margins were both marked and frozen section analysis was performed. The mediastinal resection bed was examined to
confirm meticulous hemostasis.
After confirming negative bronchial margins, the airway anastomosis was undertaken. The entire anastomosis was completed
using interrupted 3-0 Vicryl sutures. The first sutures were placed between the left side of the trachea and the most superior
margin of the left bronchus. Care was taken to compensate for the difference in luminal diameter between the trachea and
bronchus. Each of these sutures were pre-placed and tied with the knots inside the lumen after they all were placed. Each of the
sutures approximating the membranous portion of airway was placed. While these sutures were placed the endotracheal tube
was intermittently removed from bronchus to facilitate better visualization. After each of the sutures was placed the bronchial
endotracheal tube was removed and the trans-oral endotracheal tube was advanced by the anesthesiologist across the
anastomosis into the left bronchus. This was manually directed from the surgical field. The sutures on the membranous airway
were then tied with knots on the outside of the lumen. Finally, sutures were placed to re-approximate the remaining
cartilaginous portion of the airway between the right wall of the trachea and the inferior aspect of the bronchus. After each of
these sutures was placed, they were tied with the knots on the outside of the lumen.
The endotracheal tube was then withdrawn back into the trachea and the chest cavity was filled with warm saline. The airway
was pressurized to 30 cm of water and the anastomosis was observed for an air leak. No bubbles were seen and the saline
was aspirated. [SOFT TISSUE COVERAGE OF ANASTOMOSIS MAY BE PERFORMED AS WELL]. The chest ca
was again thoroughly inspected to assure complete hemostasis. A single 28 French chest tube was placed into the chest cavity
and it was secured at the skin with a 0-silk suture.
The ribs were re-approximated with #2 Vicryl sutures. The serratus anterior was re-approximated to the tissues inferior to the
muscle belly with #0 Vicryl and the latissimus dorsi fascia was closed with a running #0 Vicryl. The deep dermal and
subcuticular layers were closed with running 2-0 and 3-0 sutures respectively. A sterile dressing was placed over the incision.
The chest tube was then clamped and attached to a collection chamber without suction. The patient was then placed in the
supine position on the operating table and a #0 prolene suture was placed between his chin and the skin overlying the sternal
angle of Louis to prevent the head from being extended beyond the neutral position. The patient was then extubated in the
operating room and transferred to the intensive care unit for routine monitoring.
At the end the procedure, all sponge, instrument, and needle counts were reported correct.
36. Extrapleural Pneumonectomy for Mesothelioma
George Makdisi, MD, Francis C. Nichols III, MD

2. General endotracheal anesthesia and thoracic epidural
3. Double-lumen endotracheal tube (left-sided for right pneumonectomy and right-sided if possible for left
pneumonectomy)
4. Excise the tract of previous biopsy procedure, or Pleurx tract
5. Extended posterolateral thoracotomy, divide the latissimus and serratus
6. Excise the sixth rib for improved exposure
7. Begin extrapleural dissection around the circumference of the incision, separating the tumor from the endothoracic
fascia. Envision creating an envelope consisting of the parietal pleura with the lung on the inside
8. Continue the dissection up to and over the apex, avoiding injuries to the subclavian artery on the left and the
innominate artery and SVC on the right. Continue along the descending aorta, along the diaphragm and along the
mediastinum
9. On the left, careful sharp dissection lateral and anterior to the descending thoracic aorta performed up to about the
level of the aortic arch taking care to not injure the vagus nerve, recurrent laryngeal nerve and again any intercostal
arteries.
10. The tumor is unresectable if there is an invasion of vital mediastinal structures, (e.g., aorta, vena cava, esophagus,
epicardium, or trachea) or chest wall. If the tumor is deemed unresectable, chest tubes are placed and the chest
closed
11. The diaphragm is circumferentially excised (or, alternatively, avulsed from the chest wall). Care is taken to avoid
entering the peritoneum. Sometimes entry into the peritoneal cavity is unavoidable in which case the peritoneum is
closed with absorbable suture.
12. The crura are preserved protecting.
13. The pericardium is opened anteriorly and resected form inferior to superior and anterior to posterior down to the
level of the hilum.
14. Intrapericardial division of the pulmonary veins
15. Division of the pulmonary artery (intrapericardially on the right and extrapericardially on the left)
16. The mainstem bronchus is divided almost flush with the carina using a TA 30 thick staple load. Just prior to firing the
staple load, a breath is given by the anesthesiologist confirming no obstruction of the contralateral left mainstem
bronchus.
17. The entire en bloc specimen is removed.
18. Chest is copiously irrigated with warm saline and sterile water.
19. Hemostasis is assured.
20. Ipsilateral divided bronchial stump is tested to rule out air leaks by submerging beneath saline and having anesthesia
insufflate the ipsilateral side to 40 mm Hg.
21. Thoracic lymphadenectomy or lymph node sampling: stations 2R, 4R, 7, 8, 9, 10R for right sided tumors and stations
4L, 5, 6, 7, 8, 9, and 10L for left sided tumors.
22. Consider prophylactic ligation of the thoracic duct for right sided tumors, especially if there is a high suspicion for
duct injury.
23. There often isn’t local tissue to routinely cover the bronchus. Consider bringing up an omental pedicle through the
diaphragmatic opening.
24. The diaphragm is reconstructed with a somewhat floppy 2 mm thick polytetrafluoroethylene (PTFE) patch. The patch
is reimplanted into the chest wall anteriorly, laterally, and posteriorly with individually placed #1 nonabsorbable
suture. Medially the patch is secured to the crura and remaining pericardium with 0 nonabsorbable suture. A
laparoscopic tacking device can be helpful to secure the patch posteriorly.
25. The pericardial defect is reconstructed with a 1 mm thick fenestrated PTFE patch. The patch is secured in place with
either running or interrupted #2-0 nonabsorbable suture.
26. Hemostasis is again meticulously checked for and the chest again irrigated with several liters of warm saline.
27. 500 - 750 cc of antibiotic solution similar to a Clagett closure is left within the chest cavity at the discretion of the
surgeon.
28. An angled 28 Fr. straight chest tube is tunneled, placed in the chest cavity, and loosely secured in place with a #0-
silk pursestring suture. The chest tube is placed to water seal (AND NEVER TO SUCTION).
29. The chest is then closed in the usual fashion with multiple layers of running # 1 absorbable suture. The skin is closed
with a running #4-0 subcuticular suture. A sterile dressing is applied
30. The patient is rolled to the supine position. The authors prefer removing the chest tube at this point. With a breath
given by the anesthesiologist and held at 40 mm Hg pressure, the chest tube is removed in the usual fashion, the #0-
silk pursestring suture tied and a sterile dressing applied.
31. Chest x-ray obtained to assess the contralateral lung and pleural space and confirm appropriate midline positioning
of the mediastinal structures.
32. Patient is taken to the recovery room and extubated when appropriate.

1. The authors do not routinely perform laparoscopy unless there are concerns raised on the preoperative imaging in
which case laparoscopy is performed to rule out peritoneal involvement
2. The position of the operating table will change during various phases of the operation from steep Trendelenburg
(apical dissection) to reverse Trendelenburg (diaphragmatic dissection), to tilted left and right for anterior and
posterior mediastinal dissections
3. Excise the previous biopsy tracts
4. Place an NG tube to facilitate identification of the esophagus during the dissection
5. The tumor is unresectable if there is an invasion of vital mediastinal structures (e.g., aorta, vena cava, esophagus,
epicardium, or trachea) or diffuse chest wall involvement.
6. Pericardial invasion does not preclude resection; however, if myocardial invasion is found the tumor is deemed
unresectable. Open the pericardium medial to the area of concern and palpate for myocardial invasion.
7. For right sided EPPs, avoid ligating the azygous vein. If the vein is ligated, it can increase venous hypertension and
possibly contribute to bleeding and to lymphatic leaks.
8. For right EPPs, take care to avoid injuring the IVC and retrohepatic veins during the extrapleural dissection and
diaphragmatic reconstruction.
9. Avoid injury to the internal mammary artery and vein.
10. For patients who have had prior CABG with an ipsilateral IMA graft, special care must be taken to avoid injuring the
graft.
11. Avoid ligation of intercostal arteries
12. Avoid injury to the recurrent laryngeal nerves, which can lead to aspiration or other pulmonary complications.
13. Prior to dividing the PA, check for a rise in the PA pressures. An undue rise may preclude an EPP.
14. Argon beam coagulation to the endothoracic fascia is helpful both for tumorlysis and for hemostasis.
15. Assure adequate pain control, aggressive chest physiotherapy and early mobility, physical therapy and effective
pulmonary hygiene are very important factors in postoperative period.
16. Bronchoscopy is used liberally to clear secretions
17. In the absence of bleeding, hemodynamic instability in the OR may be due to an overly constrictive pericardial patch
or undue constriction on the IVC (for right-sided diaphragmatic reconstructions)
Template Dictation
Preoperative Diagnosis: Biopsy proven malignant mesothelioma of the [left/ right] chest
1. Partial excision sixth rib
2. [LEFT/ RIGHT] extrapleural pneumonectomy
3. left/right thoracic lymphadenectomy
Assistants: [BLANK]
Anesthesia: [eg: Thoracic epidural and general endotracheal anesthesia with double lumen endotracheal tube.]
Indication(s) for Procedure: [INDICATION – e.g.[MR/ MRS. ] [BLANK] is a [AGE] year-old [gender] who presented
biopsy proven malignant [EPITHELIOID, SARCOMATOID OR BIPHASIC TYPE] mesothelioma. Workup included:
[CXR, CT, PET, Echocardiography, and PFTs-]. There was no evidence of diffuse metastatic cancer, and [Mr/Mrs.]
[BLANK] was deemed an appropriate surgical candidate.[He/She] are now brought to the operating room in satisfactory
condition for planned surgical resection.
Left-Sided Extrapleural Pneumonectomy
After a team surgical briefing, the patient was brought to the operating room in satisfactory condition. Under general
endotracheal anesthesia with a double-lumen endotracheal tube in place, the patient was placed in the right lateral decubitus
position and prepared and draped in the usual fashion. After the surgical pause, an extended left posterolateral thoracotomy
incision was made. Both the latissimus dorsi and serratus anterior were divided. The 6th rib was excised, taking care not to
enter to pleural space. We began the extrapleural dissection, separating the pleura from the endothoracic fascia. We
immediately encountered marked thickening of the parietal pleura. Dissection was carried posteriorly and superiorly and then
anteriorly and superiorly. Attention was directed to the apex of the left chest, we were able to further dissect things free and
ultimately separate the subclavian artery from the apex of the lung. The dissection was then carried inferiorly. The aortic arch
was identified. The vagus nerve was identified and care taken to protect the recurrent laryngeal nerve. Using a combination
of blunt and sharp dissection to separate the pleura from the aorta, we continued the dissection caudally along the descending
thoracic aorta down to the costophrenic recess. The extrapleural dissection continued along the diaphragm and then along the
mediastinum. Pericardium was entered anteromedially. The pericardial space was palpated. There was no evidence of tumor
invasion into the epicardium. The pericardial opening was then extended from the level of the inferior pulmonary vein to the
PA. The diaphragm was then incised from its lateral margin and dissected bluntly off the underlying peritoneum,
circumferential resection of the diaphragm ensued. [Description of the Disease Burden – i.e. Overall, there was diffuse
tumor involvement of the pleura. However, most of the disease burden was on the diaphragm and the pleura overlying
the lower lobe.]
The pulmonary artery isolated extrapericardially. The PA was clamped with a TA-30 vascular load stapler. There was no
significant increase in the PA pressure. The stapler was fired, and the PA was divided. The superior pulmonary vein and
inferior pulmonary veins were divided intrapericardially using separate firings of a TA-30 vascular load stapler. The
posterior pericardial resection continued down to the left mainstem bronchus. The left mainstem bronchus was dissected free
from the mediastinal tissues and divided flush with the carina using a TA-30 green load stapler under direct bronchoscopic
visualization. The EPP specimen was sent to pathology as a permanent specimen. No gross residual mesothelioma was left in
the pleural cavity upon completion of this radical resection. The bronchus was submerged in saline. There was no bubbling
with a 40 mm Hg breath hold, indicating that the bronchial stump was completely intact.
A thoracic lymphadenectomy was completed. All lymph nodes were removed from stations 5, 6, 7, 8L, 9L, and 10L. The
chest was copiously irrigated with several liters of warm saline and water. Hemostasis was secure.
We then proceeded with our reconstruction. The diaphragm was rebuilt with 2-mm thick PTFE patch secured in place with
numerous #1 Polypropylene sutures. The pericardium was then rebuilt also with fenestrated piece of 1-mm thick PTFE
secured in place with running #2-0 Polypropylene suture. The chest was irrigated again, and hemostasis was assured. The
chest was irrigated with 1000 cc of modified DABS solution (Gentamicin/Polymyxin B irrigation solution). A third of the
modified DABS solution was left in the pleural cavity. A single 28-French straight chest tube was placed. A surgical pause
confirmed that all needle, sponge, and instrument counts were correct. No. 1 absorbable pericostal sutures were utilized and
the muscle layers closed with multiple running #1 absorbable suture. The subcutaneous layer closed with running #2-0
absorbable suture and the skin reapproximated with #4-0 subcuticular suture. Sterile pressure dressings were applied. The
patient was rolled to the supine position with positive pressure ventilation to 40 mm Hg. The chest tube was removed without
difficulty. The chest tube site was closed with a# 2-0 polypropylene suture. The patient tolerated the operative procedures
and left the operating room in satisfactory condition.
Right-Sided Extrapleural Pneumonectomy
Same as above except for the following:
Insertion of NG tube to aid in identification and protection of the esophagus.
The posterior dissection proceeds along the azygos vein instead of the descending thoracic aorta.
Watch for the thoracic duct, if there is concern for a lymph leak then the thoracic duct is mass ligated with a #2-0 silk
suture near the hiatus
Thoracic lymphadenectomy on the right side includes lymph node stations 2R, 4R, 7, 8R, 9R, and 10R.
37. Lung Procurement
Mara B. Antonoff, MD and Michael K. Pasque, MD
Washington University, St. Louis, MO

1. Initial on-site donor evaluation
2. Bronchoscopy
3. Incision / access
4. Visualization
5. Lung recruitment
6. Thoracic organ dissection
7. Cardioplegia/pulmoplegia cannula placement
8. Heparinization
9. PGE
10. SVC ligation
11. Left atrial venting
12. IVC hemi-transection
13. Aortic crossclamp
14. Infusion of cardioplegia/pulmoplegia
15. Extubation
16. Dissection / removal of heart
17. Retrograde flush
18. Division of mediastinal tissue
19. Tracheal transection
20. Esophageal transection
21. Pericardial division
22. Division of inferior pulmonary ligaments
23. Esophageal transection
24. Aortic transection
25. Division of remaining mediastinal posterior attachments
26. Lung block removal and packaging
Note that the above steps presume that the heart is being removed for either recipient implantation or for research purposes. If
the heart is not to be used at all, minor adjustments apply, which are addressed below.

1. Standard midline sternotomies are aesthetically displeasing and limit options for open-casket funerals. Y-shaped
midline skin incisions sparing the neck and upper chest are appreciated by families, frequently requested by funeral
homes, and mandated by some organ procurement organizations.
2. The practice of sequentially eviscerating the lungs from the pleural cavity to perform recruitment of the atelectatic
areas of the lungs is strongly discouraged. In situ recruitment or slight lung displacement is more than adequate to
clear atelectasis and lessens the possibility of severe lung hyperinflation, injury to hilar structures, and the
hemodynamic compromise that is always associated with unilateral lung evisceration. Although the routine donor may
tolerate short periods of transient hemodynamic compromise, the downward spiral that can be initiated by such
maneuvers in the borderline donor can place all organs—and thus their potential recipients—at immediate and
unnecessary risk.
3. The practice of routine division of the azygos vein by inexperienced operators has resulted in a significant incidence
of unnecessary hemorrhage, as well as damage to the adjacent upper lobe branch of the right pulmonary artery. In
most cases, a single suture tie can be placed around it near its junction with the superior vena cava and the azygos can
be divided later during organ extraction.
4. The pulmonary artery cannulation site should be a minimum of 1.5 cm from the pulmonary valve to guarantee a
generous cuff of main pulmonary artery for the subsequent cardiac implantation procedure. Placement near or even at
the bifurcation of the main pulmonary artery still leaves more than enough right and left pulmonary artery length for
bilateral lung transplantation. When the pulmoplegia cannula is being placed in the distal main pulmonary artery, the
tip of the cannula is pointed backward toward the pulmonary valve. This prevents the preferential perfusion of one
lung that may otherwise occur. If the heart is not being used for implantation in a live recipient, the pulmoplegia
cannula can be placed in the proximal main pulmonary artery near the pulmonary valve instead of distally near the
pulmonary artery bifurcation. When placed more proximally, the tip of the pulmoplegia cannula is directed toward the
bifurcation of the main pulmonary artery
5. It is not necessary to dissect the fascial attachments between the trachea and esophagus during the initial organ
dissection prior to organ preservation. Overzealous manipulation can result in several untoward events, including
dislodgment of the endotracheal tube or perforation of the esophagus or membranous trachea with mediastinal soiling.
6. Venting through the left atrium adjacent to the right superior pulmonary vein in Waterston’s groove will provide
excellent left heart decompression as long as a sucker is immediately placed through it into the left atrium. The
primary advantage of this vent site location is the elimination of the need for suture closure of the left atrial appendage
vent site. It also assures an adequate right pulmonary vein cuff.
7. It is important to carry out the organ preservation procedure in the correct order. Left ventricular distention invariably
occurs if the aortic crossclamp is applied (thus preventing left ventricular emptying) as the first step in the organ
preservation procedure, before reduction in left atrial and ventricular return.
8. The adequacy of cardioplegic solution delivery must be assured by a rapid cessation of cardiac contractile and
electrical activity. The adequacy of aortic root pressure and absence of ventricular distention must be continually
monitored during infusion of cardioplegic solution. Left ventricular distention during infusion of cardioplegic
solution mandates immediate attention. Simply passing the left atrial sucker across the mitral valve (like a standard
left ventricular vent) is the most efficient method to eliminate this problem. Repeated distention of the heart suggests
that either aortic insufficiency is present or that the vena caval and left atrial venting maneuvers are not adequate and
in need of immediate further attention.
9. The flow of gradually clearing pulmoplegia solution from the left atrial vent site must be monitored during its
infusion. Equal distribution of perfusate to both lungs must be assured, and both lungs should ‘‘blanch’’ equally. The
midline positioning of the tip of the pulmonary artery perfusion cannula must be intermittently confirmed to assure that
differential flow to one lung over the other is not occurring secondary to inadvertent cannula displacement.
10. During the retrograde pulmoplegia flush, the return of clear solution into the ipsilateral pulmonary artery assures that
the infusion is proceeding correctly. One should be sure to watch for the occasional pulmonary embolus as it is
flushed from the pulmonary artery, which should be noted, but is, of yet, of unclear clinical significance.
11. If the heart is not being used for a live recipient, there is no need to preserve a left atrial cuff for cardiac
implantation. The left atrial incision can therefore be initiated immediately adjacent to the interatrial groove
posteriorly. This maneuver optimizes the size of the left atrial cuff that remains attached to the pulmonary veins. The
incision is continued in the atrioventricular groove circumferentially around the heart, leaving the entire left atrium
with the lung block.
Template Dictation
Preoperative Diagnosis: [INDICATION—e.g. brain death secondary to trauma, etc.]
Procedure(s) Performed: Bilateral donor pneumonectomy (+/- CARDIECTOMY)
Assistants: [BLANK]
Anesthesia: General Endotracheal
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [INDICATION]. A suitable
recipient was identified and the family provided proper informed consent for organ donation.
Description of Procedure: Donor/Recipient blood typing and compatibility were confirmed with a review of all pertinent
donor history. The patient was brought to the operating room with a single-lumen endotracheal tube already in place. Standard
monitoring lines were already in place, including [LINE TYPES] in the [LATERALITY] [VESSEL].
Donor hemodynamics, inotrope/pressor infusions, telemetry monitoring, echocardiogram, and chest CT, and latest arterial
blood gas were reviewed. The patient was positioned supine. Both arms were tucked. Bronchoscopy was performed and the
airways were examined to ensure suitability for donation. Bronchoscopic examination revealed [BRONCHOCSCOPIC
FINDINGS—e.g. normal, healthy airways; thick/thin secretions which cleared easily/recurred after clearance, minor
suctioning trauma, etc]. After prepping and draping, access was obtained through a Y-shaped midline skin incision sparing the
neck and upper chest. Using electrocautery, tissues were dissected down to the sternum, and a median sternotomy was
performed in standard fashion.
Bilateral pleural spaces were entered, and the lungs were palpated and visually inspected. Findings including [FINDINGS—
e.g. apical scarring, granulomas, adhesions, normal healthy lungs, etc] were reported to the recipient team along with the
anticipated cross-clamp time.
Recruitment was attempted of all atelectatic lung segments via gentle massage and sustained inflation to 20-30 cm H2O
pressure. A pericardial well was created, and the heart and great vessels were examined for anatomic abnormalities and
injuries [NOTE ANY SUCH FINDINGS].
Thoracic organ dissection was initiated by carefully separating the main and right pulmonary arteries from the ascending aorta,
followed by taking down of the attachments of the right pulmonary artery to the superior vena cava. The superior vena cava
was further dissected free of all circumferential mediastinal attachments up to and including the innominate vein (if cardiac
transplantation is anticipated). The azygos vein was ligated near its juncture with the superior vena cava. A heavy silk suture
was passed around the superior vena cava above the level of the azygos vein.
Attention was turned toward careful sharp dissection of Waterston’s inter-atrial groove in order to allow easier subsequent
differentiation of the cardiac and pulmonary left atrial cuffs, as well as to facilitate left atrial venting.
A horizontal mattress #4-0 Prolene stitch was placed in the anterior midportion of the ascending aorta to later secure the
cardioplegia cannula. An identical stitch was placed in the [DISTAL if taking the heart vs PROXIMAL if not using the heart]
pulmonary artery. The posterior pericardium overlying the trachea (between the superior vena cava and ascending aorta) was
incised cephalad to the right pulmonary artery, allowing gentle dissection of the trachea above the carina. With careful finger
dissection, the anterior, lateral, and medial surfaces of the trachea were cleared to facilitate more rapid tracheal access during
actual organ excision.
Careful communication occurred between our team and [THE ABDOMINAL TRANSPLANT TEAM AND ALL] receiving
team[S] in order to assure appropriate timing of heparinization and cross-clamp. 30,000 units of heparin [OR OTHER DOSE
IF APPROPRIATE] were administered via central venous access. After 3 minutes, the cardioplegia and pulmoplegia
cannulae were placed and connected to their respective infusion tubing. A high-flow 6.5 mm metal-tip cannula was used for
the pulmoplegia, and a standard cardioplegia cannula for the heart preservation. The lung was reexamined for significant
atelectasis, and [NONE WAS FOUNDvs ADDITIONAL RECRUITMENT MANEUVERS WERE UNDERTAKEN .] A
syringe of prostaglandin E1 was injected into the main pulmonary artery immediately adjacent to the pulmoplegia cannula. The
superior vena cava was occluded with the previously placed supra-azygos silk suture by [TYING THE SUTUREvs
COMING DOWN ON THE RIMMEL TOURNIQUETTE ]. The left atrium was vented by [ATRIAL VENTING
TECHNIQUE—e.g. transecting the tip of the left atrial appendage, making the initial portion of the left atrial incision between
the atrioventricular groove and the left inferior pulmonary vein, or ideally (see pitfalls above) making the initial portal of the
left atrial incision adjacent to the right superior pulmonary vein in the previously dissected Waterston inter-atrial groove]. The
inferior vena cava was then vented with hemitransection (one centimeter above the diaphragmatic reflection if the heart is
being used for transplantation).
The aortic cross-clamp was applied and the cardioplegic infusion was begun at a pressure of approximately 80 mm Hg, while
the pulmoplegia was initiated through the high-flow cannula at gravity pressure. Tidal volume was reduced by half to allow a
large volume of saline slush to be placed into both pleural spaces and the pericardial well. 5.6 liters of pulmoplegia were
infused in an antegrade fashion, with cardioplegia infused until the pulmoplegia was done [WITH A TOTAL OF BLANK
ML GIVEN—should be at least a liter in an adult, but variable maximum depending on how long the lung perfusion takes).
During this period, the adequacy of pulmoplegia [+/- CARDIOPLEGIA] was ensured by monitoring the direction of the
pulmoplegia catheter and equal blanching of both lungs [+/- ADEQUATE AORTIC ROOT PRESSURE].
After the completion of preservation infusion, the apex of the heart was elevated and the inferior vena caval transection was
completed. The left atrial incision was extended from the vent site in Waterston’s groove. Extension of this initial left atrial
incision was carried out under the inferior edge of the inferior vena cava. The incision was further extended on the
undersurface of the left atrium parallel to the AV groove, halfway between the inferior pulmonary veins and the AV groove. It
was extended to the base of the left atrial appendage. The left atrial incision was then completed from inside the left atrium,
allowing visualization of the orifices of all 4 pulmonary veins. The right and left innominate veins were transected along with
the azygos vein. The arch vessels were each transected and the descending aorta divided just beyond the left subclavian with
care taken not to injure the pulmonary artery near the ligamentum arteriosum. The main pulmonary artery was then transected at
the level of the pulmoplegia cannulation site. The heart was removed from the field [AND SUBMERGED IN A STERILE
PLASTIC TRANSPORTATION CANISTER FILLED WITH PRESERVATION FLUID AND SEALED IN A STE
PLASTIC TRANSPORT BAG FILLED WITH ICE].
After removal of the heart, the lung perfusion was completed by instilling another 250 mL of retrograde flush to each of the 4
pulmonary veins, with care taken to examine for pulmonary emboli coming up through retrograde flushing. [PE’S NOTED—no
PE’s were seen, one large PE was extracted from a specific side, etc].
After completing the retrograde flush, all mediastinal tissue was divided at the level of the aortic arch vessels down to the
level of the mid-trachea. The donor was extubated and all tubes including temperature probes and gastric tubes were removed
from the esophagus. The trachea was digitally separated from the esophagus and divided between 2 TA-30 staple loads. The
esophagus was mobilized and divided with a 45 mm GIA stapler. All remaining mediastinal tissue was then divided straight
back to the thoracic spine, and the remaining organ block was gently lifted up as it was sharply dissected off of the spine down
to the level of the mid-thorax.
Attention was then turned to the lower thorax, where the pericardium was divided near its diaphragmatic attachments. Both
inferior pulmonary ligaments were mobilized and divided sharply. The lower esophagus was divided with a second firing of
the GIA 45 mm stapler. The descending aorta was sharply transected. All remaining lower mediastinal tissue was then
divided straight back to the spine, being careful to protect lung parenchyma. The remaining posterior mediastinal attachments
were taken sharply against the spine, moving cephalad, until the double-lung block was free.
[DESCRIBE BACK TABLE DISSECTION, IF PERFORMED, I.E. IF THE TWO LUNGS ARE DESTINED F
SEPARATE INSTITUTIONS: The donor aorta and esophagus were resected posteriorly. The left atrial cuff was divided in
the midline, pericardium divided in the midline, the pulmonary artery was divided at its bifurcation, and the left main bronchus
was amputated. Both hila were then fully prepared, mobilizing the pulmonary artery to the first upper lobe branch, and dividing
the bronchus one ring proximal to the upper lobe takeoff.
Excessive pericardium on both sides was then resected.]
The double-lung block [vs EACH SINGLE LUNG SEPARATELY ] was placed in a sterile plastic transport bag filled with
cold perfusate solution, while the lungs were examined for any unexpected pathology or surgical damage. The sterile plastic
transport bag was sealed and placed into a second bag, with added ice slush. This bag was then placed into a third sealed
bag. The bag was labeled, placed in a secure ice chest, and covered with ice. All relevant documentation from the donor was
secured into the ice chest. Final updates were communicated to the receiving team.
Our team then left the donor operating room with the lungs [vs HEART AND LUNGS] [WHILE THE ABDOMINAL
TEAM CONTINUED TO WORK]. The cooler was expeditiously taken from the facility accompanied by Dr. [NAME].
Complications: There were no complications noted. [OR NOTE IF THERE WERE AND WHAT THEY WERE]
38. Lung Transplantation
Mara B. Antonoff, MD and G. Alexander Patterson, MD
Washington University, St. Louis, MO

1. Lines and monitoring, including femoral arterial line placed by surgical team
3. +/- Preoperative bronchoscopy
4. Intraoperative transesophageal echocardiogram
5. Incision: Bilateral anterior thoracotomy vs. clamshell thoracotomy vs. median sternotomy vs. posterolateral
thoracotomy
6. Dissect out recipient lung(s). Isolate the main pulmonary arteries, pulmonary veins, and mainstem bronchi.
7. Back-table donor lung preparation
8. CPB decision, +/- cannulation and initiation of bypass
9. Explant lungs
10. Anastomoses in the following order: 1). Bronchus, 2). Pulmonary artery, 3). Vein (left atrial cuff)
11. Reperfusion
12. +/- CPB weaning and decannulation
13. Closure
14. Bronchoscopy

1. Decision of single vs. bilateral lung transplant: it is generally accepted that patients with septic lung disease,
particularly cystic fibrosis and bronchiectasis, require a bilateral lung transplants in order to remove the entire focus
of sepsis and prevent soiling of the allograft lung. However, patients with diseases such as emphysema tend to have
favorable outcomes with either single or bilateral lung transplants. Considerations for single vs. bilateral transplant
may be based on age, size, and co-morbidities. Bilateral lung transplants emphasized among those who are younger,
fitter, and taller.
2. For patients with emphysema, it is important to avoid hyperinflation of the native lungs. If hypotension occurs prior to
chest opening, positive pressure ventilation should be disconnected allowing intrathoracic pressure to return to
normal.
3. For any patients whose indication is septic lung disease, preoperative bronchoscopy using an adult bronchoscope
through a single-lumen tube is a critical step. All attempts should be made to thoroughly clear the airways of purulent
secretions, which helps reduce the need for cardiopulmonary bypass. If preoperative bronchoscopy is not warranted,
the patient may be intubated with a standard left-sided double lumen tube upon induction.
4. During incision and entry into thoracic cavity, avoid internal mammary artery injury. Care should also be taken to
avoid injury to recipient lungs.
5. For bilateral lung transplants, the decision as to which lung should be done first is based on the quantitative V/Q
scan. The lung that contributes a small percentage of the total ventilation and perfusion should be removed first. This
allows greater success with single-lung ventilation, using the healthier native lung during the transplant of the more
diseased side, and ventilation through the new donor lung during the dissection and implantation of the second lung.
This strategy aids in avoidance of cardiopulmonary bypass. Further, if there were to be an event that would mandate
aborting the procedure prior to completing the implantation of both lungs, it would be advantageous to transplant the
more diseased lung first.
6. Attempts should be made to detach all pleural adhesions and fully mobilize both hila prior to explantation of the first
lung. Careful attention must be directed toward managing travel times for organ procurement, in order to minimize the
ischemic time of the transplanted lungs and to also minimize the amount of time that the first implanted lung is exposed
to the entire cardiac output (thereby decreasing risk of reperfusion edema in that lung).
7. The decision regarding the use of cardiopulmonary bypass is made based on data obtained from the pulmonary artery
catheter, arterial blood gases, and trans-esophageal echocardiography. Hemodynamic instability, inability to
adequately oxygenate or ventilate with one lung, dramatic increases in pulmonary arterial pressures with unilateral
pulmonary artery clamping, and deterioration of right ventricular function are all potential reasons for
cardiopulmonary bypass. In order to minimize perioperative hemorrhage, all attempts should be made to do as much
of the dissection as possible and achieve optimal hemostasis on the chest well prior to systemic heparinization and
entry onto bypass.
8. Size-mismatched lungs: if oversized, and recognized on the back table, a lobectomy can be performed; if appreciated
after implantation, appropriate wedge resections can be performed, targeting the lingula and right middle lobe using
stapling devices.
9. Perioperative hemorrhage: may be related to large raw surface area created after explantation of septic lungs or those
that were previously pleurodesed, and is exacerbated by cardiopulmonary bypass. This may be avoided with
meticulous attention to stopping all surgically correctable bleeding and aggressive correction of coagulopathies.
Leaving the chest open (and covered with a temporary dressing) followed by delayed chest closure 24 to 48 hours
later is useful in some circumstances.
10. Technically unsatisfactory bronchial anastomosis: easily identified in the OR at postimplantation bronchoscopy.
Immediate revision should be performed for inaccurate alignment and inadequate caliber.
11. PA or PV anastomotic problems: may be identified via persistent pulmonary hypertension, unexplained hypoxemia,
pulmonary edema or findings on intraoperative TEE. Nuclear perfusion scans can be performed immediately post-op
in the ICU or even in the OR to identify any issues with flow to either lung. Gradients can be identified with
comparison of pressures on either side of the anastomosis measured intraoperatively or with contrast angiography
postoperatively. Surgical correction must be performed if clinically relevant gradient exists.
12. Primary graft dysfunction: compromised PaO2 to FiO2 ratio in the first 48 hours and the findings of panlobar
infiltrates on postoperative CXRs. (ISHLT grading system) Managed with aggressive cardiopulmonary support in
ICU, using PEEP, diuresis, iNO, aerosolized prostacyclin, and, if otherwise unresponsive, ECMO and/or
retransplantation. Avoid by ensuring absence of donor infection/aspiration/contusion, careful attention to appropriate
cold storage, limiting hyperinflation during/after procurement, using optimal lung preservation strategies, and
minimization of ischemic times.
Template Dictation
Preoperative Diagnosis: [INDICATION—e.g. pulmonary fibrosis, cystic fibrosis, chronic obstructive pulmonary disease,
etc.]
Procedure(s) Performed: [BILATERAL vs LEFT SINGLE vs RIGHT SINGLE] lung transplant (+/- cardiopulmonary
bypass)
Assistants: [BLANK]
Anesthesia: General Endotracheal
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [INDICATION]. A suitable dono
was identified. The harvest was conducted by our team and the organs were separated into separate lung grafts upon arrival at
[HOSPITAL].
Description of Procedure: The patient was brought to the operating room and general anesthesia was induced. [A SINGLE
LUMEN ENDOTRACHEAL TUBE WAS INITIALLY PLACED IN ORDER TO ALLOW THOROUGH SECRET
CLEARANCE VIA BRONCHOSCOPY. THE TUBE WAS SUBSEQUENTLY CHANGED OVER TO A STAND
LEFT-SIDED DOUBLE LUMEN TUBE ] or [THE PATIENT WAS INTUBATED WITH A LEFT-SIDED DOUBL
LUMEN ENDOTRACHEAL TUBE ] to allow lung-isolation. Standard monitoring lines were inserted, including [LINE
TYPES] in the [LATERALITY] [VESSEL]. The patient received [DOSE] of [ANTIBIOTICS] at the time of anesthetic
induction. Subcutaneous heparin was given for deep venous thrombosis prophylaxis, and sequential compression devices were
placed on bilateral lower extremities.
The patient was positioned supine with the arms tucked into the sides. All bony prominences were appropriately padded.
After suitable prepping and draping, [BILATERAL ANTEROLATERAL THORACOTOMIES ] or [MEDIAN
STERNOTOMY] or [LATERALITY, POSTEROLATERAL THORACOTOMY ] was/were made [IN THE FOURTH
VS FIFTH INTERSPACE].The sternum was divided transversely. The mammary vessels were divided between silk
ligatures. Both pleural spaces were entered and found [FREE OF ADHESIONS VS SCARRED WITH ADHESIONS ]. We
noted [INTRAOPERATIVE ANATOMIC AND HEMODYNAMIC FINDINGS AND ASSESSMENT TO INCLUDE
EXCLUDE CARDIOPULMONARY BYPASS… Consider pulmonary pressures, oxygenation, echo findings, etc.].
[Entry onto cardiopulmonary bypass, if used: The pericardium was opened in a hockey stick-shaped incision, extending down
the ascending aorta and angling over toward the right atrial appendage. The patient was fully heparinized. Two non-pledgeted
2-0 Prolene pursestring sutures were placed in the ascending aorta, and it was cannulated without difficulty. The cannula was
secured at the sternum with silk suture to prevent dislodgement of the cannula during the transplant procedure. In a similar
fashion, a 2-0 Prolene non-pledgeted pursestring suture was placed in the right atrial appendage and it was was secured to the
sternum to prevent dislodgement during the transplant procedure. The patient was then placed on cardiopulmonary bypass
without difficulty.]
[Backtable dissection, if performed: A donor/recipient time-out was performed. The lungs were brought from the cooler and
kept cold using topical application of crushed ice. The donor aorta and esophagus were resected posteriorly. The left atrial
cuff was divided in the midline, pericardium divided in the midline, the pulmonary artery was divided at its bifurcation, the
left main bronchus was amputated. Both hila were then fully prepared, mobilizing the pulmonary artery to the first upper lobe
branch, and dividing the bronchus one ring proximal to the upper lobe takeoff.
Excessive pericardium on both sides was then resected. The lungs were kept cold until the appropriate time for implantation.]
Based on the quantitative V/Q scan, the [RIGHT vs LEFT] lung was resected first [+/-AFTER THE PATIENT WAS
SAFELY PLACED ON CARDIOPULMONARY BYPAS S]. Pulmonary vein branches were divided between silk ligatures.
The upper lobar pulmonary artery was divided between silk ligatures. The distal pulmonary artery was transected beyond a
vascular staple line. Bronchial tissue was divided with cautery. The bronchus was divided well up in the mediastinum at a
site suitable for anastomosis. The pericardium was opened circumferentially. Hemostasis was achieved. Attention was then
directed to the [LEFT vs RIGHT] side where an identical extraction of the other lung was performed. [IF NOT ON
CARDIOPULMONARY BYPASS, THE FIRST LUNG IS ISOLATED, EXPLANTED, AND DONOR L
IMPLANTED; NOTE APPROPRIATE MODIFICATIONS IF NO CARDIOPULMONARY BYPASS.]
The donor [LEFT VS RIGHT] lung was brought up into the field.It was kept cold using topical application of crushed ice. The
donor and recipient bronchi were approximated with a running suture of 4-0 PDS. A central Satinsky clamp was placed. The
pulmonary arteries were trimmed to size and an end-to-end anastomosis constructed using 5-0 Prolene. Both vein stumps were
grasped and retracted laterally. A central Satinsky clamp was placed, the veins stumps were amputated, and the bridging atrial
tissue between the vein stumps was divided to create an atriotomy suitable for the venous anastomosis. A left atrial
anastomosis was then performed using a running suture of 4-0 Prolene with sutures placed in such a manner as to evert all
muscle from the lumen. The suture line was left open on its anterior aspect while the pulmonary artery clamp was released and
the lung de-aired antegrade.
The suture line was then secured. Partial perfusion was restored to the [LEFT VS RIGHT] lung and low volume ventilation
established (if done on bypass). [(If done without bypass): FULL VENTILATION AND PERFUSION WERE RESTORE
TO THE IMPLANTED LUNG.]
Attention was then directed to the [RIGHT VS LEFT] side where an identical implantation was performed. After restoration
of ventilation and perfusion of both lungs, gas exchange was [EXCELLENT, MODERATE, POOR?], hemodynamics were
[UNSATISFACTORY VS SATISFACTORY—additional steps taken if unsatisfactory].
[IF BYPASS USED: Both lungs were then fully ventilated, and the patient was weaned from cardiopulmonary bypass.
[DESCRIBE USE OF INOTROPES, PRESSORS, AND CORRESPONDING HEMODYNAMIC/ECHO FINDI .]
With this, [HE/SHE] was weaned from cardiopulmonary bypass and maintained stable hemodynamics with a s
ystemicpressure of [NUMBER], and a pulmonary artery systolic pressure in the [NUMBER]. The saturations initially were in
the [NUMBERS].The lungs appeared to be in [BLANK] condition with [no] erythema or edema. We observed [HIM/HER]
for quite some time and [HE/SHE] remained hemodynamically stable and was decannulated in the standard fashion. Protamine
sulfate was administered. Both the cannulation sites were both carefully examined and found to be completely hemostatic. The
pericardium was then loosely approximated in the midline with multiple interrupted 2-0 Vicryl sutures.]
Hemostasis was achieved in both pleural spaces. Two #24 Blake drains were brought through separate stab wounds into each
pleural space. The chest was then closed using heavy polypropylene pericostal sutures and two heavy figure-of-eight sternal
wires. Fascial sutures of Dexon and subcuticular closure and a Dermabond dressing completed the wound closure.
The patient was then extubated and re-intubated using a single-lumen tube. Flexible bronchoscopy was performed. The
airways were examined. Both bronchial anastomoses were widely patent. The donor airways were viable. Blood and
secretions were aspirated. The patient was then transferred directly to the Cardiothoracic Intensive Care Unit in stable
condition.
Estimated Blood Loss: [Blank]
Approximately [NUMBER] mL.
Sponge/instrument/needle counts: Correct.
Condition upon discharge from the operating room: The patient remained stable throughout.
Complications: There were no complications noted. [OR NOTE IF THERE WERE]
39. Bronchial and Arterial Sleeve Resection
George Makdisi, MD, Dennis Wigle, MD, PhD

2. General endotracheal anesthesia / Single lumen tube for bronchoscopy
3. Flexible bronchoscopy is mandatory to examine the extent of the tumor
4. Double-lumen endotracheal tube (left sided for sleeve resection on the right and right sided for sleeve resections on
the left).
5. Serratus-sparing posterolateral thoracotomy/ or lateral thoracotomy. Enter through the 5th intercostal space. Harvest
the intercostal muscle flap for coverage of the anastomosis.
6. Assess for pleural metastases
7. Open posterior and anterior mediastinal pleura to expose the main stem bronchus
8. Assess for local invasion and resectability
9. Dissect and divide the pulmonary veins, arteries and the fissure as usual.
10. Sharply divide the distal main bronchus and proximal bronchus for anastomosis perpendicular to the long axis
11. Get frozen section to assure negative margins, if positive resect further
12. If an arterial sleeve needs to be done, give 5000 IU of heparin before clamping the artery
13. Decide your best type of arterial reconstruction,
14. Get proximal and distal control of the pulmonary artery
15. Clamp superior and inferior pulmonary veins
16. Do Infrahilar pericardial release to decrease tension
17. End to end anastomosis, with interrupted polypropylene sutures with knots outside
18. Complete lymph node dissection
19. Check for vascular kinking when the rest of the lung is expanded
20. Cover anastomosis with intercostal muscle flap
21. Chest tube drains
22. Redo bronchoscopy to check anastomosis
23. Repeat bronchoscopy before discharge

1. The orientation of the proximal and distal airways should be maintained by traction suture at the junction of
membranous and cartilaginous airways
2. The main pulmonary artery is usually clamped after administration of 5000 U heparin. Heparin is not reversed at the
end of the operation. No further heparin; just is standard DVT prophylaxis postop
3. Bronchial fistula can be avoided by:
1. Anastomosis tension free: do hilar release
2. Lumen disparity: Bronchial size matching can be a problem; use intussusception techniques as required
3. Protect the anastomosis by wrapping with a vascularized pedicle of autologous tissue (pericardial fat, intercostal
muscle, or pleura). An intercostal flap should not cover 360 degrees of the circumference.
4. Segmental bronchial patency. It is important to check that all segmental bronchi are patent and that all the sutures are
placed in a way that does not jeopardize the patency of the segmental bronchi
5. Postoperative hemoptysis. Rule out bronchial-arterial fistula immediately. This can be avoided by isolating the
arterial reconstruction from the bronchial anastomosis
6. Vascular and bronchial kinking. It is critical to examine the anastomoses after lung reexpansion to ensure there is no
rotation or kinking
7. The main pitfalls of the use of a conduit are its sizing and length
8. Postoperative bronchial stenosis treated by dilatation or stenting if needed
Template Dictation
Preoperative Diagnosis: Endobronchial tumor involving the orifice of the [BLANK] lobe.
Procedure(s) Performed: Bronchial and arterial Sleeve resection of [BLANK]
Assistants: [BLANK]
Anesthesia: Thoracic epidural and general endotracheal anesthesia.
Indication(s) for Procedure: [Mr/ Mrs. ] [BLANK] is a [age] year-old [gender] who presented [right/ left] lung mass.
Workup included [CXR, CT, PET], biopsy had been performed, and the findings are consistent with a [pathology e.g.
endobronchial tumor involving the orifice or the [BLANK] lobe]. [Mr/ Mrs.] [BLANK] is brought now for surgical
resection
Description of Procedure: Bronchial sleeve resection of the right upper lobe
The patient was brought to the operating room and had a thoracic epidural catheter placed by the anesthesia team. The patient
was then placed in the supine position on the operating table. Following an uneventful induction of general endotracheal
anesthesia, the patient was intubated with a single-lumen endotracheal tube. We performed flexible videobronchoscopy. The
left-sided airways had normal anatomy. There were no endobronchial lesions, significant secretions, blood, pus or other
abnormalities. In the right-sided airways, there was an obvious tumor mass that had completely occluded the entire orifice of
the right upper lobe of the lung. There was tumor coming out of the orifice into the mid bronchus intermedius bronchus.
The single-lumen endotracheal tube was exchanged for a double-lumen endotracheal tube by the Anesthesia Team. He was
turned into left lateral decubitus position with the right side up. The left chest was sterilely prepped and draped in the usual
manner for a standard right posterolateral thoracotomy. We made a serratus-sparing right posterolateral thoracotomy incision
and entered the chest through fifth intercostal space. The 5th intercostal muscle pedicle was harvested for future coverage of the
anastomosis. There was no evidence of pleural disease in the chest. The tumor could be palpated centrally at the takeoff to the
right upper lobe bronchus. We took the inferior pulmonary ligament down with Bovie electrocautery up to the inferior
pulmonary vein and harvested station 9 lymph nodes. Then we started our dissection in the fissure by identifying the
pulmonary arterial branches heading down to the right lower lobe, and the middle lobe. We next proceeded with our right
upper lobectomy. The superior pulmonary vein was dissected free and ligated using an endovascular stapler. A number of
pulmonary arterial branches were identified heading to the right upper lobe. We were able to identify a large pulmonary
arterial truncal branch heading up to the right upper lobe coming off the main PA relatively proximal. This was ligated using
an endovascular stapler. As a consequence, we proceeded with dissecting out the bronchus. Given our prior bronchoscopy, it
was clear that a sleeve lobectomy would be required in order to obtain an adequate margin. Proximally, we then transected the
distal right main bronchus just proximal to the take-off of the right upper with a No. 10 blade. This allowed us to look inside
the airway, and we could see that we were grossly clear of the tumor originating from the orifice of the right upper lobe of the
lung. Then we transected the bronchus intermedius just above the takeoff of the superior segmental bronchus of the lower
lobe. The right upper lobe bronchus was now separated with the corresponding portion of the right mainstem attached. The
right main bronchial margin and the bronchus intermedius margin on the sleeve part of the airway were marked with stitches
for Pathology for orientation. The final margins were clear of tumor. We completed the fissure posteriorly with a single firing
of a blue load Endo GIA stapler. We then swept lymph nodes up toward the specimen. With the bronchus now ligated, all of
the attachments at the hilum for the right upper lobe were now free; we then performed an end-to-end anastomosis using #2-0
absorbable stay sutures placed around one cartilaginous ring at 3 and 9 o'clock on both the right main bronchus side as well as
on the intermedius bronchus side. We then used interrupted #4-0 absorbable suture. We began on the cartilaginous wall at the
12 o'clock position on both sides and then continued laterally with interrupted suture technique. Once all the cartilaginous
sutures had been placed, we then also reapproximated the membranous walls with interrupted #4-0 absorbable suture sutures
and then tied the sutures in the reverse order (the back wall tied first then the anterior wall) after tying the stay sutures down.
The bronchial anastomosis was tested under saline and was found to be pneumostatic to 35 mm of water pressure. We then
harvested a vascularized pericardial fat pad and then passed it circumferentially around our bronchial anastomosis and tacked
it to the airway in several places with mattress #3-0 silk sutures. We then completed a thoracic lymphadenectomy with
harvesting lymph nodes from station 9, 7, 2, 4, 10, and 11. The lung was reinflated. There was minimal air leak. The
intercostal muscle flap was passed around the anastomosis posteriorly taking care not to completely encircle the anastomosis.
We placed two 28-French chest tubes and closed the chest in layers with figure-of-eight #1 pericostal absorbable suture. The
lung was re-expanded under direct vision. We closed the serratus with a running #1 absorbable suture, and we closed the
latissimus in two layers with running #1 absorbable suture. The subdermal tissues were closed using #2-0 absorbable suture.
The skin was closed with a #4-0 absorbable subcuticular suture. The patient tolerated the procedure well. There were no
intraoperative complications. All needle, sponge, and instrument counts were correct on two occasions.
[Mr/Mrs.] [BLANK] appeared to tolerate the procedure well and was transferred to the recovery room in stable condition.
Left upper lobe with arterial sleeve resections:
Same as above except using right-sided double lumen endotracheal tube
We were able to completely mobilize the left lung, and the tumor did appear mobile within the left upper lobe and potentially
resectable.
We first began with an intrapericardial dissection in order to identify the relevant anatomy. The inferior and superior
pulmonary veins and the left main pulmonary artery were dissected free and umbilical tapes placed round them for vascular
control. We were able to readily identify the superior pulmonary vein, and it was ligated between two fires of a TA-30
vascular stapler. Working out along the pulmonary artery, we were able to identify a number of branches heading to the left
upper lobe. These were ligated in succession using silk ties. We did encounter some pulmonary artery branches where the
tumor was flush up against the pulmonary artery.
Working in the fissure, it was clear that there was extension of tumor and associated fibrotic tissue over on to the superior
segment. As a consequence, we dissected out the left main stem bronchus posteriorly. We were able to identify the separation
point where the bronchus bifurcated into the left upper and left lower lobes. At this point we dissected free the left upper lobe
bronchus and ligated this using a TA-30 bronchial stapler and we were only still attached to two relatively large pulmonary
arterial branches that were flush against the pulmonary artery. In order to resect this safely, 5000 U of heparin was given, and
we clamped the remaining left inferior pulmonary vein and the left main pulmonary artery in order to have vascular control.
The tumor was cut free off of the pulmonary artery with an appropriate margin on the artery. We had adequate hemostasis
while this took place. The tumor was now successfully removed with all of its attachments and sent to pathology. We
reconstructed the pulmonary artery with a primary anastomosis with running sutures of [#5-0 or 6-0] nonabsorbable
monofilament. After removal of the clamps, it appeared as though we had adequate hemostasis.
We then completed a thoracic lymphadenectomy. Lymph nodes were harvested from stations 2L, 4L, 5, 6, 7, 9, 10L and 11L.
In order to separate the area of our pulmonary sleeve from the bronchial stump we harvested a pleural flap in order to
interpose this between the artery and the bronchus. The pleural flap was tacked down on to the bronchus and surrounding
tissue using a number of #3-0 silk sutures. Once this was complete we carefully irrigated with many liters of warm saline.
Our bronchial stump was intact under saline immersion. We had adequate hemostasis. The lung was reinflated. There was
minimal air leak. We placed two 28-French chest tubes and closed the chest in layers with figure-of-eight #1 pericostal
absorbable suture. The lung was re-expanded under direct vision. We closed the serratus with a running #1 absorbable suture,
and we closed the latissimus in two layers with running #1 absorbable suture. The subdermal tissues were closed using #2-0
absorbable suture. The skin was closed with a #4-0 absorbable subcuticular suture. The patient tolerated the procedure
well. There were no intraoperative complications. A surgical pause confirmed that all needle, sponge, and instrument counts
were correct. [Mr/ Mrs.] [BLANK] appeared to tolerate the procedure well and was transferred to the recovery room in
stable condition.
Techniques of Pulmonary Artery Reconstruction
1. Patch reconstruction after partial resection. The wall of the vessel on the opposite side should be free of tumor. It can
be associated with a standard lobectomy or a lobectomy with a sleeve resection of the bronchus. The patch
(autologous or Bovine pericardium) is held in place by two stay sutures of polypropylene #5-0. We tie the lower stay
suture then continue running sutures while keeping some degree of looseness on the patch which is desirable at this
stage, the looseness will disappear after declamping. The upper stay suture is not tied but simply keeps the patch in
the correct place. The pericardium is usually harvested anteriorly to the phrenic nerve; the defect is small and can be
left open with no fear of cardiac herniation.
2. Sleeve resection with end-to-end-anastomosis (as described in our case). Sleeve resection of the artery is usually
required when the circumference of the vessel is extensively invaded. It is required also when vascular and bronchial
reconstructions are performed simultaneously, with a marked shortening of the bronchial axis. After the resection the
ensuing defect can be reconstructed by end-to-end anastomosis after bronchial reconstruction, caliber discrepancy is
compensated by the elasticity of the wall of the vessel. Sectioning the vessel can improve exposure of the bronchial
side. In this situation, the vascular anastomosis should be completed after performing the bronchial reconstruction. It
is accomplished with a #5-0 or 6-0 nonabsorbable monofilament. Caliber discrepancy between the two sides of the
anastomosis is typically not a problem and matching is greatly helped by the elasticity of the vessel
3. Sleeve resection followed by reconstruction with a prosthetic conduit as polytetrafluoroethylene (PTFE) can be used
when a long bronchial segment separates the two pulmonary artery stumps such that an end-to-end anastomosis is not
feasible. The proximal anastomosis between the pulmonary artery and the conduit is performed first. The distal
anastomosis is performed last
4. Reconstruction of the main PA at its origin under cardiopulmonary bypass. This is an option of last resort
II. Adult Cardiac Surgery
1. Aortic Root Replacement for Ascending Aortic Aneurysm
Fawwaz R. Shaw, MD and Edward D. Verrier, MD
University of Washington, Seattle, WA.

1. Placement of appropriate monitoring lines and induction of general endotracheal anesthesia.
2. Review of the preoperative CT scan or MRI identifying annulus size, location of sinotubular junction, extension of
disease into aortic arch and coronary anatomy.
3. Operating room briefing with Anesthesia, Perfusion, and Nursing teams regarding intraoperative plans, cannulation
strategies, myocardial protection plans, possible inotropic needs, antibiotic coverage, post-operative coagulation, local
hemostatic agents planned, type of conduit and valve planned, annular and button stitches planned and need for left
ventricular vent.
4. Evaluation of the heart and valve function with intraoperative transesophageal echocardiography.
5. Venous and appropriate arterial cannulation (distal ascending aorta versus femoral or right axillary arteries).
6. Cardiopulmonary bypass. (Depth of cooling, possible deep hypothermic circulatory arrest (DHCA) and re-warming
timing.)
7. Myocardial protection strategy (solution, timing and mode of delivery).
8. Examination of the aorta and identification of the proximal and distal extents of the aneurysm.
9. Division of the proximal aorta above the sinotubular junction.
10. Examination of the aortic root and determination of the need for valve replacement versus repair/resuspension, or an
aortic interposition graft versus a Bentall procedure.
11. Excision of the aortic valve, meticulously removing debris and debriding the annulus if heavily calcified.
12. Careful dissection and release of the coronary buttons from the aortic wall marking the proper orientation with a
stitch.
13. Completion of the proximal division of the aorta.
14. Selection of an appropriately sized composite aortic-valved conduit.
15. Placement of the annular valve stitches. (Pledgeted versus un-pledgeted, left ventricle to aorta versus aorta to left
ventricle.)
16. Securing the valved conduit via the sewing ring. (Ensure all pledgets are accounted for.)
17. Re-implantation of the coronary arteries.
18. Completion of the distal aortic anastomosis. (Determine need for Teflon felt reinforcement.)
19. De-airing the heart and conduit.
20. Remove cross clamp after hot shot.
21. Placement of temporary pacing wires.
22. Wean from cardiopulmonary bypass.
23. Examination of the heart for function and the valve for leaflet excursion, function and paravalvular leaks.
24. Ensure hemostasis, place chest/mediastinal tubes and close the chest.

1. If contraindication to mechanical aortic valve. (A bioprosthetic-valved conduit can be created by first selecting an
appropriately sized bioprosthetic valve. An aortic conduit approximately 3-5 mm larger than the valve is selected. The
sewing ring of the valve is then secured to the graft with a running 4-0 polypropylene suture creating a watertight
anastomosis between the sewing ring and the aortic conduit. The valve leaflets are then examined for appropriate
excursion and to ensure no leaflet impingement prior to tying the suture.)
2. Inability to place a retrograde cardioplegia cannula in the coronary sinus.
3. Inappropriately placed arterial cannula in the ascending aorta with insufficient room for cross clamp placement.
4. Injury to the conduction system as a result of deep valve stitches in the region of the right and non coronary sinuses.
5. Coronary occlusion due to suboptimal lay of the coronary arteries after reimplantation.
6. Length of conduit too long (causing kinking) or too short (causing tension).
7. Incomplete or excessive mobilization of the coronary arteries leading to tension, twisting or kinking of the coronary
anastomosis.
8. Failure to completely debride a calcified aortic annulus leading to abnormal seating of the valved conduit and poor
hemostasis.
9. Inadequate de-airing maneuvers or air embolus down the right coronary leading to right ventricular dysfunction.
10. Breaking a stitch during tying of conduit to annulus (leading to possible loss of pledget and need for a repair stitch).
Template Dictation
Preoperative Diagnosis: Ascending aortic aneurysm, Annuloaortic ectasia
Procedure(s) Performed: Aortic Root and Valve replacement [Type of conduit/valve, e.g. #25 ATM Medical Mechanical
Valved Conduit].
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE]o l d [G ENDER]who developed [SYMPTOMS e.g. progressively worsening
shortness of breath and dyspnea] and was found to have [FINDINGS e.g. 6.5 cm ascending aortic aneurysm with a
bicuspid aortic valve].
Description of the Procedure: The patient was brought to the operating room where an intra-operative briefing or huddle was
performed with the surgical, anesthesia, nursing and perfusion teams, confirming the correct patient, diagnosis and operative
plan. The patient was placed in the supine position and general endotracheal anesthesia was instituted. Appropriate monitoring
lines were then placed. Preoperative transesophageal echocardiogram was performed to evaluate cardiac and valve function.
The chest, abdomen and lower extremities were prepped and draped in sterile fashion.
A midline incision was made from the sternal notch to just distal to the xiphoid process and the sternum was transected in the
midline. The anterior mediastinum was entered, the pericardium was opened and a pericardial cradle was created. Mediastinal
anatomy was then carefully reviewed. The aorta was dissected and inspected. Systemic heparinization was performed with 3
mg/kg of intravenous heparin via a centrally placed intravenous catheter. We instituted cardiopulmonary bypass via central
cannulation with a two stage right atrial cannula and a distal ascending aortic cannula. The patient was allowed to
systematically drift in temperature. We placed a cannula in the coronary sinus for retrograde cardioplegia confirmed by TEE,
and one in the ascending aorta for antegrade cardioplegia. A left ventricular vent was placed via the right superior pulmonary
vein and placement was also confirmed by TEE.
Both antegrade and retrograde cardioplegia were administered. Warm glutamate/aspartate blood cardioplegia was utilized for
induction antegrade followed by cold blood cardioplegia for maintenance. Cold blood cardioplegia was given every 20
minutes for the duration of the operation either via the coronary sinus or directly into the orifices of the coronary arteries by
hand-held cannulae. Prior to removal of the cross clamp a hot shot of substrate enriched warm blood cardioplegia was given.
Carbon dioxide was infused into the operative field to minimize air accumulation in the heart.
We opened the aorta obliquely above the sinotubular junction and found [FINDINGS e.g. a congenitally bicuspid aortic
valve with marked dilation of the sinuses]. We elected to proceed with the following aortic root operation [AVR with
ascending aorta replacement, a Bentall procedure, a David procedure, hemi-arch replacement]. The diseased valve was
carefully excised at the level of the annulus with care to remove all calcium debris. We then excised the ascending aorta,
carefully creating the left and right coronary artery buttons for subsequent re-implantation. The coronary buttons were marked
with temporary 4-0 Prolene sutures to maintain proper orientation.
Interrupted 2-0 pledgeted TiCron sutures were sequentially placed in the annulus of the aortic valve from below, with the
pledgets on the ventricular side. We then selected an appropriate sized composite valved prosthesis [SELECTED
CONDUIT]and placed our TiCron sutures through the sewing ring. The valved prosthesis was gently lowered into place at
the level of the annulus and the sutures were carefully tied to tightly secure the prosthesis to the annulus. Full excursion of all
valve leaflets was confirmed. We created holes using an ophthalmic cautery in the conduit at the appropriate height, adjacent to
the left and right coronary buttons. We used a 6-0 Prolene suture in a running fashion to anastomose the coronary buttons to the
conduit. The conduit was then sized for appropriate length and the distal end of the graft was anastomosed in an end to end
fashion using running 4-0 Prolene suture reinforced with a Teflon felt strip.
We then placed the patient’s head down, filled the heart with blood, temporarily turned off the left ventricular vent and gently
ventilated the patient to remove pulmonary vein air. We also vented the ascending aorta to complete our de-airing maneuvers.
The cross clamp was removed after warm substrate enhanced cardioplegic solution was administered. Temporary pacing
wires were placed.
Spontaneous rhythm was ensured [or the patient was temporarily paced] and the patient was weaned gradually from
cardiopulmonary bypass on low dose inotropic support. Transesophageal echocardiography demonstrated preserved
ventricular function, no aortic insufficiency and appropriate excursion of the valve leaflets. We then decannulated the patient
once all de-airing maneuvers were completed and reinforced our cannulation sites with appropriately placed sutures. Heparin
was fully reversed with [DOSE] Protamine. We ensured adequate hemostasis and placed a [SIZE e.g. 32 Fr]chest tube in the
mediastinum [and pleural spaces if necessary]. The sternum was closed with interrupted [SIZE e.g. 22 gauge] stainless
steel wires. The fascia was closed with 0 Vicryl suture in running fashion. We closed the deep dermal layer with 2-0 Vicryl
suture in running fashion and re-approximated the skin edges with 4-0 Monocryl in a subcuticular fashion. A sterile dressing
was then placed over the incision and at the chest tube site.
Needle, sponge and instrument counts were reported as correct x 2. The patient was transferred to the Intensive Care Unit with
stable vital signs. The post-operative huddle / debriefing was completed.
2. Aortic Root Replacement (Endocarditis)
Michael O. Kayatta, MD and Michael E. Halkos, MD, MSc
Emory University, Atlanta, GA

2. Open pericardium and create pericardial well
3. Arterial cannulation
4. Venous cannulation
5. Initiate CPB and place aortic cross-clamp to administer cardioplegia
6. Transect aorta and remove all infected tissue including aortic valve
7. Create coronary buttons
8. Proximal anastomosis (homograft to aortic annulus)
9. Coronary to homograft anastomoses
10. Distal homograft to aorta anastomosis
11. Remove aortic cross clamp
13. Wean from CPB
14. Venous and aortic decannulation

1. Insufficient myocardial protection
2. Inadequate LV drainage with LV vent
3. Bunching of the homograft during anastomosis leading to aortic valve incompetence
4. Injury to coronary artery ostia
5. Inadequate control of hemostasis prior to sternal closure
6. Bleeding complications
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. aortic valve endocarditis with aortic root abscess]
Procedure(s) Performed: Aortic root replacement with [SIZE] homograft aortic root conduit [DETAILS– e.g. extent of
tissue removed]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE]year old [GENDER]with [DURATION]history of [COMPLAINT– e.g. sepsis with
persistent bacteremia and aortic root abscess]. Preoperative echocardiogram reveals [FINDINGS – e.g. aortic valve
vegetation with aortic root dilation].
obtained. A right internal jugular central venous line and pulmonary artery catheter and radial arterial line were inserted.
Preoperative transesophageal echocardiogram was then performed to evaluate cardiac function, aortic valve and root
pathology. We then proceeded to prep and drape the chest, abdomen, groins, and lower extremities in sterile fashion. A time
out was performed. [ANTIBOTIC] was given within 60 minutes of incision. Median sternotomy was then performed. The
pericardium was opened and a pericardial well was created. Epiaortic ultrasound was then performed which revealed a grade
[GRADE] aorta. The aortic cannulation sutures were then placed in the ascending aorta below the level of the innominate
artery. The right atrial cannulation sutures were then placed within the right atrium.
A total of [UNITS (400U per kg)] of systemic heparin was administered. The aortic cannula was then inserted, secured and
de-aired. A venous cannula was then placed and secured in the right atrium. A retrograde cannula was placed through the right
atrium into the coronary sinus. A DLP vent was then inserted into the ascending aorta for administration of antegrade
cardioplegia. The aortic cross-clamp was placed. Antegrade cardioplegia was administered and rapid arrest of the heart
followed. After 1 liter of high potassium antegrade cardioplegia, 500cc of retrograde cardioplegia was given. Ice was applied
to the heart. The patient was cooled to [32-34] degrees Celsius. Additional myocardial protection was achieved with
continuous retrograde cardioplegia. Additional doses of cardioplegia were administered via antegrade every thirty minutes
[or continuously]. A left ventricular vent was placed via the right superior pulmonary vein.
After arrest of the heart with cardioplegia, the ascending aorta was opened transversely with a #15 blade just above the level
of the sinotubular junction. The aortic root was then dissected free of surrounding structures. All aortic leaflets were then
excised. The aortic sinus tissue was then excised to the level of the aortic annulus. The left and right coronary buttons were
then created leaving adequate aortic tissue to be able to perform the anastomoses. Radical debridement of all infected tissues
was then carried out [include specifics]. All contaminated instruments were then removed from the field. #4-0 pledgeted
sutures were placed at each commissure for retraction.
Following this, a series of #2-0 Tevdek pledgeted horizontal mattress aortic-based sutures were placed circumferentially
around the aortic annulus. These were then brought through the base of a [SIZE] homograft conduit. [Alternatively a running
suture technique can be utilized.] The conduit was then seated down into the LVOT. The sutures were then tied and cut. The
coronary ostia on the homograft were then enlarged, and the coronary buttons were then sewn into the homograft ostia using
running [#5- or #6-0] Prolene suture. Finally, the distal homograft was anastomosed circumferentially to the ascending aorta
using a running #4-0 Prolene suture.
The aortic cross-clamp was then removed. All suture lines were evaluated for hemostasis. A total of [NUMBER] chest tubes
were placed in the [LEFT/RIGHT] pleural space, and [NUMBER] chest tubes were placed in the mediastinum.
[ATRIAL/VENTRICULAR] pacing wires were then inserted and tested for appropriate capture. The heart was then de-aired,
and the LV vent was removed. The patient was weaned from cardiopulmonary bypass and the DLP vent was removed.
Transesophageal echocardiogram revealed a competent aortic valve. The venous cannula was removed, and the cannulation
sutures were tied down. The aortic cannula was then removed, and the cannulation sutures tied down. Protamine was then
slowly administered. Adequate hemostasis was then confirmed within the mediastinum. The sternum was then closed with
stainless steel sternal wires. The fascia was then closed with a #1 PDS suture. The deep dermal layer was then closed with
#3-0 PDS suture in running fashion. The skin and subcuticular layer was closed with #4-0 Monocryl in running fashion.
All instrument, sponge and needle counts were confirmed to be correct, twice, at the end of the operation. The patient was
3. Total Arch/Hemiarch Replacement with DHCA – Dissection
Tom P. Theruvath, MD, PhD and John S. Ikonomidis, MD, PhD

1. ECG, pulse oximetry, bilateral upper extremity arterial monitoring, PA Catheter
2. Induce general anesthesia
3. Mark midline chest incision and bilateral groins for possible arterial access if needed
4. TEE, Foley, end-tidal CO2, temperature probes (nasopharyngeal, bladder, rectal), bi-hemispheric cerebral oxygen
saturation monitoring
5. Prep and drape to include both legs circumferentially
6. Pass CPB lines and prime circuit
7. Median sternotomy with 1-2 cm extension cranially to supraclavicular notch
8. Dissection superior to innominate vein to visualize innominate artery and evaluate arch to determine whether total or
just proximal transverse (hemirach) arch needs to be replaced.
9. Systemic heparinization (400 IU/Kg)
10. Dissection of Innominate artery and construction of end/side anastomosis to a 10 mm Hemashield graft (chimney
graft) with 5-0 Prolene for arterial cannulation
11. Confirm ACT > 460 sec and connect Hemashield graft to arterial cannula (soft flow tip), secure with heavy silk ties
twice, de-air and connect to arterial side of pump oxygenator
12. Confirm absence of pericardial effusion/hemopericardium and prepare to control hypertension once opening
pericardium. Prepare pericardial well and assess root/proximal ascending aorta to decide whether root needs to be
reconstructed
13. Placement of dual stage venous cannula and connect to venous side of pump oxygenator
14. Retrograde autologous priming with placement of antegrade dual stage cardioplegia and root vent and retrograde
cardioplegia tacks
15. Commence CPB and start systemic cooling to 25 C. Dose steroid for cerebral protection
16. Aorta is crossclamped proximal to innominate artery takeoff and heart arrested with a combination of antegrade and
retrograde cold blood cardioplegia with topical ice saline cooling
17. Aorta is transected midway, resected back to sinotubular junction and trimmed cranially up to the crossclamp.
18. If the false lumen has caused dissection proximally into the sinuses of Valsalvae, the false lumen can be obliterated
by utilizing a sandwich technique with placement of a Teflon strip in between the dissected walls and reinforced
with surgical adhesives. (if dissection involves base of aortic root or coronary ostia, aortic root reconstruction by re-
suspension, remodeling or replacement of aortic valve with coronary artery bypasses needs to be considered; this
involves complex reconstruction not discussed in this chapter)
19. Tubular Dacron graft is sized (approximately 26 mm – 30 mm)
20. Once 25 C is reached, Trendelenburg position is assumed, propofol is given, head is packed in ice, and a DeBakey
peripheral vascular clamp is applied to the base of the innominate artery. The crossclamp is removed.
21. Selective antegrade cerebral perfusion is commenced with decreased flows to maintain a mean right brachial artery
pressure of 60-70 mmHg.
22. Aorta is resected into the arch with undercutting of the proximal hemiarch such that the takeoffs of all 3 great vessels
are easily visualized OR the aorta is resected back to the proximal descending aorta leaving an island of arch
surrounding the great vessels just distal to left subclavian artery (leave all three brachiocephalic vessels attached to a
single arterial button).
23. The tubular Dacron graft is trimmed and beveled and a proximal anastomosis is made between it and the hemiarch
with running 3-0 Prolene suture to carefully include all layers with each needle bite O R the tubular Dacron graft is
trimmed and an anastomosis between the distal aorta in a running fashion with 3-0 Prolene and the arch button using
the same suture technique is constructed.
24. Anastomoses are reinforced with a small amount of surgical adhesives circumferentially (we do not utilize Teflon
felt strips).
25. The aortic arch is carefully de-aired after removing the peripheral vascular clamp at the base of the innominate artery
and a crossclamp reapplied after adequate flush to the ascending/transverse arch.
26. Anastomoses are inspected carefully and repair sutures placed were necessary
27. Rewarming is begun and full flow perfusion is re-established via innominate artery
28. The Dacron graft is trimmed to length for proximal anastomosis
29. Antegrade cardioplegia tack/root vent is placed into ascending graft and retrograde cardioplegia tack removed
30. Proximal anastomosis is performed with 3-0 Prolene
31. Following warm cardioplegia dose ventricular pacing wires are placed and crossclamp removed
32. Once rewarmed to 36 C, the patient is weaned from CPB. De-airing (assessed by TEE) and hemostasis is assured.
33. Antegrade cardioplegia tack/root vent and venous cannula are removed, Protamine given and the arterial cannula
removed (the Hemashield graft is tied twice with heavy silk), and all cannulae sites reinforced with 4-0 Prolene
sutures
34. Chest is closed in usual fashion after placement of mediastinal chest tube and oblique sinus/right lateral 19 Fr
Blake drain

1. Usual complications with sternotomy, dissection, and cannulation
2. Inability to place antegrade cardioplegia/root vent cannula due to anterior wall dissection involvement
3. Organ (especially cerebral) mal-perfusion and need for alternative arterial cannulation site (e.g. right subclavicular
cutdown for right axillary cannulation or groin cutdown for femoral arterial cannulation)
4. Distal reentry tear leading to mal-perfusion after placement of crossclamp with need to pursue repair during
fibrillatory arrest
5. Severe Aortic insufficiency with aortic root dilation and involvement of aortic valve with need for either aortic valve
resuspension or replacement (due to their complexity we do not describe these scenarios)
6. Dissection involves coronary arteries and coronary button/bypass has to be constructed to proximal Dacron graft.
7. Improper de-airing
8. Too long of conduit with need to re-cross clamp, shorten and re-anastomose end/end ascending aorta graft
9. Bleeding from anastomoses (common challenge, especially needle holes and need for adjuncts in hemostatsis
including local adjuncts, e.g. surgical adhesives, and systemic adjuncts, e.g. Factor VII)
Template Dictation
Preoperative Diagnosis: Acute Type A Aortic Dissection
Post-operative Diagnosis: Same
Procedure(s) Performed: Repair of ascending and hemiarch [OR TOTAL ARCH]aorta for acute type A aortic dissection
utilizing profound hypothermic circulatory arrest and selective antegrade cerebral perfusion via innominate artery.
Assistants: [BLANK]
Anesthesia: [BLANK]
Operative Findings: A [XX]-cm ascending aorta with friable tissues and a dissection flap visualized in the ascending aorta.
[SIGNIFICANT TOTAL TRANSVERSE AORTIC ARCH HEMATOMA/INTIMAL FRAGMENTATION
SIGNIFICANT ANEURYSMAL ENLARGEMENT WAS DEMONSTRATED NECESSITATING TOTAL AR
REPLACEMENT]. The aortic valve was competent and without pathologic changes.
Description of Procedure: With the patient in supine position under general anesthesia with monitoring lines in place, the
chest, abdomen, and lower extremities circumferentially were prepped and draped in sterile fashion. Cardiopulmonary bypass
lines were passed and primed. A median sternotomy was made and extended slightly cranially in the midline towards the neck
through which the innominate vein was identified and retracted with vessel loops. The innominate artery was carefully
dissected and proximal and distal control was obtained. The bypass lines were cut and the patient was systematically
heparinized. A side-biting clamp was placed on the innominate artery. A longitudinal arteriotomy was made in the artery and
an end-to-side anastomosis was made between a 10-mm Dacron graft which was attached to a 7 mm Soft-Flow arterial
cannula. Following completion of the anastomosis, the clamp was removed and no leaks were observed. The graft and cannula
were de-aired and attached to the arterial side of the pump oxygenator.
The pericardium was opened in inverted-T fashion and extended upwards to include the entire ascending aorta. A pericardial
well was created. The ascending aorta was friable with a bluish hue indicating ascending aortic dissection [without or with
aneurysmal dilation at X X cm]. [THE ASCENDING AORTA DEMONSTRATED SIGNS OF DISSECTION WI
HEMOTAMA INVOLVEMENT OF THE TRANSVERSE ARCH WITHOUT OR WITH ANEURYSMAL DILAT
AT XX CM]. TEE confirmed [absence/presence] of a pericardial effusion and [absence/presence] of aortic insufficiency. A
dual-stage venous cannula was positioned and secured through the right atrial appendage and attached to the venous side of the
pump oxygenator. Retrograde autologous priming was started and antegrade and retrograde cardioplegia tacks were inserted.
Following confirmation of an ACT greater than 460 seconds and completion of retrograde autologous priming,
cardiopulmonary bypass was commenced and systemic cooling to 25 C was initiated in preparation for hypothermic
circulatory arrest and replacement of the aorta into the proximal hemiarch [ASCENDING AORTA AND TOTAL ARCH ].
The heart was arrested by placement of a crossclamp at the distal ascending aorta and with a combination of antegrade and
retrograde cold blood cardioplegia with topical ice saline cooling. Every 20 minutes throughout the procedure 250 cc of
retrograde cold blood cardioplegia was given to maintain myocardial protection.
The ascending aorta was transected in its midportion. It was dissected backwards to the crossclamp and removed leaving
about 1 cm proximal to the clamp. This specimen was sent to pathology for sectioning and assessment of cystic medial
degeneration. The proximal portion of the aneurysm was then dissected free and removed to the level of the sinotubular
junction. At this point, it was possible to inspect the aortic valve and it was found to be a competent tricuspid aortic valve
without pathologies. Both left and right coronary ostia were unobstructed and without involvement of the dissection flap. To
exclude a proximal false lumen, a Teflon strip was placed in between the layers of the proximal aortic wall, and reinforced
carefully with BioGlue .
At this time, the patient's systematic temperature had reached 25 C. The head of the patient was packed in ice and propofol
and steroids were applied for cerebral protection adjuncts. A small right angle clamp was placed at the innominate artery
proximal to the graft and flows were reduced to approximately 1 to 1.5 L/min to maintain a right brachial artery pressure of
approximately 60 to 70mmHg mean. The main crossclamp was removed and cardiotomy suction was used to clear the
operative field. The ascending aorta was then resected more distally with undercutting of the proximal hemiarch such that all 3
great vessels were easily visualized. [THE AORTA WAS THEN RESECTED FURTHER TO JUST DISTAL TO TH
LEFT SUBCLAVIAN ARTERY TAKEOFF LEAVING AN ISLAND OF ARCH SURROUNDING THE GRE
VESSELS, LEAVING ALL THREE BRACHIOCEPHALIC VESSELS ATTACHED TO A SINGLE ARTER
BUTTON. CAREFULL DISSECTION WAS PERFOMED TO SPARE THE LEFT RECURRENT LARYNG
NERVE] A [XX]-mm tubular Dacron graft was brought into the operative field and trimmed accordingly. The distal
anastomosis was made between it and the hemiarch with a running 3-0 Prolene suture. This anastomosis proceeded smoothly
and was reinforced with a small amount of BioGlue circumferentially. [THE DISTAL ANASTOMOSIS WAS FIRST
CREATED BETWEEN THE ARTERIAL ISLAND AND THE GRAFT WITH A CIRCULAR RUNNING
PROLENE AFTER WHICH THE DACRON GRAFT WAS TRIMMED TO CREATE THE DESCENDING AOR
ORIFICE TO DACRON GRAFT ANASTAMOSIS WITH A RUNNING 3-0 PROLENE IN THE SAME FASH
ANASTOMOSES WERE REINFORCED WITH A SMALL AMOUNT OF BIOGLU E CIRCUMFERENTIALLY ].
The newly constructed distal anastomosis was de-aired by removal of the innominate artery clamp, ending the selective
antegrade cerebral perfusion and a crossclamp was reapplied to the more proximal Dacron graft, reestablishing full bypass
flow. The anastomosis was inspected for leaks and repair sutures with 4-0 Prolene were placed as necessary. Systemic
rewarming was begun.
Attention was turned to the proximal portion of the ascending aorta. The Dacron graft was trimmed to length for a tight fit to the
sinotubular junction of the aorta. The retrograde cardioplegia catheter was removed and the site tied down. An antegrade
cardioplegia tack/root vent was placed into the anterior midportion of the Dacron graft to which the cardioplegia line was
attached. The proximal anastomosis was then created with a 3-0 Prolene suture in the usual circumferential running fashion.
Prior to tying the suture the heart was allowed to refill for de-airing and a 500 cc dose of warm cardioplegia was delivered.
Ventricular pacing wires were placed.
The crossclamp was removed and the patient was defibrillated into normal sinus rhythm/resumed spontaneous normal sinus
rhythm. After an appropriate period of rewarming and de-airing, ventilation was begun and the patient was weaned off
cardiopulmonary bypass. Once the systemic temperature had reached 36 C, the cannulae were removed with uneventful
protamine administration. Hemostasis was obtained and confirmed at all cannulation, anastomoses, and dissection sites. A 36
Fr mediastinal chest tube was left in the mediastinum followed by a 19 Fr Blake drain in the posterior pericardium. The
sternum was closed with a total of X stainless steel wires followed by wound irrigation and closure of fascia, soft tissue, and
skin anatomically with running Vicryl sutures in layers. The skin was cleaned and sterile dressings applied. The sterile drapes
were removed and the patient was transferred to the Cardiothoracic Intensive Care Unit in critical but stable condition having
tolerated the procedure well.
At the end of the procedure all sponge, instrument and needle counts were counted twice and reported to be correct. Dr. [XX]
was scrubbed for [XX] parts of the procedure
PERFUSION DATA: Cardiopulmonary bypass time[XX] minutes with a crossclamp time of [XX] minutes and a hypothermic
circulatory arrest time with selective antegrade cerebral perfusion of [XX] minutes.
All instrument, sponge and needle counts were confirmed to be correct, twice, at the end of the operation. The patient was
Parth Amin MD and Jeffrey Schwartz MD
Loyola University Medical Center, Maywood, IL

1. Invasive monitoring and general anesthesia
2. Right femoral arterial line
3. TEE to evaluate for aortic regurgitation
4. Right axillary exposure
5. Heparinization for axillary conduit/graft
6. Sternotomy
7. Atrial pursestring
8. Initiate cardiopulmonary bypass
9. Begin cooling
10. SVC pursestring for retrograde cerebral perfusion
11. Right superior pulmonary venous vent
12. Cross clamp (if associated procedures)
13. Administration of antegrade [possible retrograde] cardioplegia
14. Trendelenberg position
15. Snare cerebral vessels
16. Excise aneurysm
17. Create island [possible separate grafts]
18. Wean patient from cardiopulmonary bypass when cooled
19. Invaginate graft 5-10 cm
20. Sew distal anastomosis
21. Cannulate graft after de-airing
22. Resume lower body flow/bypass
23. Sew island to graft
24. De-air and resume full cardiopulmonary bypass flow
25. Re-warm
26. Sew proximal anastomosis
27. De-air
28. Wean off cardiopulmonary bypass
29. Pacer wires
30. Chest and mediastinal tubes
31. Hemostasis
32. Close sternotomy and axillary cannulation site

1. Sternotomy/wound problems
2. Cooling/rewarming too rapidly
3. Inadequate de-airing
4. Prolonged circulatory arrest time
5. Incomplete occlusion of the SVC with tourniquet
6. Inadequate length of elephant trunk
7. Bleeding
Template Dictation
Preoperative Diagnosis: Arch and descending aortic aneurysm
Assistants: [BLANK]
Anesthesia: [BLANK]
Circulatory Arrest Time: [Minutes]
Products: [FFP/Platelets/PRBCs]
Indication(s) for Procedure:[AGE] year old [GENDER] with a past history of [dissection, aneurysm], who presents with
an arch and descending thoracic aneurysm with maximal diameter [cm]. Given the risk of rupture, and the risk and benefit
profile, repair was discussed. Concomitant [coronary artery disease and/or valvular pathology was/was not] noted on
cardiac catheterization and preoperative echocardiography.
Description of Procedure: The patient was brought to the operating room, positioned in a supine manner, and underwent
induction of general anesthesia. Pulmonary artery catheter, radial and femoral arterial lines, adequate intravenous access, and
foley catheter were placed. The patient was then prepped and draped in a sterile fashion. A right infraclavicular incision was
made, deepened through pectoralis fascia, and the axillary vein exposed. The vein was then dissected circumferentially and
retracted such that the axillary artery was exposed and circumferentially controlled. 100 units/kg heparin was then systemically
administered. The axillary artery was clamped, an arteriotomy made, and a standard 5-0 Prolene continuous anastomosis was
fashioned in an end-to-side manner to an 8 mm Dacron graft. The graft was then clamped after flushing and de-airing. The
anesthesiologist then confirmed [no aortic insufficiency] with transesophageal echocardiography.
A median sternotomy was performed extending from below the sternal notch to the tip of the xiphoid process. A pursestring
was then placed at the right atrial appendage. The innominate, left common carotid artery, and left subclavian arteries were
then circumferentially dissected and controlled. The remainder of the total dose heparin was then administered directly into the
right atrium. The ACT was then maintained at greater than 450 seconds. The right axillary conduit was then cannulated and de-
aired. A dual-staged venous cannula was inserted into the right atrium and directed to the inferior vena cava. Cardiopulmonary
bypass was initiated with concomitant cooling to 18 degrees centigrade. A right superior pulmonary vent was then placed
through a 4-0 prolene pursestring suture. A 4-0 Prolene pursestring was then placed in the superior vena cava for retrograde
cerebral perfusion. The SVC was encircled with an umbilical tape. An antegrade cardioplegia suture was also placed in the
ascending aorta.
If additional procedures or ventricular distension. Upon fibrillation of the heart, the ascending aorta was cross-clamped just
proximal to the innominate artery. Ice was placed upon the heart and 1200 cc of cold blood cardioplegia was administered. [If
aortic valve or significant coronary disease pathology present, describe procedure during cooling].
After approximately 45 minutes of cooling, the patient was placed in steep Trendelenburg position. Cardiopulmonary bypass
was weaned and the patient separated from cardiopulmonary bypass. The ascending aorta and aortic arch were then excised,
leaving an island for the cerebral and upper extremity vessels. The aorta was then transected just beyond the left subclavian
artery. [In the case of a previous dissection, describe dissection flap fenestration into the descending thoracic aorta.] The
innominate and left common carotid artery were then snared, and antegrade cerebral perfusion initiated at a rate of 10
cc/kg/min.
A [size mm] Dacron graft was then invaginated and delivered into the descending thoracic aorta in order to create an elephant
trunk. The distal portion of the elephant trunk was approximately 5-10 cm in length and marked with multiple metal clips. The
distal anastomosis was then fashioned with a running 3-0 Prolene suture with felt reinforcement. The left vagus nerve and
esophagus were protected during dissection. The graft was then withdrawn from inside the outer and cut to length. The graft
was then filled with saline irrigation and after adequate de-airing, the graft was cannulated and flow resumed to the lower
body. Antegrade cardioplegia was then delivered directly into the coronary ostia. A circumferential patch was cut from the
Dacron graft which corresponded to the cerebral and upper extremity vessel island. A 3-0 Prolene continuous anastomosis was
then performed. The tourniquets were released from the innominate, left common carotid, and the left subclavian artery as the
axillary. The graft was de-aired, clamped proximal to the takeoff of the innominate artery, and warming instituted. Total
circulatory arrest time was [minutes].
The proximal anastomosis was performed using 3-0 prolene suture with Teflon strips. Warm antegrade cardioplegia was then
given and the cross-clamp released. After 50 minutes of re-warming, ventricular pacing wires were placed, and mediastinal
and pleural tubes were placed and secured to the skin. Cardiopulmonary bypass was weaned and the venous pursestring
secured. The axillary conduit was tied off with a large silk suture. Hemostasis was obtained. The right axillary incision was
closed with multiple layers of absorbable suture. The pericardium was re-approximated and the sternotomy was closed with
alternating single and double sternal wires. The fascial closure was performed with absorbable suture, as was the dermal, and
subcuticular layer. Sterile dressings were placed on the wounds. The patient was then taken to ICU in stable condition having
tolerating the procedure well.
Parth Amin MD and Jeffrey Schwartz MD

1. Appropriate invasive monitoring
2. Spinal drain
3. Right lateral decubitus positioning with hips supine
4. Left femoral arterial and venous access
5. Confirm lines by transesophageal echocardiography
6. Thoracoabdominal exposure
7. Divide diaphragm radially
9. Clamp proximal descending aorta
10. Open aorta
11. Identify elephant trunk
12. Clamp elephant trunk
13. Perform anastomosis with new graft
14. Determine extent of aneurysm
15. Maintain femoral flows greater than 60 mmHg
16. Maintain systemic perfusion greater than 70-80 mmHg
17. Open aorta and identify visceral vessels
18. Maintain cold blood cardioplegia at 10 cc/kg/min to each visceral segment
19. Create beveled anastomosis for visceral segment
20. Sew distal anastomosis onto visceral segment
21. Perform left renal anastomosis
22. Wean off cardiopulmonary bypass
23. Reverse anticoagulation
24. Obtain hemostasis.
25. Close femoral exposure
26. Re-approximate diaphragm
27. Place chest tubes and peri-aortic drain
28. Close thoracoabdominal incision

1. Renal failure
2. Mesenteric ischemia
3. Spinal ischemia/paraplegia
4. Disruption of proximal Elephant trunk anastomosis
5. Bleeding
6. Lower extremity ischemia
Template Dictation
Preoperative Diagnosis: Arch and descending aortic aneurysm
Assistants: [BLANK]
Anesthesia: [BLANK]
Circulatory Arrest Time: [Minutes]
Indication(s) for Procedure: [AGE] year old [GENDER] with aortic arch aneurysm extending to the distal descending
thoracic aorta. The first operation was performed to repair the ascending and aortic arch. The patient now presents to complete
the repair of the aneurysm.
Description of Procedure: The patient was brought to the operating room and positioned in a supine manner. After induction
of general anesthesia, a right femoral arterial line, and right radial arterial line were placed. Spinal drain was then placed.
Right internal jugular approach was then used for placement of pulmonary artery catheter. After exchange to a double lumen
tube, bronchoscopy was performed to assure appropriate positioning. A transesophageal echo probe was then inserted. The
patient was then positioned in a right lateral decubitus position with access to the left groin. The patient was then prepped and
draped in a sterile manner.
An oblique left groin incision was made for femoral arterial and venous exposure. The femoral vein and artery were
circumferentially dissected and controlled. Concentric 5-0 Prolene pursestring sutures were placed in both vessels. A
thoracoabdominal incision was made extending through the left chest in the 7th intercostals space, across the costal margin, and
ending midway between the anterosuperior iliac spine and umbilicus. The diaphragm was divided radially, with a 2-3
centimeters left off the chest wall. The retroperitoneum was dissected free and the left common iliac was encircled. The left
renal artery was identified and encircled.
A counter incision was made in the 4th intercostal space and the aorta dissected free of the surrounding tissue. The proximal
descending thoracic aorta was encircled. The patient was then given 300 units/kg of heparin with repeat assessment throughout
the procedure to maintain ACT greater than 450 seconds. The femoral artery and vein were then cannulated using Seldinger
technique and echocardiographic confirmation of venous line in the right atrium. Cardiopulmonary bypass was then initiated
with cooling to 32 degrees Centigrade.
A clamp was placed on the proximal descending aorta and another clamp placed just above the visceral segment. The proximal
descending aorta was opened and the previously placed elephant trunk/Dacron graft identified. The graft was clamped.
Intercostals were identified and oversewn with 3-0 Prolene suture. A [size mm] Dacron graft with 10 mm sidearm was then
sewn to the previously placed graft an end-to-end, 4-0 Prolene, standard continuous anastomosis. The proximal clamp was then
moved down to the distal graft to assess the hemostasis of the anastomosis. Once hemostasis was assured, the femoral flow
was decreased and the aorta was then opened its entire length. Below the visceral segment, the aorta was normal. Pruitt
catheters were placed in the right renal, celiac, SMA, and left renal. The distal aorta was clamped and flow was then resumed
to maintain femoral arterial pressures in excess of 60 mm Hg, with systemic pressure greater than 80 mmHg. Cold blood at 20
degrees Centigrade was administered to each visceral at a rate of 200 cc/branch vessel/minute.
An side-to-side anastomosis was then performed to the visceral segment with a 3-0 Prolene standard continuous fashion. The
graft was de-aired through the side-arm. After completing the suture line, clamp was released and the viscera were reperfused.
The side arm of the Dacron graft was then anastomosed to the left renal with running 6-0 Prolene suture. At this point, the distal
graft was cut to length and anastomosed to the aortic bifurcation.
Cardiopulmonary bypass was then weaned off. Arterial and venous cannula were removed and the femoral pursestrings
secured. Protamine reversal was given. Hemostasis was excellent. The aneurysm sac was then reapproximated over the graft.
A right angle and straight chest tube were positioned and secured to the skin. A Blake drain was left around the aneurysm itself.
The diaphragm was re-approximated using large PDS sure. The ribs were then reapproximated using large Vicryl sutures. The
fascia, dermis, and subcuticiular skin layer were then closed with absorbable suture. Sterile dressing was placed on the
wound. The patient tolerated the procedure well and was transferred to ICU in stable condition.
6. Endovascular Management of Acute Type B Dissection
Parth Amin, MD1, and Joss Fernandez, MD2
1
2
Missouri Heart Center, Columbia, MO

1. Invasive arterial pressure monitoring
2. Spinal drain placement
3. Femoral arterial exposure
4. Contralateral percutaneous femoral access
5. Intravascular Ultrasound (IVUS)
6. True lumen sheath placement
7. Wire access into true lumen
8. Confirmation of true lumen wire access with IVUS
9. Ultrasound evaluation of mesenteric arteries
10. Ultrasound evaluation of renal arteries
11. Delivery device for thoracic graft into true lumen
12. Fluoroscopic confirmation of perfusion to all vessels

1. Access site complications
2. Stenting of false lumen
3. Persistent Malperfusion of Viscera
4. Lower extremity ischemia
5. Renal failure
6. Mesenteric ischemia
7. Paralysis
8. Cerebrovascular Accident
Template Dictation
Preoperative Diagnosis: Acute Type B Dissection with Malperfusion
Assistants: [BLANK]
Anesthesia: [BLANK]
Contrast: [mL Type of contrast]
Indication(s) for Procedure: Patient is a [age /gender] with an acute Type B dissection. Despite medical management, the
patient was found to have arterial malperfusion to the kidneys, intestine, and/or lower extremity. As a result of the
malperfusion, urgent intervention was indicated. The goal of endovascular vascular management of acute type B dissections
was to decompression the false lumen, re-pressurize the true lumen and assure perfusion of visceral vessels whether through
individual vessel stenting from true lumen to branch or fenestration of the obstructing intimal flap. Discussion included open
and endovascular fenestration, thoracic stent graft placement, and bypass. The risk/benefit profile favored endovascular stent
placement.
Description of procedure: The patient was brought to the operating room, positioned in a supine manner, and had left radial
arterial line and large bore venous access placed. The patient’s right arm, abdomen and groins were then prepped and draped
in a sterile manner. The preoperative CT scan revealed that the [right/left] femoral artery was perfused by the true lumen. A
right femoral cut down was performed using a transverse incision 1 cm below the inguinal ligament. The femoral artery was
circumferentially dissected and controlled. Systemic heparin 100 units/kg was then administered. A Micropuncture system was
used for femoral access, and exchanged for a 9 French sheath. Contralateral percutaneous femoral access was then obtained
with a micropuncture system. An 0.035 inch guidewire and pigtail catheter were taken to the aortic arch from this approach.
If femoral access vessels too small for delivery device: A transverse incision was made in between the anterior superior iliac
spine and the umbilicus. The anterior fascia was incised, the muscle split, and the retroperitoneal plane entered. The iliac
bifurcation was identified, circumferentially dissected, and controlled. After adequate heparinization, the iliac artery was
clamped, an arteriotomy made, and a standard 6-0 prolene running anastomosis performed to an 10 mm Dacron graft.
An 0.035 inch Glidewire was then advanced to the arch of the aorta under fluoroscopic guidance. An intravascular ultrasound
was then used to confirm location of the wire in the true lumen. The left renal vein was used as a landmark to identify the
celiac artery, the superior mesenteric artery, and the right and left renal arteries. The following vessels were fed by the true
lumen [mesenterics, renals, lower extremity]. Malperfusion to the [mesenterics, renals, lower extremity] was noted on
IVUS. Pressure measurements were also taken in the true lumen using a standard 5F catheter.
If difficulty in assessing true lumen: Right brachial access was performed using a micropuncture system and exchange
performed to a 5 French sheath. A 300 cm angled 035 inch Glidewire was advanced from the right arm into the aortic arch. A
snare was then brought from the femoral approach and used to bring the right arm wire to the [right/left] femoral artery. An
IVUS was then used to confirm the wire location in the true lumen].
Measurements of the diameter and length of the thoracic stent graft were taken from the preoperative CT scan. The diameter
was oversized by < 10% of the approximate normal native aortic diameter. Based on IVUS localization the intimal defects or
fenestrations were marked. The proximal and distal landing zones were then marked at minimum 2 cm proximal and distally.
After the access wire was exchanged for a stiffer wire, the delivery device was taken to the descending thoracic aorta.
The blood pressure was brought down to a systolic pressure in the 100-110 mmHg range. After a breath hold, the thoracic stent
graft was deployed. The pigtail catheter was taken to the aortic arch and then another angiogram was taken. The graft was
deployed in the appropriate position. Significant reduction in perfusion of the false lumen was noted. Additional angiographic
views of the mesenteric, renals, and iliac vessels were undertaken. Contrast was noted to fill in an antegrade fashion, with no
delay, in all the vessels noted.
If individual branch vessel malperfusion is still present: Wire access was then obtained into the [mesenteric, renal] artery
with malperfusion. A Guidecath system was then used to access the orifice of the vessel. Once in the vessel, the system was
exchanged to an 0.014 platform. An angiogram was performed and sizing determined. A balloon expandable stent was then
deployed from the true lumen into the branch vessel. Repeat angiogram showed perfusion of the stented artery.
If the true lumen of the visceral aorta is still compressed compromising multiple branch vessels: Endovascular fenestration is
performed. IVUS is introduced into the right femoral access where the wire has been confirmed to be in the true lumen. After a
wire was placed across a more proximal fenestration, a snare was brought to capture the wire from below. The snared wire
was then pulled down, causing a tear in the intimal flap. Once the fenestration was created, IVUS was repeated to confirm
fenestration and branch vessel patency.
The wires and catheters were removed. The arterial exposure was closed with a running 5-0 prolene suture. The wound was
then closed in multiple layers. The distal pulses were evaluated and were [palpable/dopplerable]. The patient was taken to
ICU in stable condition, having tolerated the procedure well.
7. Aortic Valve Replacement for Aortic Insufficiency or Aortic Stenosis
Amy Fiedler, MD, and Frederick Y. Chen, MD, Ph.D
Brigham and Women’s Hospital, Boston MA

5. Open pericardium, pericardial well, survey ascending aorta cannulation and clamp sites for plaque burden with epi
aortic ultrasound
6. Systemic heparanization (400 u/kg)
7. Check ACT
10. Myocardial protection cannula placement (antegrade and/or retrograde cardioplegia)
11. Initiate CPB
12. Aortic cross clamp
13. Arrest heart with antegrade cardioplegia (1200 mL) and topical cooling for cardiac arrest (+/- retrograde
cardioplegia)
14. Place LV vent
15. Aortotomy
16. Excise valve and debride calcium from annulus
17. Irrigate and inspect LVOT, anterior leaflets of mitral valve for debris.
18. Size valve
19. Seat and tie valve in place Close ascending aorta in layers
20. Initial De-airing
23. Arterial and ventricular pacer wire placement and pace heart
24. Complete de-airing
25. Wean from CPB
26. Protamine administration for heparin reversal (test dose first)
27. Aortic and Venous decannulation

1. Stay midline during sternotomy
2. Avoid injury to innominate vein while making pericardial well
3. Gentle tissue handling important to avoid
4. cannulation complications such as aortic dissection/bleeding, right atrial tear
5. Avoid areas of calcification for cannulation and clamp site leading to stroke
6. Insufficient myocardial protection and cardiac arrest (cross clamp not across, aortic insufficiency, insufficient venous
drainage)
7. Coronary sinus injury with retrograde cardioplegia cannulation
8. Inadequate decalcification leading to paravalvular leak
9. Undersizing of the valve leading to patient/prosthetic mismatch.
10. Oversizing of the valve leading to coronary artery compromise
11. Poor strut placement obstructing the coronary artery ostia.
12. Improper deairing prior to removal of aortic root vent
13. Inadequate control of hemostasis prior to sternal closure/bleeding from cannulation sites
Template Dictation
Preoperative Diagnosis: Severe, symptomatic aortic stenosis, aortic insufficiency, acute on chronic systolic heart failure
Procedure(s) Performed: Aortic valve replacement (specify valve type, specify technique i.e: supra-annular technique)
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION]history of [COMPLAINT- i.e: increasing
shortness of breath, dyspnea on exertion, chest pain]. Pre-operative echocardiography reveals [FINDINGS].
Description of Procedure: The patient was taken to the Operating Theatre on [DATE]. The patient’s identity and planned
procedure verified, and the patient was placed on the operating room table in supine position. General anesthesia was
obtained and invasive hemodynamic monitoring lines were placed. A trans-esophageal echocardiogram was then performed to
evaluate cardiac and valve function. We then prepped and draped the chest, abdomen, groins, and lower extremities in the
standard sterile fashion. A time out was performed, with patient and procedure again verified. Median sternotomy was
performed and a pericardial cradle was hung. We then adequately heparinized the patient and cannulated the ascending aorta
in an area free of calcification and cannulated the right atrium as well. Antegrade cardioplegia cannula was placed. We then
went on cardiopulmonary bypass with an ACT greater than 450 and delivered cold antegrade cardioplegia directly into the
root after crossclamping the aorta. The heart went into a quick diastolic arrest. An LV vent was placed. Aortotomy was
performed and the valve visualized. The calcified aortic valve was removed and passed off the table as specimen.
Calcification at the level of the annulus was carefully debrided. The annulus, LVOT, and anterior leaflets of the mitral valve
were then copiously irrigated to remove any extra particulate debris. The valve annulus was measured. It would comfortably
accommodate a [INSERT VALVE TYPE AND SIZE HERE] appropriately and using horizontal mattress pledgeted sutures,
secured it in place via the supra-annular technique. We then performed aggressive de-airing maneuvers and closed the
ascending aorta in two layers with 4-0 Prolene suture. We placed the patient in Trendelenburg position and removed the aortic
cross clamp with the aortic vent on high. We placed atrial and ventricular pacing wires and began pacing appropriately and
subsequently separated from CPB without difficulty after final de airing. We removed the venous cannula and inspected the
valve grossly and found it to be free of paravalvular leak with appropriate gradients. We then gave protamine. After half the
dose of protamine was administered, the aortic cannula were removed. All cannulation sites were further reinforced with
additional suture. We closed the thymic tissues over the ascending aorta. [NUMBER OF]mediastinal drains were then
placed. The sternum was then closed with [INSERT NUMBER]sternal wires. The fascia was closed with #1 PDS in a
running fashion. The deep dermal layer was then closed with #2-0 Vicryl suture in running fashion. The skin and subcuticular
layer was closed with #3-0 Monocryl in a running fashion. The skin was then cleansed with sterile saline and dressed with an
antibiotic ointment and a Primapore dressing.
All instrument, sponge, and needle counts were confirmed to be correct x 2 at the end of the surgical procedure. The patient
was subsequently transferred to the postoperative cardiac surgical intensive care unit in critical condition.
8. Aortic Valve Replacement with Aortic Root Enlargement
Sandeep Sainathan, MD, and David D. Yuh MD
Yale University, New Haven, CT.

1. Informed consent
2. Large bore IV insertion and general endotracheal anesthesia. Watch for ventricular fibrillation on induction
3. Intraoperative monitoring line insertion (arterial line and pulmonary artery catheter) and Foley catheter insertion
4. Intraoperative transesophageal echocardiogram. Confirm valvular morphology, gradients, valve area, annular
dimensions, assess left ventricular dimension, and function.
6. Open pericardium, pericardial stay sutures
7. Survey ascending aorta for plaque burden either with palpation or epiaortic ultrasound. Mobilize the ascending aorta
from the main pulmonary artery.
8. Systemic heparinization (400 u/kg)
10. Venous cannulation with a two stage venous cannula inserted via the right atrial appendage
11. Antegrade aortic cannula insertion and +/- retrograde coronary sinus cannula
12. Check ACT (>400 sec)
13. Initiate CPB, cool to 32 degrees centigrade
14. LV vent via the RSPV
15. Aortic cross clamp (reduce CPB flow rate, apply cross clamp, and increase CPB flow to 2.0-2.5L/min/m2)
16. Antegrade cardioplegia and topical cooling with cold saline for cardiac arrest (+/-Retrograde cardioplegia)
17. Asses for adequacy of antegrade cardioplegia by adequate distension of the aortic root with rapid myocardial arrest
and lack of left ventricular distention. If there is significant AI, can use either direct administration of the
cardioplegia after aortotomy via ostial cannula or use retrograde cardiologic arrest. However, the adequacy of right
ventricular protection needs to be confirmed after performing an aortotomy and observing good retrograde flow from
the right coronary ostia. If poor, supplement with antegrade ostial injection
18. Saturate the field with CO2 gas
19. Aortotomy in oblique manner starting 10-20 mm above the right coronary artery. Excise aortic valve leaflets.
Debride and size the annulus. Calculate the EOA (Effective Orifice Area) for the prosthetic valve indexed to the
body surface area with chart provided by the manufacture. A value less than 0.85 cm2/m2 can lead to a patient-
prosthesis mismatch and a value below 0.65 cm2/m2 represents severe patient-prosthesis mismatch. A value
between 0.85 to 0.65 cm2/m2 may be acceptable in a sedentary high-risk patient with significant annular
calcification, as compared to the risk from a more extensive aortic root enlargement procedure
20. Option to deal with a small aortic annulus include: Use a valve one size up than measured size by placing the valve
with canted up in the non-coronary sinus, use of a Medtronic Freestyle valve, aortic annular enlargement, aortic root
replacement, and left ventricle apical to descending aortic conduit. In adults, annular enlargements are made
posteriorly (Nicks and Manougian’s techniques), in the fibrous part of the aortic annulus in the region of the aortic –
mitral valve continuity. In children, annular enlargements are generally made anteriorly (Konno), in the muscular part
of the aortic annulus as generally there is an associated subannular obstructive component.
21. Once a decision is made to perform an aortic annular enlargement, carry the oblique aortotomy towards the middle of
the non-coronary sinus (Nick’s method). This provides an annular enlargement to accommodate a valve one size
larger than originally sized. When the aortotomy is carried down the commissure between the non-coronary and left
coronary cusp into the anterior mitral leaflet (Manougian’s method), a much larger annular enlargement to
accommodate a prosthesis two sizes larger than originally sized can be obtained. The Konno, which is a method used
predominantly in children provides the maximum enlargement but with more technical complexity. Each of the
resultant defects is repaired with native pericardium, bovine pericardium or Dacron graft. Care needs to be taken to
repair the roof of the left atrium in Manougian’s method.
22. Valve replacement and closure of the aortotomy after deairing the aorta.
23. Antegrade warm blood cardioplegia “hot shot” administration for rewarming
24. Remove aortic cross clamp with continued deairing of the left heart.
26. Arterial and ventricular pacer wire placement
28. Wean from CPB
29. Venous decannulation
31. Aortic decannulation

1. Ventricular fibrillation on induction of general anesthesia in AS
2. Inability to arrest a hypertrophied left ventricle with significant AI with antegrade cardioplegia. Use ostial antegrade
injection or a retrograde coronary sinus injection.
3. Avoid fracturing a plaque during aortic cross clamping. If not able to avoid the plaque, avoid application of the cross
clamp perpendicular to the plaque to prevent a fracture.
4. Injury to the pulmonary artery during aortotomy due to inadequate mobilization of the ascending aorta from it.
5. Injuring the right and left coronary ostia during aortotomy, due to either a low incision or abnormally located high
ostial position.
6. Aggressive annular debridement resulting in annular disruption, injury to AV nodal conduction tissue, and injury to the
anterior leaflet of the mitral valve.
7. Injury to the left atrial dome during annular enlargement.
8. Injury to anterior mitral subvalvar apparatus and extensive enlargement of the anterior mitral intertrigonal area
causing mitral insufficiency.
9. Poorly controllable hemorrhage from the posterior annular area or left atrial dome after removal of the cross clamp
with poor access.
10. Insufficient aortic wall to securely close an aortomy due to extension of the aortomy less than 10 mm from the
annulus.
11. Narrow sino-tubular junction preventing adequate closure of the aortotomy around the stent posts of the bioprosthetic
aortic valve.
13. Inadequate control of hemostasis prior to sternal closure/ bleeding from cannulation sites and aortic suture line.
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. severe aortic stenosis, aortic regurgitation]
Procedure(s) Performed: Aortic valve replacement (bioprosthetic/mechanical) with root enlargement
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT –E.g. shortness of
breath, syncope, chest pain]. Preoperative echocardiography revealed
Operative Findings: [- e.g. AS – Trileaflet/bileaflet aortic valve with an area of 0.8 cm2 with a mean gradient of 40 mm Hg
with an annulus size of 19 mm and preserved LV function. Preoperative coronary angiography revealed no significant
obstructive disease. AR- Trileaflet/bileaflet aortic valve with a central regurgitation jet, vena contracta of > 6mm with a
regurgitant volume > 50%, annulus size of 19 mm, and preserved LV function.]
administered via an endotracheal tube. A right internal jugular central venous line, pulmonary artery catheter, radial arterial
lines were inserted, and a urinary catheter was placed.
Preoperative transesophageal echocardiogram was then performed to evaluate cardiac and valvular function. It confirmed the
preoperative transthoracic findings. We then proceeded to prep and drape the chest, abdomen, groins, and lower extremities in
sterile fashion. A time out was performed.
Median sternotomy was then performed. After identification of the innominate vein, the pericardium was opened. There were
no pericardial adhesions and pericardial stay sutures were placed. The ascending aorta was mobilized from the main
pulmonary artery. The ascending aorta was measured at the root and the sinotubular junction and was [cms]. In addition, there
was no palpable calcification in the ascending aorta. The aortic cannulation sutures were then placed in the ascending aorta
below the level of the innominate artery. The right atrial cannulation sutures were then placed within the right atrial appendage.
A total of [UNITS] of systemic heparin was administered. The aortic cannula was then inserted, secured and de-aired. A two-
stage venous cannula was then placed and secured in the right atrial appendage. A DLP (dual lumen aortic root cannula with
vent) cannula was then inserted into the ascending aorta for administration of antegrade cardioplegia. A retrograde cannula
was placed in the coronary sinus through a pursestring suture placed in the low right atrium.
Cardiopulmonary bypass was initiated and the patient was cooled to 32 degrees centigrade. A left ventricular vent was placed
via the right superior pulmonary vein. The aortic cross-clamp was placed. Antegrade cardioplegia was administered and there
was rapid arrest of the heart followed by administration of retrograde cardioplegia. Cooled saline was applied to the heart. (In
case of AI/ AS with associated AI, after application of the aortic cross clamp, an ascending aortotomy was performed and
antegrade cardioplegia was directly administered via the coronary ostia via ostial cannulas).The operative field was saturated
with CO2 gas.
After administering [BLANK] mL of cardioplegia, an aortotomy was made 10-20 mm above the right coronary artery and
extended in an oblique fashion towards the non-coronary cusp. The aortic valve was inspected. It was tricuspid/bicuspid with
severe calcification of the leaflets with/without commissural fusion. The leaflets were excised keeping as close as possible to
the annulus. Following this, the left ventricular outflow tract was packed with a gauze and the annulus gently debrided of
calcifications. The debris was carefully collected via an open ended sucker. Following this, the left ventricular outflow tract
pack was removed and thorough cold saline irrigation was delivered into the aortic root and left ventricular cavity to wash out
any missed debris. The annulus was sized. The annulus was sized to 19 mm with an effective orifice area indexed to the
patient’s body surface area at less than 0.85 cm2/m2. Hence, a decision was made to enlarge the aortic annulus.
1. Nicks method: The oblique aortotomy was carried through the middle of the non-coronary sinus up to the
base of the anterior mitral leaflet. With this incision, we were able to size the annulus up to 21 mm with the effective
orifice area indexed to the body surface area of the patient now greater than 0.85 cm2/m2. The resultant defect in the
sinus was repaired using a 5mm wide Dacron graft with running 4/0 polpropylene sutures. Following this, non-
everting 2/0, polyester pledgeted annular sutures were placed in an interrupted fashion around the aortic annulus. In
the area of the repair, in the non-coronary sinus, the plegeted sutures were placed from outside the aortic wall
incorporating the Dacron graft. Following this, the annular sutures were passed through the sewing ring of the aortic
prosthesis. The aortic prosthetic was gently lowered to sit upon the aortic annulus and the sutures were tied and cut.
The right and left coronary ostia were inspected for adequate clearance from the prosthesis. The sinotubular junction
was of an adequate size to accommodate the stent posts of the prosthesis and hence the Dacron graft was trimmed
accordingly. (In case the sino-tubular junction is constrictive around the stent posts, the patch can be incorporated in
the aortomy closure at this level in order to enlarge it). The aortotomy was closed with 4/0 polypropylene sutures in
2 layers, with the first deeper layer comprised of a continuous suture in a horizontal mattress fashion and the second
superficial layer in a simple running fashion. Before tying the suture, the aorta and left heart were deaired through the
aortotomy.
2. Manougian method: The oblique aortotomy was carried through the commissure between the left and non-
coronary cusp onto the anterior leaflet of the mitral valve after opening the adjoining roof of the left atrium. The
resultant defect was repaired using a 5mm wide Dacron patch starting at the apex of the anterior mitral leaflet
incision with 5/0 polypropylene suture. Care was taken to incorporate the roof of the left atrium into the patch repair.
Following this, non-everting 2/0 polyester plegeted annular sutures were placed in an interrupted fashion. In the area
of the repair, the pledgeted sutures were placed from outside the aortic wall incorporating the Dacron graft.
Following this, the annular sutures were passed through the sewing ring of the aortic prosthesis. The aortic prosthetic
was gently lowered to sit upon the aortic annulus and the sutures were tied and cut. The right and left coronary ostia
were inspected for adequate clearance from the prosthesis. The sinotubular junction was of an adequate size to
accommodate the stent post of the prosthesis and hence the Dacron graft was trimmed accordingly. The aortotomy
was closed with 4/0 polypropylene sutures in 2 layers, with the first deeper layer comprised of a continuous suture in
a horizontal mattress fashion and the second superficial layer in a simple running fashion. Before tying the suture, the
aorta and left heart were deaired through the aortotomy.
A hot shot of cardioplegia was administered and the patient was rewarmed. The aortic cross-clamp was then removed. The
retrograde cardioplegia cannula was removed. Two chest tubes were placed in the mediastinum. Temporary atrial and
ventricular pacing wires were then inserted and tested for appropriate capture. The heart was de-aired, and the DLP vent and
LV vent were removed. The patient was weaned from cardiopulmonary bypass. TEE showed a well-seated valve with no
paravalvular leaks, mean gradient [NUMBER], and normal movement of the anterior leaflet of the mitral valve.
The venous cannula was removed, and the cannulation sutures were tied down. A test dose of protamine was administered and
the patient was monitored for adverse reaction before the protamine was resumed. The aortic cannula was then removed, and
the cannulation sutures tied down.
Adequate hemostasis was then confirmed within the mediastinum. All instrument, sponge and needle counts were confirmed to
be correct x 2.The sternum was then closed with a total of [NUMBER] stainless steel sternal wires. There was no change in
the hemodynamics after sternal closure. The wound was irrigated with antibiotic solution. The presternal fascia was then
closed with 0-0 Polyglactin suture in a running fashion. The deep dermal layer was then closed with 2- 0 Polyglactin suture in
a running fashion. The skin and subcuticular layer was closed with 4-0 Polyglactin suture in a running fashion. Sterile
occlusive dressing was applied to the skin incision. The mediastinal drains were connected to an underwater seal on
suction.The patient was subsequently transferred to the postoperative cardiac surgical intensive care unit.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this operation.
9. Biatrial Cox-Maze Ablation for Atrial Fibrillation
Mark J. Kearns, MD and Jamil Bashir, MD
Division of Cardiovascular Surgery, St. Paul’s Hospital
University of British Columbia Vancouver, BC, Canada

1. Right pulmonary veins bluntly dissected
2. Bipolar radiofrequency clamp device inserted around right pulmonary veins and ablation performed
3. Left pulmonary veins bluntly dissected
4. Clamp device used to ablate left pulmonary veins
5. Small incision at base of right atrial appendage
6. Clamp device used for ablation from atrial incision to superior cavoatrial junction along the atrial free wall
7. Vertical right atriotomy
8. Clamp device for ablation lines from posterior aspect of vertical atriotomy extending along superior and inferior vena
cavae, respectively
9. Cryoablation probe inserted through first (small) atrial incision, to create ablation line connecting the incision to the
tricuspid annulus (above the septal leaflet)
10. Cryoablation probe again used to connect anterior aspect of vertical atriotomy to tricuspid annulus (above the antero-
posterior commissure)
11. Left atrial appendage amputation
12. Clamp device to ablate between amputation site and left superior pulmonary vein
13. Standard left atrial incision
14. Clamp device to create adjoining ablation lines between superior and inferior pulmonary veins, respectively
15. Clamp device oriented from inferior aspect of left atriotomy towards mitral annulus around P2; ablation performed at
this site
16. Cryoablation probe used to extend above ablation line to the mitral annulus, both endocardially, and epicardially
(crossing the coronary sinus)
17. Closure of left atrial appendage amputation site

1. Friable atrial tissue, prone to injury
2. Injury to pulmonary arteries and veins
3. Inadequate hemostasis
4. Hemorrhage
5. Blood product transfusion and related adverse effects
6. Injury to conduction tissue and need for permanent pacemaker
7. Prolonged CPB and cross-clamp times
8. Failure to achieve lesion transmurality
9. Procedural failure
Template Dictation
Preoperative Diagnosis: [INDICATION—e.g. symptomatic AF, undergoing other cardiac operations; asymptomatic AF,
undergoing other cardiac operations and where the ablation can be performed with minimal additional risk.]
Procedure(s) Performed: [X] and surgical AF ablation (DETAILS—e.g. cardiac incisions, energy source(s) used, extent of
lesion sets employed, whether testing for exit block was performed, and additional CPB and cross-clamp times required for
the ablation).
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with a [DURATION] history of [COMPLAINTS—symptoms
accounted for by condition X, in addition to symptom burden associated with AF]. In addition to preoperative
investigations for condition X, include details regarding the type of AF (paroxysmal or persistent), and any past interventions
used to treat it (pharmacologic, cardioversion, electrophysiology ablation attempts).
Description of Procedure: [DETAILS of preparation for procedure X (the primary cardiac surgical indication)]. With the
arterial and bicaval cannulation sutures in place, heparin [UNITS] was administered intravenously. The patient remained in
[RHYTHM] and the absence of left atrial thrombus was confirmed by trans-esophageal echocardiography [for the patient in
AF at the time of surgery, document whether they were converted to normal sinus rhythm for the purpose of testing for exit
block]. The aorta and both cavae were cannulated in standard fashion. The superior and inferior vena cavae were freed
circumferentially, and ensnared with umbilical tapes just distal to both caval cannulation sites. Cardiopulmonary bypass was
then instituted at normothermia.
The right superior and inferior pulmonary veins were dissected circumferentially to allow the passage of a bipolar
radiofrequency clamp device [MANUFACTURER]. The jaws of the clamp were closed around both right-sided veins, and
ablation carried out as indicated by [MANUFACTURER]. The clamp was removed and cleaned with saline-soaked gauze.
Next the left superior and inferior pulmonary veins were identified and dissected circumferentially. The ablation clamp was
carefully positioned around both veins, closed and ablation was performed as previously described. [Document whether exit
block at the pulmonary veins was tested for, to ensure completeness of the ablation]. The patient was then cooled to 34
degrees Celsius, and both caval tapes were snared securely using rubber tourniquets.
A small incision was made at the base of the right atrial appendage and the clamp device was inserted. The clamp was
oriented towards the junction of the right atrium and superior vena cava, along the right atrial free wall. The clamp was closed,
and ablation carried out at this site. A vertical right atriotomy was performed approximately 2cm from the first free wall
ablation. The clamp was then used to perform two ablation lines, orthogonal to the right atriotomy incision, starting from its
base and oriented superiorly and inferiorly along both cavae, respectively. Next, a cryoablation device was inserted through
the small incision at the base of the right atrial appendage. The probe was oriented to create an endocardial line of ablation
from its entry point to the tricuspid annulus (above the septal leaflet). Following copious saline irrigation to remove the
cryoablation probe safely, it was repositioned to join the anterior aspect of the vertical right atriotomy with the tricuspid
annulus above its antero-posterior commissure. An endocardial line of ablation was created at this site, and the probe was
removed as described previously.
Cannulation sutures were placed in the aorta proximal to the arterial cannulation site, and an antegrade cardioplegia/venting
catheter was introduced and secured in place. Cardiopulmonary bypass flows were reduced, and the ascending aorta was
clamped prior to the resumption of full flow. Cold blood cardioplegia [VOLUME] was administered down the antegrade
cannula to achieve complete electro-mechanical cardiac arrest. Once arrest was achieved, the left atrial appendage was
identified and amputated. The bipolar radiofrequency clamp device was introduced through the appendectomy and oriented
towards left superior pulmonary vein. The clamp was closed and a line of ablation was created joining the left atrial
appendage base with the left superior pulmonary vein.
A standard left atrial incision was performed next, and the bipolar clamp device was used to create two adjoining ablation
lines across the superior and inferior pulmonary veins, respectively. From the inferior aspect of the left atriotomy, the clamp
device was used to create a line of ablation oriented towards the mitral annulus, in the region of the P2. A cryoablation probe
was used to fully extend this lesion down to the mitral annulus both endocardially, and epicardially, crossing the coronary
sinus. The site of left atrial appendage amputation was then closed in two layers using 5-0 prolene suture.
[DETAILS of the remainder of the cardiac operation (procedure X), including: closure of cardiac incisions, re-warming,
de-airing, weaning from cardiopulmonary bypass, heparin reversal and hemostasis, drains left in situ, atrial and
ventricular pacing wires, sternal and soft tissue closure, and details regarding patient stability and level of
pharmacologic support at the end of the case].
Instrument, sponge, and needle counts were correct. The patient was transferred to the cardiac surgical intensive care unit in
stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the case.
10. Coronary Artery Bypass Grafting with Cardiopulmonary Bypass
Damien J. LaPar, MD, MSc and Gorav Ailawadi MD
University of Virginia, Charlottesville, VA

5. Conduit choice and LIMA harvest
6. Open pericardium, pericardial well, survey ascending aorta for plaque burden (consider epiaortic ultrasound),
cannulation and proximal anastomosis sites.
10. Myocardial protection cannula placement (DLP in aortic root, +/-retrograde cannula in coronary sinus)
12. Initiate CPB
13. Aortic cross clamp (reduce CPB flow rate, apply cross clamp, increase CPB flow to 2.0-2.5L/min/m2)
14. Antegrade cardioplegia (1200 ml) and topical cooling with ice for cardiac arrest (+/- retrgrograde cardioplegia)
15. Distal anastomoses (start with right side for instillation of cardioplegia down completed vein graft for better right
heart myocardial protection).
16. Proximal anastomoses
22. Wean from CPB

3. Avoid IMA injury
4. Cannulation catastrophe (Aortic dissection/ bleeding, Right atrial tear)
5. Poor choice of location of aortic cannula/ crossclamp (leading to stroke)
drainage)
8. Difficulty finding coronary arteries, including intramyocardial vessels
9. Injury to coronary artery/ posterior wall while opening coronaries
10. Opening coronary proximal to lesion
11. Kinking of bypass grafts and/or insufficient graft length resulting in tension of graft
13. Bleeding from distal anastomoses
14. Inadequate control of hemostasis prior to sternal closure/ bleeding from cannulation sites.
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. Unstable angina, 90% stenosis LAD, 80% proximal PDA]
Procedure(s) Performed: Coronary artery bypass grafting (DETAILS – e.g. LIMA to LAD, SVG to PDA)
Assistants: [BLANK]
Anesthesia: [BLANK]
EBL: [ml]
CPB Time: [Minutes]
Aortic Cross Clamp Time: [Minutes]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT – e.g. increasingly
worse chest pain and shortness of breath]. Preoperative coronary catheterization reveals [FINDINGS -e.g. 90% stenosis of
LAD and 80% stenosis of proximal PDA with estimated ejection fraction of 50-55%].
Preoperative transesophageal echocardiogram was then performed to evaluate cardiac function and valve function. We then
proceeded to prep and drape the chest, abdomen, groins, and lower extremities in sterile fashion. A time out was performed.
Median sternotomy was then performed. Simultaneous to this, a right lower extremity endoscopic saphenous vein harvest was
performed, performed by physician's assistant. After performing the sternotomy, we then proceeded to harvest the left internal
mammary artery in a pedicled fashion. Once dissected, 5000 units of heparin were administered prior to distal division.
Hemostasis of the LIMA bed was confirmed. Following harvest of the LIMA, the IMA retractor was removed and a
sternotomy retractor placed. After identification of the innominate vein, the pericardium was opened and a pericardial well
was created. The aortic cannulation sutures were then placed in the ascending aorta below the level of the innominate artery.
The right atrial cannulation sutures were then placed within the right atrium. A total of [UNITS]of systemic heparin was
administered. The aortic cannula was then inserted, secured and de-aired. Venous cannula was then placed and secured in the
right atrium. A retrograde cannula was placed through the right atrium. A DLP vent was then inserted into the ascending aorta
for administration of antegrade cardioplegia. The aortic cross-clamp was placed. Antegrade cardioplegia was administered
and there was rapid arrest of the heart followed by retrograde cardioplegia. Ice was applied to the heart.
After administering [BLANK] mL of cardioplegia, a suitable site on the [TARGET – e.g. posterior descending coronary
artery] was located. Using a #15C blade, the artery was opened. A saphenous vein graft was trimmed, splatulated and a
running #7-0 Prolene suture was used to create an end-to-side anastomosis. Antegrade cardioplegia was then administered
through the SVG and hemostasis and flow through the graft was confirmed. A suitable site on the [TARGET – e.g. left
anterior descending coronary artery] was identified along the mid portion. Using a #15C scalpel blade, the artery artery
was opened. The LIMA was then trimmed to an appropriate length and spatulated. A bulldog was placed on the LIMA. We
then performed the distal LIMA anastomosis using running #7-0 Prolene in an end-to-side fashion. We then tested the
anastomosis by removing the bulldog clamp to confirm patency of the graft and hemostasis. An adequate length of the
[LEFT/RIGHT] sided saphenous vein graft to the PDA was then assessed by briefly filling the heart and measuring its length
to the aortic root. The vein was trimmed proximally and spatulated. The heart was then drained, and the site for proximal
anastomosis was selected. A #11 blade was used to create an aortotomy and an aortic punch was then used to enlarge the
aortotomy, and the proximal anastomosis was completed using running #6-0 Prolene.
Once the proximal anastomosis was complete, hot shot cardioplegia was administered and the patient was rewarmed. The
bulldog was removed from the LIMA. The aortic cross-clamp was then removed. A total of[NUMBER] chest tubes were
placed in the [LEFT/RIGHT] pleural space, and [ N U MB E R]chest tubes were placed in the mediastinum.
[ATRIAL/VENTRICULAR] pacing wires were then inserted and tested for appropriate capture. The heart was de-aired,
and the DLP vent was removed and cannulation sutures tied down. The patient was weaned from cardiopulmonary bypass.
The venous cannula was removed, and the cannulation sutures were tied down. A test dose of protamine was administered
and the patient was monitored for adverse reaction before the protamine was resumed. The aortic cannula was then removed,
and the cannulation sutures tied down. Adequate hemostasis was then confirmed within the mediastinum and left chest wall
LIMA harvest site. The sternum was then closed with a total of[NUMBER] stainless steel sternal wires. The wound was
irrigated with Betadine saline and antibiotic saline. The fascia was then closed with #1 Vicryl suture in running fashion. The
deep dermal layer was then closed with #2- 0 Vicryl suture in running fashion. The skin and subcuticular layer was closed
with #3-0 Monocryl in running fashion. The skin of the wound was cleansed with sterile saline and dressed with antibiotic
ointment and a Primapore dressing.
11. Coronary Artery Bypass Grafting with Mammary and Vein Grafts -
Off Pump
Uthman Aluthman, M.D, and Teresa M. Kieser, MD
Libin Cardiovascular Institute of Alberta, Division of Cardiac Surgery, University of Calgary, Calgary, Alberta, Canada

6. Open pericardium, pericardial well, survey ascending aorta for plaque burden (consider epiaortic ultrasound).
7. Systemic heparinization
8. OctoBase retractor, Trendelenberg position of OR table +/-lateral rotation of OR table to expose distal target
without hypotension; placement of posterior pericardial sutures and/or pericardial sling to position/elevate heart for
optimal exposure for distal anastomosis; Octopus tissue stabilizer to stabilize the anastomotic site, possible use of
Starfish heart positioner to aid in exposure of target site and improve hemodynamics during anastomosis completion,
possible placement of temporary atrial +/- ventricular pacing wires to stabilize rhythm and/or to counteract
bradycardia especially if performing RCA distal anastomosis, placement of proximal snare (retracto-tape) on native
coronary artery to control bleeding during performance of distal anastomosis; use of intra-coronary shunt for signs of
ischemia or for better visibility; use of blower-mister for accurate visualization during performance of distal
anastomosis.
9. Distal anastomosis (es)
10. Proximal anastomosis

3. Avoid IMA injury
4. Difficulty finding coronary arteries, including intramyocardial vessels
5. Specific to off-pump: during performance of distal anastomosis- signs of ischemia, hypotension, hemodynamic
compromise, and ventricular arrhythmia/fibrillation during performance of distal anastomosis, necessitating urgent
conversion to on-pump CABG; suboptimal bypass requiring revision/redo of bypass
6. Injury to coronary artery/ posterior wall while opening coronaries
7. Opening coronary proximal to lesion
8. Kinking of bypass grafts and/or insufficient graft length resulting in tension of graft
9. Bleeding from distal anastomoses
Template Dictation
Preoperative Diagnosis: [BLANK]
Procedure(s) Performed: Elective double coronary artery bypass grafting (CABG) off pump, left internal mammary artery
(LIMA) to left anterior descending artery (LAD), Great Saphenous Vein Graft (GSVG) to marginal artery.
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [NAME] is a [AGE]-year-old [GENDER] with [DURATION] history of [COMPLAINT].
Preoperative coronary catheterization reveals [BLANK finding]. ECHO intraoperatively [BLANK finding]
Operative Findings: The patient had reasonable LAD and marginal artery to bypass and excellent conduits of left internal
mammary artery and saphenous vein from the left lower leg. Heart function was normal without any regional wall motion
abnormalities seen on the trans-esophageal echo. She/He did have 1 unit of PRBC’s.
Description of Procedure: Under general anesthesia and endotracheal intubation, a right internal jugular central venous line,
pulmonary artery catheter and radial arterial line were inserted. Chest, groins and lower extremities was prepped and draped
in the usual sterile fashion. The chest was opened via midline sternotomy. The left internal mammary artery was taken down
via the skeletonized technique with the use of the Harmonic scalpel and the Bugge retractor. Simultaneous to this, a left lower
extremity greater saphenous vein was harvested by open technique, performed by a physician’s assistant. Once all conduits
were harvested and hemostasis maintained, 300 IU/Kg of heparin were administered achieving ACT around 400.
The Bugge retractor used to harvest the LIMA was exchanged for the Octobase retractor. The patient was placed in deep
Trendelenburg position, and with a heart sling attached to the posterior pericardium 1 cm away from the border of the left
atrium and 2/3 from the inferior vena cava and 1/3 the distance from the left inferior pulmonary vein, the heart was elevated.
The LIMA was brought through the hole in the pericardium. The Octopus tissue stabilizer was used to stabilize the site of the
LIMA to LAD anastomosis. A retracto-tape was placed on the LAD proximal to the location of the anastomosis. LIMA was
trimmed to an appropriate length and spatulated. Using a # 15 scalpel blade, LAD was opened and a 1.5 mm shunt was inserted
into the LAD. A running #7-0 Prolene suture was used to create an end-to-side anastomosis. The systolic blood pressure was
kept above 100 with 0.4 mg norepinephrine and the end-tidal CO2 was carefully monitored to avoid drops of more than 2-3
mmHg. This anastomosis was hemostatic and transit-time flow was used to check the flow, resistance (Pulsatility Index) and
diastolic filling and found to be adequate. Using the previously placed proximal snare to occlude the LAD, we tested for
competitive flow, which there was none because the LAD had a 90% stenosis. The heart was placed in the neutral position and
transit-time flows were re-measured and were found to be good.
The patient was placed deeper in the Trendelenberg position and the OR table was rotated toward the surgeon’s side; the heart
sling was repositioned so as to expose the later wall of the left ventricle. The reversed saphenous vein was gently distended to
check for leaks. The marginal artery was identified and the Octopus tissue stabilizer was used to stabilize the intended
location of the distal anastomosis. A proximal snare and intracoronary shunt was used as for the LIMA-LAD anastomosis, and
the saphenous vein to marginal artery anastomosis was performed using continuous 7.0 Prolene. The heart and patient were
then both placed in neutral position.
The proximal saphenous vein to ascending aorta anastomosis was then completed using the Heartstring device so as to avoid
any clamping of the ascending aorta. The anastomosis was performed using 6-0 Prolene and was hemostatic. Transit-time flow
was then used to measure graft flow, resistance and diastolic filling and found to be adequate.
Protamine was given to reverse the heparin. Both graft flows were checked again with transit-time flow. Blake drains were
placed in the left pleural cavity and in the anterior and posterior mediastinum. Pacing wires were placed in the surface of the
right atrium and right ventricle and tested for appropriate capture.
The sternum was closed with #5 stainless steel sternal wires x 8. The fascia was closed with #0 Ethibond, the subcutaneous
layers with #2-0 Vicryl and the skin with #3-0 Monocryl in running fashion.
All instruments, sponge and needle counts were confirmed to be correct x2 at the end of operation. The patient tolerated the
procedure well and was taken to the cardiovascular intensive care unit in stable condition on low dose Dopamine and IV
nitroglycerin.
The total OR time: [BLANK]
ECHO findings: [BLANK]
Transit time flows were as follows: LIMA to LAD: [BLANK] mL per minute/PI [BLANK]/DF [BLANK%]; with proximal
snare was [BLANK] mL per minute/PI [BLANK]/DF [BLANK%]. Post Protamine: [BLANK] (ml/min)/ PI [BLANK] /DF
[BLANK].
The SVG to Marginal artery: [BLANK] mL per minute/PI [BLANK]/DF [BLANK%]; with proximal snare was [BLANK] mL
per minute/PI [BLANK]/DF [BLANK%]. Post Protamine: [BLANK] (ml/min)/ PI [BLANK] /DF [BLANK]
12. Coronary Artery Bypass Grafting + Mitral Valve Repair VS
Replacement
Kenan W Yount MD MBA and Leora T Yarboro MD

1. Lines & monitoring (e.g., large bore central +/- pulmonary artery catheter; arterial)
2. Intraoperative transesophageal echocardiogram (i.e., assess for mechanism)
4. Conduit harvests (e.g., endoscopic saphenous vein harvest, LIMA harvest)
5. Open pericardium, pericardial well, survey ascending aorta for plaque burden (consider epiaortic ultrasound),
cannulation, proximal anastomosis sites
8. Bicaval cannulation
9. Myocardial protection and vent placement (DLP in aortic root, retrograde cannulation in coronary sinus)
10. Check ACT
11. Initiate CPB
12. Initial interatrial groove dissection
13. Aortic cross-clamp (reduce CPB flow rate, apply cross-clamp, increase CPB flow)
14. Anterograde +/- retrograde cardioplegia +/- topical cooling for cardiac arrest
15. Distal anastomoses (consider starting with right side for instillation of cardioplegia down completed vein graft for
better right myocardial protection).
16. Interatrial groove dissection and retractor (e.g., Cosgrove) insertion
17. Inspect valve for pathology and mechanism; decide on repair vs. replacement
18. Leaflet excision with chordal sparing (or valve leaflet repair/resection); careful debridement
19. Sutures through annulus and through replacement valve (or annuloplasty ring)
20. Close atriotomy +/- leave left ventricular vent
23. Remove aortic cross-clamp
25. Temporary pacing wire placement
27. Wean from CPB
29. Protamine administration for heparin reversal (test dose, first)

1. Entry
1. Midline during sternotomy
2. Innominate vein injury while making pericardial well
2. Harvest
1. LIMA injury during harvest
2. Heparinization during LIMA and saphenous harvest
3. Cannulation
1. Aortic dissection with arterial cannula insertion
2. Aortic cannulation and cross-clamp site selection (to avoid stroke)
3. Right atrial or caval tear with bicaval venous cannula insertion
4. Coronary sinus injury with retrograde cannula insertion
4. Protection
1. Inadequate myocardial protection and cardiac arrest (e.g., cross-clamp not across, aortic insufficiency,
insufficient venous drainage)
2. Ordering of bypass grafts
5. Bypass Grafting
1. Difficulty finding coronary arteries (e.g., intramyocardial segments)
2. Posterior injury during opening of coronary arteries
6. Mitral
1. Consider approach (e.g., generally interatrial, but may require transeptal if atria are not enlarged)
2. Decision to repair or replace mitral valve
3. Careful leaflet excision and annular debridement if calcified (e.g., to avoid stroke from embolization, to avoid
risk of AV dissociation)
4. Careful placement and tying of sutures (e.g., to avoid perivavular leak, to avoid injury to surrounding structures)
5. Adequate venting +/- Valsalva to de-air during atriotomy closure
7. Closure & Decannulation
1. Kinking of bypass grafts and/or insufficient graft length resulting in graft tension after completion of proximal
anastomosis
2. Avoid excessive manipulation of the heart (e.g., to prevent AV dissociation—generally why distal bypasses are
completed before mitral in addition to augmenting myocardial protection)
3. Inspecting postoperative TEE for residual regurgitation
4. Improper de-airing prior to vent removal
5. Bleeding from atriotomy site, anastomotic sites, cannulation sites
6. RIMA injury during sternal wire placement
Template Dictation
Preoperative Diagnoses: [INDICATION – e.g. severe mitral regurgitation, coronary artery disease, congestive heart failure]
Postoperative Diagnoses: Same
1. Coronary artery bypass grafting x [NUMBER], [DETAILS – e.g., LIMA to LAD, SVG to PDA
2. Mitral valve [REPAIR/REPLACEMENT] with a [NUMBER] mm [TYPE OF VALVE OR ANNULOPLASTY
RING]
3. [SIDE] endovascular vein harvest
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with a [DURATION] history of [COMPLAINT –e.g., increasing
worse chest pain and shortness of breath]. [HE/SHE] was found to have severe mitral insufficiency on a recent
echocardiogram and a preoperative coronary catheterization revealed multi-vessel coronary artery disease with [FINDINGS –
e.g., 90% stenosis of LAD and 80% stenosis of the proximal PDA with an estimated ejection fraction of 35%]. After a
discussion of the risks and benefits, the patient was consented for coronary artery bypass grafting with a mitral valve repair
versus replacement; should replacement be necessary, the patient had a stated preference of receiving a
[TISSUE/MECHANICAL] valve.
Description of the Procedure: The patient was correctly identified in the holding area and brought to the operative suite
where [HE/SHE] was placed supine on the operative table. The patient’s identity and planned procedure were verified. After
adequate induction of general anesthesia, the patient was intubated with a single-lumen endotracheal tube. A right internal
jugular central venous line with a pulmonary artery catheter was placed as well as a radial arterial line, Foley catheter, and
transesophageal echocardiogram probe. A preoperative transesophageal echocardiogram was performed to evaluate cardiac
function and valve function. The patient’s chest, abdomen, groins, and lower extremities were then prepped and draped in the
usual sterile fashion. A time-out was completed.
The physician assistant performed an endoscopic saphenous vein harvest in the right lower extremity. Concomitantly, a median
sternotomy was performed using a sternal saw. The left internal mammary artery was harvested in a pedicled fashion. Once
dissected, 5000 units of heparin were administered prior to distal division. There was excellent flow after distal division. The
LIMA was wrapped in a lidocaine soaked sponge for use at a later time. Hemostasis of the vascular bed was confirmed. The
mammary retractor was then removed and replaced with a sternal retractor.
After identification of the innominate vein, the pericardium was opened and a pericardial well was fashioned. Aortic
cannulation sutures were placed in the ascending aorta below the level of the innominate artery in preparation for arterial
cannulation. Right atrial cannulation sutures were then placed in the right atrial appendage and the right atrial-IVC junction in
preparation for bicaval venous cannulation. The patient was systemically heparinized with [UNITS] of heparin. The aortic
cannula was then inserted into the ascending aorta, de-aired, and secured. The venous cannulas were then placed through the
right atrial appendage into the SVC and through the right atrial-caval junction into the IVC. A retrograde cannula was then
placed into the coronary sinus without difficulty. A DLP vent was inserted into the ascending aorta. The patient was then
placed on cardiopulmonary bypass. Initial dissection of the interatrial groove was performed. The cross-clamp was applied;
antegrade and retrograde cardioplegia were given with immediate arrest of the heart. Cold topical solution was applied and
cardioplegia was given every 20 minutes for the remainder of the case.
The bypass began with the SVG to PDA anastomosis. The PDA was opened using a #15C scalpel. The anastomosis was
completed distally in an end-to-side fashion using a running #7-0 Prolene. Antegrade cardioplegia was then administered
through the graft, which was found to be patent and hemostatic. The proximal graft was then left free to cardioplegia. A suitable
site on the LAD was identified along its mid-portion. The LIMA graft was then trimmed to the appropriate length and clamped
with a bulldog. The anastomosis was completed in an end-to-side fashion using a running #7-0 Prolene. The bulldog clamp
was removed, and the graft was found to be patent and hemostatic.
To address the mitral valve, the interatrial groove was opened and the left atrium was entered sharply with a #15 blades
scalpel. This incision was then extended with Metzenbaum scissors. Cosgrove retractors were placed to better visualize the
mitral valve. There appeared to be normal valve leaflets but abnormal leaflet tethering in the subvalvular apparatus with
nonviable left ventricular muscle inferiorly. Consequently, the decision was made to replace rather than repair the valve, and
the anterior leaflet was excised while leaving the chordal attachments in place. The valve was then sized and a [SIZE] mm
[TYPE] [TISSUE/MECHANICAL] valve was selected. Sutures were placed through the annulus and brought to the sewin
ring of the valve, which was then tied down. The replacement valve appeared to be well-seated. It was tested and found to be
hemostatic. We therefore closed the atriotomy around the left ventricular vent with a single layer of running #3-0 Prolene, and
the vent was placed to suction to aid in de-airing.
The patient was allowed to rewarm. A site for the proximal bypass graft anastomosis was selected on the aorta. An aortotomy
for the proximal anastomosis of the saphenous vein graft was made with a #11-0 blade scalpel followed by an aortic punch to
enlarge the aortotomy, and the proximal anastomosis was completed using a running #5-0 Prolene.
A hot shot was given, and the cross-clamp was removed. Ventricular pacing wires were then placed and the patient was paced
at 80 beats per minute. Four chest tubes were placed: 2 in the mediastinum and 1 in each pleural space. The follow-up
transesophageal echocardiogram confirmed that there was no residual air in the heart and that the mitral valve had no
perivalvular leak. All vents were then removed, and the patient was subsequently weaned from bypass. The IVC and SVC
cannulas were removed. Protamine was given. The aortic cannula was removed. The cannulation sites were then tied down
and confirmed to be hemostatic. The patient’s sternum was then reapproximated with #6-0 stainless steel wires. We irrigated
the sternum with a solution of Betadine and Ancef. The fascia was closed with a running #1-0 Vicryl followed by a deep
dermal layer of running #2-0 Vicryl. The skin was closed in a running subcuticular fashion using #3-0 Monocryl. Bacitracin
was applied to the incision sites, which were then covered with sterile Primapore dressing.
All instrument, sponge, and needle counts were confirmed to be correct x 2 at the end of the operation. The patient was
transferred to the post-operative unit in critical condition.
13. Coronary Artery Bypass Grafting with Aortic Valve Replacement
Michelle C. Ellis, MD and Jonathon W. Haft, MD
University of Michigan, Ann Arbor, MI

6. Open pericardium, pericardial well, assess ascending aorta for plaque burden (consider epiaortic ultrasound or
alternative cannulation strategy)
7. Systemic heparinization (300u/kg)
10. Cardioplegia cannula placement (antegrade via aortic root, retrograde via coronary sinus)
11. Check ACT (>350sec)
14. Antegrade cardioplegia +/- topical cooling, followed by retrograde cardioplegia
15. Assess and plan distal targets
16. Aortotomy, excision of aortic valve leaflets and debridement of the annulus
17. Choose prosthetic valve and size
18. Irrigate left ventricle and aortic root copiously while giving retrograde cardioplegia
19. Distal coronary anastomoses
20. Place annular sutures and implant valve
21. Close aortotomy
23. Retrograde hot shot/warm blood cardioplegia
26. Temporary epicardial pacer wire placement
27. Wean from cardiopulmonary bypass
28. Protamine administration and decannulation
29. Assess hemostasis, place pleural/mediastinal tubes

2. IMA injury
3. Cannulation complication (aortic dissection/disruption, inadequate anticoagulation)
4. Poor choice of aortic cannula/cross clamp location (too low/inadequate space for aortotomy and proximals, stroke
risk)
5. Insufficient myocardial protection (retrograde cannula malpositioned)
6. Coronary sinus injury
7. Quality/caliber of targets
8. Twisting, kinking, or inadequate length of graft
9. Valve-patient mismatch
10. Inadequate debridement of annulus
11. Poor seating of valve, occlusion of coronary ostia
12. Damage to prosthetic valve (commissure posts, leaflets) during suture tying
13. Inadequate de-airing prior to aortic root vent removal
14. Perivalvular leak
15. Inadequate control of hemostasis prior to sternal closure
Template Dictation
Preoperative Diagnosis: [INDICATION exertional or unstable angina, dyspnea]
1. Endoscopic vein harvesting
2. Coronary artery bypass grafting [DETAILS conduit used and targets]
3. Aortic valve replacement [PROSTHETIC IMPLANT info]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLIANT: Exertional chest
pain, syncope]. Preoperative cardiac catheterization reveals [FINDINGS]. Preoperative cardiac echocardiography
demonstrates [FINDINGS]. The patient has chosen a [VALVE CHOICE: bioprosthetic to avoid lifelong warfarin, or a
mechanical prosthetic to reduce risks of future degenerative valve dysfunction].
Description of Procedure: The patient was taken to the operating room on [DATE] and was placed upon the operating room
table in the supine position. Swan Ganz catheter and radial artery lines were inserted. General endotracheal anesthesia was
administered. Preoperative transesophageal echocardiogram was then performed to evaluate cardiac and valve function. The
patient was prepped and draped in the usual sterile fashion.
The saphenous vein was endoscopically harvested from the lower extremity, length sufficient for X Number bypass grafts. The
tributaries of the vein were controlled with clips and silk ligatures. The access incision was closed in layers.
The chest was opened through a median sternotomy incision. The left pleural cavity was opened and the left internal mammary
artery was fully mobilized. The patient was heparinized systemically with 300 IU/kg after which, the internal mammary was
transected distally and prepared for anastomosis. The pericardium was opened. Pericardial stays were used for retraction. The
space between the aorta and pulmonary artery was exposed. Purse string sutures were placed in the [LOCATION: distal
ascending aorta or transverse aortic arch], right atrial appendage, and right atrium. A Prolene purse string suture was placed in
the right superior pulmonary vein. After ensuring adequate anticoagulation, arterial cannulation and dual-stage venous
cannulation was achieved. An antegrade cardioplegia catheter was placed in the ascending aorta. A retrograde cardioplegia
catheter was placed via the right atrium into the coronary sinus, positioning confirmed by transesophageal echocardiography
and pressure transduction. A left ventricular vent was placed via the right superior pulmonary vein. Cardiopulmonary bypass
was initiated. The aortic cross clamp was applied. Cardioplegia was administered in an antegrade fashion followed by
retrograde via the coronary sinus [NOTE: If there is significant aortic valve insufficiency, then antegrade cardioplegia may not
be delivered effectively]. A good diastolic arrest was achieved. The patient was cooled systemically to approximately 32
degrees Celsius.
300-500 ml of retrograde cardioplegia was administered in 20 minute intervals throughout the period of the aortic occlusion.
The aorta was then opened revealing a [DETAILS: heavily calcified tricuspid valve, with/without fused right and left
leaflets]. The aortic valve was then excised, the annulus debrided of any remaining calcium deposits and the left ventricle
copiously irrigated with cold saline. The annulus was sized. A Xmm prosthetic [IMPLANT type: Trifecta, MagnaEase, St.
Jude mechanical] aortic valve was selected.
The epicardial vessels were identified and incised. The distal anastomoses were accomplished next. Individual segments of
reverse saphenous vein were sewn to the [TARGETS: diagonal, obtuse marginal, posterolateral branch of the circumflex
artery, distal right coronary or posterior descending] artery respectively. Each of these anastomoses were carried out with
running sutures of 7-0 Prolene. The anastomoses were tested for patency and hemostasis with gentle syringe infusion. The left
internal mammary artery was then brought through a window in the pericardium and was sewn to the left anterior descending
vessel with a running suture of 7-0 Prolene. The proximal clamp on the internal mammary was briefly removed to confirm both
patency and hemostasis of this anastomosis.
Pledgeted 2-0 Ethibond sutures were placed circumferentially along the aortic valve annulus with pledgets oriented
[DETAILS: on the ventricular side for bioprosthetics, on the aortic side for mechanical prosthetics]. Sutures were then passed
through the sewing ring, the valve lowered into position and tied securely in place. The valve was inspected to be certain it
was well seated and the coronary ostia were unobstructed. The aortotomy was closed with a continuous running suture of 5-0
Prolene. The vein grafts were cut to the appropriate length and spatulated. X number of aortic tissue buttons were excised and
used as X proximal anastomoses for the saphenous grafts, which were carried out with running sutures of 5-0 Prolene.
A terminal dose of warm blood cardioplegia (the hot shot) was administered retrograde and the aortic cross clamp was then
released. The heart was de-aired using the left ventricular vent and the ascending aortic vent. Temporary pacing wires were
placed on the surface of the [LOCATION: right atrium, right ventricle].
With the patient fully re-warmed, the heart resumed good contractility and resumed a [TYPE: normal spontaneous or paced]
rhythm. The lungs were inflated. [DETAILS: Inotropes were initiated if the ventricular function was impaired or the cross
clamp period was prolonged]. The patient was weaned from cardiopulmonary bypass. Transesophageal echocardiography
revealed a well seated valve with no insufficiency and acceptable gradients. The left chest was aspirated. Protamine was
administered and decannulation was accomplished. Hemostasis was achieved from all sites, including the skin fat, the
mammary bed, cannulation sites, and all proximal and distal anastomotic sites. The entire wound was inspected for hemostasis
and was felt to be adequate. [NUMBER] mediastinal tube and [NUMBER] left pleural tube were placed.
The incision was then closed in layers with #5 stainless steel wires used to approximate the sternum, 2-0 PDS suture used to
approximate the fascia, 2-0 monocryl to approximate the subcutaneous tissue, and 4-0 monocryl subcuticular closure used to
approximate the skin. Sterile dressings were applied. The patient tolerated the procedure well and transferred to the ICU in
stable condition.
All sponge, instrument, and needle counts were correct at the completion of the case.
14. DeVega Tricuspid Valve Repair
Mathéau A Julien, MD, PhD and Duc Thinh Pham, MD
Tufts Medical Center, Boston, MA

5. Open pericardium, pericardial well, survey ascending aorta for plaque burden
8. Dual stage venous cannulation
9. Restriction of SVC and IVC return into the operative field with Rummels
10. Myocardial protection cannula placement (DLP in aortic root)
12. Initiate CPB
13. Aortic cross clamp (reduce CPB flow rate, apply cross clamp, increase CPB flow to
14. 2.0-2.5L/min/m2)
15. Antegrade cardioplegia (1200 ml) and topical cooling with for cardiac arrest
16. Check for PFO once right atrium opened
17. During suturing, take up a segment of annular tissue with each bite, but leave only a small space between each bite
18. Use of a tricuspid valve annuloplasty calibrator in order to narrow the annulus to the desired size
19. Testing tricuspid valve competence by distending the right ventricle using a Robinson catheter
22. Closure of right atriotomy
25. Drainage tube placement
26. Wean from CPB

3. Cannulation catastrophe (aortic dissection/ bleeding)
5. SA node or right phrenic nerve injury during SVC isolation/cannulation
6. Inadvertent azygous vein rather than SVC cannulation
7. Excessive bleeding or cardiac manipulation during IVC cannulation
8. Inadvertent hepatic vein rather than IVC cannulation
9. Insufficient myocardial protection
10. Insufficient venous drainage
11. Failure to address PFO
12. Injury to tricuspid valve leaflets
13. Failure to improve degree of tricuspid regurgitation
14. Insufficient de-airing prior to removal of aortic root vent
15. Inadequate control of hemostasis prior to sternal closure/ bleeding from one of numerous cardiotomies
Template Dictation
Preoperative Diagnosis: Tricuspid Valve Insufficiency
Procedure(s) Performed: DeVega Tricuspid Valve Repair
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] mild functional tricuspid regurgitation by echocardiography.
While the annular dilatation of moderate to severe tricuspid regurgitation should be managed with a ring-reinforced
annuloplasty, the suture annuloplasty technique of DeVega was chosen and has successfully been employed for the repair of
mild regurgitation. Of note, this technique is becoming of more historical interest, due to compelling evidence suggesting a
higher recurrence rate.
Description of Procedure: After informed consent was obtained, the patient was brought to the operating room and placed in
the supine position. General endotracheal anesthesia was induced. A central venous catheter, Swan-Ganz catheter, radial
arterial catheter, and Foley catheter were inserted. The patient was prepped and draped in the usual sterile manner. A median
sternotomy was performed. The heart was then exposed and marsupialized by supporting the right side of the pericardium. The
SVC and IVC were each looped using umbilical tape on a Rummel tourniquet. The patient was systemically heparinized, and
cardiopulmonary bypass lines were brought up. Double pursestring sutures were placed in the ascending aorta, and it was
cannulated in the usual fashion. The venous line was Y'ed for SVC and IVC cannulation, and after placing single pursestring
sutures, these were cannulated as well, using right-angle cannulas. Once a therapeutic ACT was achieved the patient was
placed on cardiopulmonary bypass and kept warm.
An aortic root vent / antegrade cardioplegia DLP cannula was placed in the proximal ascending aorta. The aorta was
crossclamped, and cardioplegia given antegrade into the aortic root. After there was good cardiac arrest, the superior and
inferior vena caval tapes were snared down. The operative field was flooded with carbon dioxide. The right atrium was then
opened. No atrial septal defect was identified. Attention was then turned to the tricuspid valve. The valve leaflets were thin
and pliable, and the pathology was limited to dilatation of the annulus. To fashion the DeVega annuloplasty, a double-armed 2-
0 pledgeted Prolene suture was used. Starting at the commissure between the septal and anterior leaflets of the tricuspid valve,
sequential stitches were taken through the tricuspid valve annulus, leaving only a small space between each bite and taking up a
segment of annular tissue with each bite. The suture line was completed at the septal-posterior leaflet commissure. The
opposite needle was then used to make a second row of suture in the floor of the atrium just outside the annulus of the tricuspid
valve. This stitch was also completed at the septal-posterior leaflet commissure. Both needles were passed through a free
Teflon pledget. With the aid of a tricuspid valve annuloplasty calibrator, the suture was tightened in order to narrow the
annulus to the desired size. Afterwards, tricuspid valve competence was tested by distending the right ventricle using a
Robinson catheter. The right atriotomy was then closed with a double-layer running Prolene suture
The patient was successfully weaned off of cardiopulmonary bypass. The heart was deaired and decannulated. The heparin
was reversed with protamine. Two temporary right atrial and right ventricular epicardial pacing wires were placed. The
pericardial cavity was copiously irrigated, hemostasis was assured, and two mediastinal drainage tubes were placed. The
sternum was reapproximated with wires. The rectus and pectoralis fascia were closed with 0 Vicryl. The subcutaneous tissue
was closed with 2-0 Vicryl, and the skin was closed with 3-0 Monocryl. All wounds were sterilely dressed. Instrument and
sponge counts were correct. The patient tolerated the procedure well and was sent to the critical care unit in stable condition.
15. Donor Heart Procurement
Alexandra Tuluca, MD and Hari Mallidi, MD, FRCSC
Baylor College of Medicine/ Texas Heart Institute, Houston, TX

1. Final checklist at the site:
1. ABO compatibility
2. Serology (HIV, HCV, HbsAg and CMV)
3. Laboratory findings (Troponin, Na, ABG)
4. ECG ( look for Atrial fibrillation, bundle or AV blocks and signs of hypertrophy, long QT)
5. Echocardiography (valvular abnormalities, LV and RV function, wall motion, wall thickness)
6. Chest X-ray
7. Coronary angiogram (if performed)
8. Medications during ICU course (especially catecholamine requirements)
3. Dissect and remove thymus, open pericardium longitudinally, create pericardial well
4. Expose the great vessels, Aorta with the arch branch vessels
5. Visual inspection and palpation of the heart for injury and lesions; Palpate LM coronary (behind the PA) and branch
coronary arteries for evidence of calcification
6. Dissect SVC and IVC circumferentially; Ligate and divide the azygous vein
7. Separate aorta and pulmonary artery
8. Insert cardioplegia cannula in ascending aorta
9. Systemic heparin (300 units/kg)
10. Ligate the SVC above the azygous vein
11. Cross-clamp the aorta
12. Incise IVC supradiaphragmatic - check with liver team
13. Vent the heart (pulmonary vein, main PA or LA appendage - if heart-lung block)
14. Arrest the heart with cardioplegia solution and copious topical cooling
15. Divide SVC and IVC
16. Incise the pulmonary veins/ left atrium
17. Divide the aorta (usually distal arch, with preservation of the arch vessels) and the PA as long as possible; If
harvesting for complex congenital transplant divide the PA at branch PA level
18. Remove the heart and inspect again for lesions, contusions, etc.
19. Store in sterile bag ( 3 bag method, first with cold perfusion solution, outer two with ice water)

1. Forgetting to heparinize
2. Allowing ventricular distention
3. Back-walling aorta with cardioplegia needle or angiocath thereby failing to administer cardioplegia
4. Allowing to aortic root pressure to get too high when administering cardioplegia
5. Caution to stay supradiaphragmatic when dividing the IVC
6. Not enough length on the SVC, IVC or the great vessels
7. Injuring RA / Dome of LA when preserving RSPV for lung team
8. Injuring the coronary sinus during IVC transection
9. Failure to identify structural abnormalities
10. Failure to adequately cool and preserve the heart
Template Dictation
Preoperative Diagnosis: N/A
Procedure(s) Performed: Donar heart procurement
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: N/A
Description of Procedure: The donor is positioned supine and prepped and draped in standard sterile fashion from chin to
knees. A standard median sternotomy is performed. The thymus is removed and the pericardium is opened longitudinally in a
reverse-T along the diaphragm. A pericardial well is created and the great vessels are exposed. The heart is visually
inspected and palpated to identify myocardial contusions, coronary atherosclerosis or previous infarction.
The heart mobilization begins by dissecting the SVC from the right atrium to the innominate vein. The azygous vein is ligated in
the process and the SVC is encircled with heavy ligature. The IVC is mobilized circumferentially. Next, the aorta is separated
from the pulmonary artery and isolated with umbilical tape. A cardioplegia cannula is inserted in the ascending aorta through a
purse-string suture and secured with a Rommel tourniquet.
Once the abdominal organs and lungs are mobilized and prepared for explanation, the patient is administered 300 units/kg of
heparin intravenously. Anesthesia is asked to pull back any venous neck lines they may have and the SVC is ligated as distal as
possible. The IVC is incised and blood allowed to drain into the pericardium. The heart is further vented by incising a
pulmonary vein (or alternatively, the left atrial appendage if lungs or a heart-lung block is being harvested). The aortic cross-
clamp is applied just proximal to the takeoff of the innominate artery and the heart is arrested with a single flush (1000ml or
10mL/kg for larger donors) of cold crystalloid cardioplegia solution. Watch at this time for appropriate aortic root distention,
quick cessation of electrical activity and left ventricular relaxation without distention. Rapid cooling of the heart is achieved
with copious topical cold saline solution in the pericardial well. The cardioplegia cannula can now be removed and the purse-
string tied.
The IVC is fully transected. The heart is wrapped in an ice-soaked lap pad and the apex of the heart is elevated. The remaining
pulmonary veins are divided from inferior to superior, followed by branch pulmonary arteries. If lungs are also harvested, the
main PA is divided close to the bifurcation and adequate left atrial cuffs must be negotiated. The aorta and the SVC are divided
last with more than adequate length.
The donor heart is then placed in a sterile bag with perfusion solution, then two additional outer bags with sterile ice water.
The organ is then placed in a cooler with ice and transported to the recipient hospital.
16. Hemiarch Replacement with DHCA – Aneurysm
Thomas J Zeyl MD and Tomas D Martin MD
CAVEAT: Aortic surgery, including that of the arch, may vary from institution to institution. Cannulation strategies and
cerebral protection can be completed differently. Strategies such as right axillary cannulation for antegrade cerebral protection
and bypass, or retrograde cannulation for cerebral protection are both valid methods. The described procedure omits these
techniques.

1. Appropriate patient identification
6. Dissect prepericardial fat/thymus to expose innominate vein
7. Open pericardium, pericardial well, survey ascending aorta/arch for pathology and potential cannulation site
11. Retrograde cannula in coronary sinus
13. Initiate CPB and cooling
14. LV vent placement
16. Antegrade cardioplegia if no associated AI via a slotted cardioplegia needle, then retrograde cardioplegia
17. Aortotomy with resection of ascending aorta to sinotubular junction.
18. Once electrocerebral silence and adequate temperature, place patient in trendelenberg, turn cardiopulmonary bypass
off and remove aortic cannula and cross clamp.
19. Complete resection of aorta into the arch and as far as needed to get to normal aorta, create beveled graft with side-
arm
20. Distal anastomosis
21. Reperfusion through side-arm on graft
22. Rewarm
23. Proximal anastomosis to sinotubular junction
24. Deairing via root with slotted needle, retrograde cardioplegia
27. Atrial and ventricular pacer wire placement
29. Check for air, remove LV vent, then wean from CPB
30. Remove root vent and venous cannulas
31. Protamine administration for heparin reversal
32. Ligate graft side-arm

2. Avoid injury to innominate vein and aneurysmal aorta during initial dissection/creation of pericardial well
6. Inadequate cerebral protection (prolonged ischemic time prior to reperfusion)
7. Inadequate deairing prior to removal of aortic root vent
8. Acquired coagulopathy and bleeding
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. size and extent of aneurysmal disease]
Procedure(s) Performed: Ascending Aorta with Hemiarch Replacement with DHCA using a [DETAILS – Size of Graft]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE]year old [GENDER] with a history of [DISEASE – size of aneurysmal disease, and or
rate of growth of aneurysm]. Preoperative CT scan revealed [FINDINGS]
Description of Procedure: The patient was taken to the operating room and [HIS/HER] identity and planned procedure
verified. The patient was placed on the operating room table in the supine position and general anesthesia was obtained.
Hemodynamic catheters were inserted and transesophageal echocardiogram was performed to evaluate cardiac and valve
function. The patient was prepped and draped in the usual sterile fashion. The chest was entered via standard median
sternotomy. The heart was exposed, and the ascending aorta was inspected and showed [OPERATIVE FINDINGS] . The
patient was systemically heparinized with a total of [UNITS] of systemic heparin. Epiaortic ultrasound was performed to
assess the aortic wall. The aortic cannulation sutures were then placed in the ascending aorta below the level of the
innominate artery take off. The right atrial cannulation sutures were then placed in the right atrium. The retrograde cardioplegia
sutures were placed in the right atrium and the left ventricular vent sutures were placed in the right superior pulmonary vein.
The ACT and systemic pressure was confirmed and the aortic cannula was then inserted, secured and de-aired. Venous cannula
was then placed and secured in the right atrium. A retrograde catheter was placed into the coronary sinus and secured. The
patient was placed on cardiopulmonary bypass and eventually cooled to [TEMP] degrees centigrade and electrocerebral
silence. Upon fibrillation, a vent was placed in the left ventricle via the right superior pulmonary vein. The aortic cross-clamp
was placed and antegrade cardioplegia was administered upon which there was rapid arrest of the heart. This was followed by
retrograde cardioplegia. The aorta was opened just proximal to the cross clamp and the ascending aorta was resected to just
superior to the sinotubular junction with visualization of the right and left coronary ostia. Once the patient reached
approximately [TEMP] degrees centigrade and electrocerebral silence, [HE/SHE] was placed in Trendelenburg position and
the pump was turned off. The aortic cannula and cross clamp were removed. The ascending aorta was transected cephalad and
the aorta was resected all the way up into the aortic arch, including all diseased aorta in the arch, until there was noted to be
relatively normal sized aorta. A [SIZE] side-arm graft was chosen and beveled to fit the transverse arch. The graft was sewn
end-to-end to the underneath side of the aortic arch utilizing a running 3-0 Prolene suture. Upon completion of the anastomosis,
bioglue was utilized on the graft to cover needle holes. The side-arm was then connected to the arterial line through a regular
tubing connector. After de-airing the graft, the graft was clamped and reperfusion was begun. A cross clamp was applied
proximal to the joining of the side-arm. Cerebral ischemia time was [TIME] minutes. Rewarming was begun. The graft was
cut to the appropriate length and anastomosed end-to-end to the proximal aorta utilizing a running 3-0 Prolene suture. This was
done right at the sinotubular junction. Upon completion bioglue was placed on the graft to cover suture holes. The heart was
de-aired in the routine fashion utilizing active suction in the aortic root and the left ventricle and retrograde cardioplegia was
given. The crossclamp was removed. The patient was rewarmed to [TEMP] degrees.
Atrial and ventricular pacing wires were then inserted and tested for appropriate capture. A [NUMBER] chest tube was
placed in the mediastinum and large Blake drains in the [LEFT/RIGHT] pleural space. The heart was de-aired, and the LV
vent was removed after minimal air was seen by echo. The patient was weaned from cardiopulmonary bypass. The venous
cannula was removed, and the cannulation sutures were secured. Protamine was administered and the patient was monitored
for adverse reactions. Coagulopathy was assessed and hemostasis secured. The aortic side-arm was clamped and cut. The
remaining stub of the side-arm was closed with a 3-0 Prolene suture and 2 large clips placed at the base. The operative field
was thoroughly inspected for bleeding.
Once adequate hemostasis was achieved, the sternum was closed with a total of [NUMBER] stainless steel sternal wires
utilizing a figure of eight interlocking fashion. Vancomycin powder was placed in the wound prior to sternal closure. The
fascia was then closed with #1 Vicryl suture in running fashion. The deep dermal layer was then closed with #2- 0 Vicryl
suture in running fashion. The skin and subcuticular layer was closed with #4-0 Monocryl in running fashion followed by
Dermabond on the skin.
subsequently transferred to the postoperative cardiac surgical intensive care unit in critical, but stable condition.
17. Aortic Root Replacement with Homograft for Aortic Root Abscess
(Native And Or Prior Bentall)
Muhammad Aftab, MD, Ourania Preventza, MD
Baylor College of Medicine/Texas Heart Institute, Houston, TX

4. Right infraclavicular incision for Right axillary cannulation (consider in cases of redo sternotomies)
5. Dacron graft anastomosis to right axillary artery (alternative an innominate artery cannulation can be performed after
the chest is opened )
6. Femoral venous cannulation for cardiopulmonary bypass (CPB) (optional)
7. Redo sternotomy
8. Systemic heparinization (400 U/kg). Ensure that activated clotting time (ACT)is >450 seconds
9. CO2 in the operative field
10. Distal ascending aortic cannulation (alternative to axillary artery graft or to innominate artery cannulation)
11. Dual-stage venous cannulation of right atrium
12. Initiate CPB (2-2.5 L/min/m2)
13. Systemic hypothermia (28-32°C)
14. Lysis of adhesions
15. Left ventricular sump via right superior pulmonary vein
16. Retrograde cardioplegia cannula in coronary sinus
17. Distal ascending aorta cross-clamped
18. Antegrade cold blood cardioplegia, except in severe aortic insufficiency
19. Combination of antegrade and retrograde cold blood cardioplegia (every 10-15 min during the operation)
20. Divide the native ascending aorta distal to previous graft anastomosis
21. Excise the infected composite valved graft
22. Wide local debridement
23. Mobilize the right and left main coronary buttons
24. Sharp debridement of the infected annular and sub annular region, if necessary
25. Reconstruct the tissue defect with autologous pericardium, bovine pericardium or the mitral leaflet of the valved
homograft as needed
26. Completely remove all prosthetic material, previous pledgets, and sutures
27. Aortic annular sizing and selection of homograft
28. Thawing of cryopreserved aortic root homograft as per protocol
29. Trim the proximal end of homograft with 3- to 4-mm myocardial cuff
30. Homograft to aortic annulus/left ventricular outflow tract anastomosis
31. Left main coronary button anastomosis
32. In case of inadequate mobilization of the left main coronary button, an 8- or 10-mm rifampin soaked Dacron graft or
SVG as an alternative is used as hemi-Cabrol
33. Distal trimming of homograft
34. Distal anastomosis of homograft to ascending aorta
35. Ensure excellent hemostasis along all the anastomoses
36. Additional interrupted sutures for anastomotic reinforcement, as needed
37. Verify right coronary artery (RCA) button alignment and mobility
38. Start rewarming slowly when the RCA button anastomosis starts
39. RCA button reimplantation to the homograft
40. In case of inadequate mobilization of RCA button, place a saphenous vein graft as an interposition graft between the
origin of the RCA button and the homograft (hemi-Cabrol). If hemi-Cabrol (after completion) not satisfactory,
perform coronary artery bypass grafting (CABG) to the RCA
41. Place patient in Trendelenburg position, perform deairing maneuvers, and remove the aortic cross-clamp
42. Confirm spontaneous cardiac rhythm, place pacing wires
43. Continue deairing
44. Once patient is rewarmed (36.5°C), resume ventilation
45. Fill the heart with blood and allow the heart to eject
46. Wean from CPB
47. Protamine and sequential decannulation
48. Ensure hemostasis
49. Mediastinal irrigation with antibiotics
50. Residual mediastinal abscess cavity debridement. In an event of a large non collapsible periaortic cavity, omentum
can be mobilized to fill mediastinal cavity
51. Place mediastinal drains

1. The primary indication for aortic root replacement with a cryopreserved homograft is endocarditis of the native or
prosthetic aortic valve or composite valved graft with extensive periannular involvement.
2. A safe redo sternotomy is an important initial step in successful reoperative aortic root surgery.
Considerations for a safe sternal reentry include:
1. Careful evaluation of preoperative imaging to assess the proximity of vital structures to the sternum
2. Use of an oscillating saw for the anterior table, initially leaving the untwisted sternal wires in place, lifting the
sternal edges and incising the posterior table under direct vision, removing the sternal wires after incising the
posterior table
OR
3. Lifting the sternal edges of the xiphoid process dissect the periaortic tissue and cardiac structures under direct
vision from the back of the sternum and then use of regular vertical saw for the sternotomy
4. Use of peripheral cannulation (femoral -femoral bypass, or femoral to axillary bypass before sternal entry in
high- risk situations where the right ventricle or the aorta is adherent at the back of the sternum. In these cases
placement of the patient on CPB prior to sternal entry is advisable
3. Dual-stage right atrial venous cannulation is standard. Femoral venous cannulation can be performed in high-risk
cases.
4. Complete debridement of all the infected necrotic tissue and removal of any foreign material from the previous
operation, including sutures, pledgets, and graft material, is paramount in homograft aortic root replacement for aortic
root infection.
5. Coronary buttons are prepared and mobilized. In redo root operations, their mobilization becomes increasingly
difficult.
6. Preoperative planning also includes ensuring that the local tissue bank contains the sizes of aortic homografts within
your desired annulus diameter range, based on the preoperative echocardiograms and preoperative computed
tomography (CT) scan.
7. The aortic annulus is sized by using the standard Freestyle valve sizer or Hagar dilators.
8. A properly matching homograft with an annular (internal) diameter of equal size or a size difference of no more than 2
mm is ideal.
9. The homograft should be carefully evaluated for valve morphology and integrity, as well as for any injuries sustained
during the processes of procurement, preservation, and thawing.
10. The proximal end of the homograft is trimmed such that a 3- to 4-mm cuff of myocardium is left below the nadir of the
cusps. The anterior mitral leaflet is initially retained during the trimming to repair any annular or periannular defect,
if needed.
11. Allograft implantation in anatomic orientation is fairly straightforward, especially when the native aortic valve is
tricuspid and both annuli match closely.
12. All the anastomoses are performed with monofilament sutures (eg, polypropylene) in a running fashion. Using foreign
material to reinforce the anastomoses is avoided, but if it is necessary, autologous (or bovine) pericardium is the
material of choice.
13. Constant tension on the suture line should be maintained by the assistant during the anastomosis; tightening the loose
suture line with nerve hooks ensures a hemostatic anastomosis.
14. Any kinking or overstretching of the main coronary arteries during the reimplantation of coronary buttons into the
homograft root should be avoided.
15. In reoperative situations, when significant scarring around the root or heavy calcification around the coronary ostia
precludes the safe direct coronary button re-implantation, an interposition saphenous vein grafts (SVG) between the
origin of the RCA button and the homograft (a hemi-Cabrol) can be used. SVG to RCA can be used as an alternative
and the RCA button is oversewn
1. .For the left coronary button we prefer Dacron graft (8 or 10 mm) soaked in rifampin as the alignment is better
than the SVG but SVG can be also used. Ideally any prosthetic material should be avoided.
16. Postoperative bleeding due to coagulopathy should be addressed with targeted blood-product transfusion guided by
the laboratory results.
17. Postoperative hypertension should be avoided to prevent any suture line disruption.
Template Dictation
1. Group B streptococcal endocarditis of composite (mechanical) valved graft.
2. Post resection and replacement of aortic root (Bentall procedure) for annuloaortic ectasia and aortic valve
insufficiency.
3. Periannular abscess.
4. New York Heart Association classification III.
1. Redo median sternotomy.
2. Right axillary artery or innominate artery cannulation with an [BLANK]-mm Dacron end-to-side graft for pump
return.
3. Total cardiopulmonary bypass.
4. Resection of previous composite valve graft (Bentall) prosthesis and wide debridement of infected tissue.
5. Extensive debridement of mediastinal abscess cavity.
6. Replacement of aortic root with [BLANK]-mm × [BLANK]-cm valved homograft root.
7. Bypass to the right coronary artery with reverse autologous saphenous vein graft.
Drainage: Two 36 Fr Argyle chest tubes were placed in the mediastinum for the drainage.
Fluids and Products: x crystalloid, x colloid, x PRBC, x FFP, x Platelets, x cell saver
Urine output: [BLANK]
CPB time: [BLANK]
Cardiac ischemia time: [BLANK](cardiac ischemia and aortic x clamp are the same in cases that circulatory arrest is not
performed)
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] who had undergone aortic root replacement with a composite
mechanical valve graft 3 years earlier. He initially developed a right eye and sinus infection. Two weeks later, he presented to
the hospital with a high-grade fever and dyspnea on exertion. He was febrile and in respiratory distress. Empiric antibiotics
were immediately started. Computed tomography showed abnormal fluid collection around the graft. Group B streptococcus
was identified in the blood culture. Transthoracic echocardiography revealed mechanical aortic valve stenosis with a 16×6-
mm mass at the aortic annulus and a fluid collection around the graft, consistent with the infective endocarditis of previous
composite valve graft and perigraft abscess. Consequently, it was decided that operative intervention was indicated, with
resection of composite valve graft and replacement with a homograft.
Description of Procedure: After informed consent was obtained and the patient’s identity and the surgical site were
confirmed, the patient was brought to the operating room and positioned supine on the operating table. Adequate general
anesthesia was induced, and all the necessary monitoring lines were placed. Bilateral cerebral near-infrared spectroscopy
sensors were placed to monitor brain oxygenation throughout the procedure. A transesophageal echocardiography (TEE) probe
was inserted by the anesthesia team. The chest, abdomen, and legs were prepped and draped in sterile surgical fashion. An
incision was made under the right clavicle in the deltopectoral groove. The right axillary artery was exposed after the
pectoralis major muscle fibers were separated and the pectoralis minor muscle was divided. Adjacent veins were carefully
mobilized. We do not touch the cord of the brachial plexus. Intravenous heparin (5000 U) was administered by anesthesia, and
a partial occluding clamp was placed on the axillary artery. A [BLANK] mm Dacron graft was anastomosed end-to-side with
6-0 polypropylene and connected to the arterial line of the cardiopulmonary bypass circuit for pump return. [For innominate
artery cannulation: The innominate artery is exposed. Intravenous heparin (5000 U) was administered by anesthesia, and a
partial occluding clamp was placed on the innominate artery. A [BLANK] mm Dacron graft was anastomosed end-to-side with
6-0 polypropylene and connected to the arterial line of the cardiopulmonary bypass circuit for pump return. During the
innominate artery cannulation we keep the MAP 90 mmHg]. [For femoral venous cannulation: A vertical curvilinear incision
was made in the inguinal region anterior to the femoral vessels and deepened through the subcutaneous tissue, exposing the
fascia. The left/right common femoral vein was exposed. Venous cannulation was done using the standard Seldinger technique
through a purse string of 5/0 polypropylene. A 23/25 Fr dual-stage venous cannula was inserted into the right atrium with TEE
guidance, and satisfactory venous drainage was achieved.] A midline incision was made over the sternum and carried down to
the presternal fascia with electrocautery. The chest was entered through the previous median sternotomy (with an oscillating
sternal saw initially leaving the untwisted sternal wires in place, lifting the sternal edges and incising the posterior table under
direct vision, removing the sternal wires after incising the posterior table, or with the regular, vertical saw by lifting
initially the sternal edges of the xiphoid and dissecting the perioartic tissue and cardiac structures under direct vision from the
back of the sternum) and hemostasis was achieved with electrocautery. Adhesions from the previous operation were taken
down with careful sharp dissection.
The patient was then systemically heparinized to keep the ACT>450 seconds. A dual-stage venous cannula was introduced
though a purse string in the right atrium with the tip directed into the inferior vena cava and secured with a Rummel tourniquet
[Optional: Alternative to femoral venous cannulation]. Cardiopulmonary bypass was initiated. A retrograde cardioplegia
cannula was inserted into the coronary sinus, and its position was confirmed by palpation, pressure transduction and or TEE
guidance. A left ventricular sump was inserted via the right superior pulmonary vein and the patient was cooled to 32°C.
The distal ascending aorta was cross-clamped. Antegrade and retrograde cardioplegia was given intermittently and generously
for myocardial protection. The native ascending aorta was divided distal to the previous anastomosis, and stay suture was
placed for retraction. Significant edema and purulent material were encountered as the infected composite valve graft was
sharply excised. Portions of the graft were noted to be densely adhered to the surrounding tissue, and some portions were
easily separated. The adhesions were taken down with a careful sharp dissection. The right and left main coronary artery
buttons were mobilized. The prosthetic aortic valve was sharply excised from the aortic annulus. The annulus was decalcified,
and stay sutures were placed over the site of commissures for optimal exposure. The aortic annulus and sub annular region
were carefully evaluated for any evidence of aortoventricular or periannular abscess or infected granulation tissue. All the
infected annular and sub annular tissue was sharply debrided with a wide local excision. A periannaulr abscess was
encountered and debrided of necrotic tissue. The tissue defect was reconstructed with autologous pericardium (or with bovine
pericardium_ which was secured to the firm, healthy myocardial tissue by using 3/0 polypropylene in continuous fashion). All
the previous pledgets and sutures were carefully and completely removed. Wherever possible, the surrounding tissue was also
completely debrided.
To select a homograft of appropriate diameter, the aortic annulus was sized with standard valve sizers. The homograft was
thawed as per protocol and trimmed. The homograft was sutured to the aortic valve annulus and left ventricular outflow tract
with 2/0 polypropylene in a running fashion. The proximal suture line was reinforced with simple interrupted 3/0
polypropylene. Next, after adequate mobilization of the left coronary button, the left coronary button’s alignment with the
respective homograft coronary ostium was ensured. The coronary ostium of the graft was enlarged. With continuous 5/0
polypropylene, the left main coronary button was attached to the posterior aspect of the homograft and reinforced with 6/0
polypropylene.[If mobilization of the left coronary button is inadequate due to previous surgery, an 8 or 10 mm Dacron graft
soaked in rifampin or a SVG, is used as hemi-Cabrol]. The homograft was then cut to length and anastomosed to the ascending
aorta with continuous 4/0 polypropylene in an end-to-end fashion. The anastomosis was reinforced with additional 5/0
polypropylene suture. Similarly, the correct positioning of the right coronary artery to the homograft ostium was verified. The
right coronary artery could not be adequately mobilized for a safe coronary button reattachment. A saphenous vein graft was
harvested and placed as an interposition graft (reversed saphenous vein graft) between the origin of the right coronary button
and the homograft (hemi-Cabrol). At the completion of the anastomosis, the right coronary artery was not aligned to our
satisfaction. A coronary artery bypass using SVG to the Right coronary artery was performed. A #11 blade was used to create
an aortotomy in the homograft for proximal vein graft anastomosis, and an aortic punch was then used to enlarge the aortotomy.
The proximal anastomosis was performed with running 6/0 polypropylene.
Patient was placed in the Trendeleburg position, and after de-airing maneuvers, the cross-clamp was removed. The patient was
rewarmed to 36.5°C. Temporary epicardial pacing wires were placed. The patient was weaned from cardiopulmonary bypass
without difficulty. Protamine was administered to reverse the heparin, and all cannulas were sequentially removed. All the
suture lines and surgical sites were confirmed to be hemostatic. The mediastinum was copiously irrigated with antibiotics, and
the abscess cavity was thoroughly and completely debrided. Two 36 Fr Argyle chest tubes were placed in the mediastinum for
drainage. The sternum was closed with stainless steel wires. The presternal fascia and subcutaneous and subcuticular tissues
were closed in layers with absorbable sutures. Sterile dressings were applied, and the chest tubes were connected to drainage
reservoirs. Sponge, needle, and instrument counts were correct. The patient, intubated, was transferred to the intensive care
unit in a stable hemodynamic condition.
18. Unexpected Intraoperative Complications
George Makdisi, MD, John M. Stulak, MD
Massive Air Embolism

1. Perfusionist
1. Discontinue cardiopulmonary bypass, clamp arterial and venous lines
2. De-air bypass circuit
3. Add necessary volume to the reservoir if needed
4. Cool the perfusate to 20 degrees Celsius
2. Anesthesia
1. Position table in steep Trendelenburg position
2. Administer 100% Oxygen
3. Resuscitate with volume and pressors (keep MAP>60 mmHg)
4. Can consider administration of steroids/barbiturates/mannitol
3. Surgeon
1. Disconnect the arterial line from the aortic cannula
2. Disconnect the venous line from the SVC cannula
3. Connect the arterial line to:
1. SVC cannula if bicaval cannulation was performed
2. Single two-stage venous cannula can be withdrawn slightly so as to direct it from the RA into the SVC first
4. Initiate retrograde cerebral perfusion
1. Can consider cooling to 32 oC (temperature is per surgeon’s discretion)
2. Flow: 300 ml/min
3. For 2-5 minutes (until all air is vented back through aortic cannula/root vent site)
4. Bilateral carotid compression by anesthesia team
5. Keep retrograde cerebral perfusion pressure < 25 mmHg
6. Retrograde cerebral perfusion can be repeated
5. Discontinue perfusion and reconnect the arterial and venous lines back to aortic and SVC cannulae respectively
6. If single atrial cannula that was in SVC, withdraw it back to the RA
1. Initiate normal cardiopulmonary bypass
4. Cool for 28 o C (surgeon discretion based on clinical scenario)
5. Maintain mild hypothermia for approximately 30-40 minutes
1. Massage coronary arteries
2. De-air the heart as usual (needle aspiration of the left ventricular apex, left ventricular vent placed through the
right superior pulmonary vein, or aortic root vent)
6. Anesthesia/Perfusionist:
1. Ensure normoglycemia
2. Diuretics if needed
3. Cardiologist/anesthesia perform TEE to look for presence of air in the heart
4. Consider hyperbaric oxygen postoperatively
5. Proceed with planned case if patient condition allows

1. Delayed response and recognition
2. Maneuvers to prevent significant brain injury
1. Cooling the patient expeditiously
2. Immediate carotid artery compression
3. Avoid excessively high perfusion pressure during retrograde cerebral perfusion (Goal: < 25mm Hg)
4. Administer 100% inhaled oxygen
5. Consider steroids/ barbiturates, and mannitol
3. Consider hyperbaric oxygen postoperatively
1. Hypothermia offers several advantages, including protection of cerebral metabolism during the period of
ischemia, reduction of cerebral edema that follows cerebral air embolism and increased solubility of gas in
blood and tissues, thereby decreasing the size of emboli.
Template Dictation
Preoperative Diagnosis: severe aortic stenosis
Postoperative Diagnosis: severe massive air embolism
Procedure(s) Performed: [BLANK] (Example) Bioprosthetic aortic valve replacement, establishment of temporary
retrograde cerebral perfusion, management of massif air embolism.
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] who presented [BLANK] Workup included [CXR, cardiac
angiography, TTE], [Mr/ Mrs.] [BLANK] is brought now for surgical intervention.
Description of Procedure: The patient underwent general anesthesia in the supine position, and the monitoring lines were
placed. The patient was prepped and draped in the usual sterile fashion. A primary sternotomy was completed without
incident. The heart was dissected from adhesions. Heparin was administered. A 22-French straight aortic cannula was
placed through two concentric pursestring sutures in the ascending aorta. A 28-French a right-angle venous cannula was
placed in the superior vena cava and a 32-French right-angle venous cannula was placed in the inferior vena cava. An aortic
root vent was placed. The patient was placed on cardiopulmonary bypass at 2.4 L/min per m2 for [Blank] minutes. An aortic
cross-clamp was applied and cold blood cardioplegia given in the antegrade catheter establishing adequate rapid diastolic
arrest of the heart. The case was started as planned. We were notified by the perfusionist that there were difficulties in
maintaining bypass flow. Air bubbles were seen in the aortic cannula, and a diagnosis of massive air embolism was
suspected. The perfusionist was asked to cease cardiopulmonary bypass and a clamp was placed on the aortic cannula. The
patient was placed in steep Trendelenburg position. The perfusionist clamped both the arterial and venous lines, and the
bypass circuit was de-aired. The arterial line was disconnected from the aortic cannula, and then connected to the SVC
cannula. Retrograde cerebral perfusion was started at a flow of 300 ml/min for 3 minutes with perfusion pressure < 25
mmHg. During this time, the anesthesia team was repeating bilateral carotid compression, and retrograde cerebral perfusion
was repeated once, as all air was cleared from the bypass tubing. Then the arterial and venous lines were connected back to
normal aortic and SVC cannulae respectively and started normal cardiopulmonary bypass the patient was cooled to 28o C for
30 minutes with repeated massage coronary arteries, the heart was de-aired as usual. During the case the patient received
steroids, barbiturates, and Mannitol. The patient remained normoglycemic, and transesophageal was done to look for any
gross air in the heart. The case was then undertaken as planned [check dictation from other chapter of the book]. After
completion of the procedure, the aortic-cross clamp was removed. Atrial and ventricular pacing wires were placed. The
patient as mechanically ventilated at this point. The patient was weaned off of cardiopulmonary bypass and the venous
cannulae were removed. The cardiologist performed TEE to look for presence of air in the heart, and condition of the
[BLANK procedure] . Once there was no air in the heart, the aortic root vent was removed and the site repaired with an
interrupted Prolene suture. Protamine was administered and hemostasis was obtained. Chest tubes were placed in the
mediastinum. The aortic cannula was removed and site repaired with pledgeted Prolene sutures. The mediastinum was
irrigated. The sternum was reapproximated with interrupted #6 stainless steel wires. The fascia was sutured with interrupted
#1 Absorbable suture. The subcutaneous tissues were sutured with continuous #2-0 Absorbable sutures. The skin was sutured
with continuous #4-0 Absorbable sutures. The patient tolerated the procedure well. All needle, sponge, and instrument counts
were correct on two occasions. The patient was taken to the hyperbaric oxygen postoperatively.
Intraoperative Aortic Dissection

ESS After/During cannulation (Prior to Initiation of Cardiopulmonary Bypass)
1. Suspicion of ascending aorta dissection
1. Bluish discoloration or hematoma in the ascending aorta
2. High arterial line pressure
2. Do not go on bypass
3. Perform TEE to visualize intimal flap and extent of the dissection
1. Confirm patient stability with anesthesia
2. Cannulate right femoral artery if dissection is identified in ascending aorta
3. Confirm the wire is in the true lumen
4. RA for venous cannulation
5. Cardioplegia: retrograde and through the coronary ostia
6. CPB
7. Confirm flow in the true lumen, carotid and coronary artery (TEE)
8. Cool to circulatory arrest, ice on head, Trendelenburg position
9. Perform the planned procedure
10. Replace the ascending aorta and resect the dissection entry site
11. If the patient is unstable, then expeditious groin cannulation is necessary
4. Option if the dissection is limited to the ascending aorta
1. TEE-guided direct cannulation of the ascending aorta true lumen (Seldinger technique), recommended only in
experienced hands
5. While on bypass
1. Sudden increase in the arterial line pressure
2. Evaluate the ascending aorta/TEE
3. Discontinue CPB immediately
4. Cannulate the groin
5. Proceed as outlined above

1. The dissection could start at the site of aortic cannulation, the proximal vein graft anastomosis after CABG, aortic
root vent and an aortotomy after aortic valve replacement. The main preventive measure is awareness of a possibility
of dissection and meticulous surgical technique in handling the tissue
2. Have high suspicion when there is bluish discoloration or hematoma in the proximity of the aortic cannulation site
expanding to the aorta, high arterial pressure when you insert and test your aortic cannula, sudden increase in the
arterial line pressure during bypass, or unexplained bleeding from the aortic root vent or proximal anastomotic sites.
3. Perfusion the false lumen? Check with TEE and do Seldinger technique to cannulate the true lumen, if not go to the
groin for femoral cannulation (recommended)
4. Femoral cannulation be aware of the extent of dissection, be sure that you cannulating and perfusing the true lumen,
can consider right axillary artery cannulation for arterial inflow
5. Localized dissection can be fixed with a side bite clamp and strips of Teflon felt (in very select circumstances)
6. If extensive, deep hypothermic circulatory arrest and hemiarch replacement under direct vision is necessary
7. Check for the aortic valve condition if you have moderate or severe regurgitation, commissural resuspension may be
required. If not durable, then consider aortic valve or root replacement
8. Check for coronary dissection and consider bypass grafting if needed
9. Reinforce the distal and proximal aorta with double layer of Teflon felt before doing the distal anastomosis
10. Careful hemostasis, good chest tube drainage, and correction of any coagulopathy are critical components
11. Be aware of all complication of Aortic root replacement and dissection pitfalls described in other chapters
12. Don’t hesitate to add other cardiac support like ECMO, RVAD or LVAD, IABP could be used carefully because of
the distal dissection.
13. Be aware of Lower extremity compartment syndrome if femoral cannulation
Template Dictation
Preoperative Diagnosis: Aortic Dissection
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] who developed an aortic dissection intraoperatively, [Mr/ Mrs.]
[BLANK] is brought now for surgical intervention.
Description of Procedure: The patient underwent general anesthesia in the supine position and the monitoring lines were
placed. The patient was prepped and draped in the usual sterile fashion. A primary sternotomy was completed without
incident. The heart was dissected from adhesions. Heparin was administered. A 22-French straight aortic cannula was
placed through two concentric pursestring sutures in the ascending aorta. A 20-French a right-angle venous cannula was
placed in the superior vena cava, a right-angle venous cannula was placed in the inferior vena cava. An aortic root vent was
placed. The patient was placed on cardiopulmonary bypass at 2.4 L/min per m2 at 32 degrees centigrade for [Blank] minutes.
An aortic cross-clamp was applied and cold blood cardioplegia given in the antegrade catheter establishing adequate rapid
diastolic arrest of the heart. The case [Blank] was started and performed as planned.
Dissection from aortic root vent site at the end of the case with aortic valve damage and RCA dissection/ECMO
After removing the aortic root vent there was a bleeding from this site, and a reinforcing suture of 4-0 Prolene backed with felt
pledgets was placed.
However, upon tying the sutures, there was an aortic dissection that developed immediately and involved the entire ascending
aorta and aortic arch. There was massive bleeding from the very proximal portion of the aorta, and it turns out that the
dissection had sheared the right coronary orifice. There was also aortic regurgitation. We had to quickly recannulate the right
atrium and institute bypass. I then cooled the patient to 20 degrees centigrade, and we manually compressed the heart to
prevent distension. When an adequate level of hypothermia was achieved, we used an [Blank minute] period of circulatory
arrest. I transected the aorta obliquely beneath the arch. We excised the aorta above the sinotubular ridge and infused
cardioplegia into the left coronary ostium. Repeat infusions of 400 cc were given at 20-minute intervals during the [Blank
minute] cross-clamp period. I repaired the distal aorta using two strips of felt, one inside and one outside. These were tacked
together, and then we used fibrin glue between the adventitial layer and the media. A 26-mm Hemashield graft was beveled
and sewn to the distal aorta with continuous 4-0 Prolene. I switched our cannulae to a femoral artery cannula. This was
placed through the right femoral artery, and we resumed flow. I de-aired the graft and the brachiocephalic arteries and then
applied an aortic cross-clamp just proximal to our anastomosis. Hemostasis was satisfactory. I then inspected the proximal
aorta, and it was clear that the aortic tissues were so friable that we would not be able to preserve the valve. The dissection
extended into the noncoronary sinus and completely dehisced the right coronary artery and the right aortic sinus. The left
coronary ostium was intact, but the valve was severely damaged, and because the tissues were so friable, I did not think I
could repair this. Therefore, I excised the aortic valve and the proximal aorta, leaving only the button around the left coronary
ostium. We selected a [Blank Valve]. This was placed inside a tube graft and tacked with 4-0 Prolene sutures. We then
sewed this composite prosthesis to the aortic valve annulus with interrupted mattress suture of 2-0 Ethibond backed with felt
pledgets. The felt pledgets were on the ventricular side of the valve annulus. After tying the sutures securely, we reinforced
the initial layer with over-and-over 3-0 Prolene suture. Next, the graft was trimmed, and we made a button opposite the left
coronary ostium. The left coronary ostium was sewn to the graft with 5-0 Prolene. We then trimmed the distal graft to the right
and sewed the distal graft to the proximal graft. This was accomplished with 4-0 Prolene. I dissected in the right AV groove
and identified the right coronary artery. During a period of cooling, we harvested a segment of saphenous vein from the left
thigh. This reverse saphenous vein was sewn to the right coronary artery with 7-0 Prolene. We had released the aortic cross-
clamp prior to doing this anastomosis. I put a partial occlusion clamp on the graft in the ascending aorta and excised a small
button. The vein graft was beveled and sewn to the aorta with continuous 5-0 Prolene suture. At this point, we released
bulldog clamps on the vein graft, and we had re-established blow in the right coronary artery. Flow in the right coronary graft
w as [Blank mL/min]. The cardiac contractions were feeble, but the bleeding seemed to be coming under control. TEE
showed aortic dissection in the distal aorta with a double lumen. It was clear that the patient would require hemodynamic
support, and I initially planned to insert an intra-aortic balloon. However, because of the fragility of the tissue and the
potential difficulty with the dissected descending aorta, I felt it was safer to use extracorporeal membrane oxygenation. We
had switched our cannula back from the groin to the ascending aortic graft, and we left this in place. We then placed a second
cannula in the right atrium. These two cannulae were connected to the ECMO circuit, and we discontinued regular bypass and
began ECMO support. Protamine was administered. There was a great deal of bleeding from all cut surfaces.
The patient had very feeble contraction but did have right ventricular function and some left ventricular contraction when the
heart was decompressed. It is our hope that with time his ventricular function will improve. We removed the first venous
cannula and repaired the atrial appendage with 2-0 nonabsorbable suture. Considerable time was taken to try to improve
hemostasis, although the patient had continued bleeding.
Flow through the ECMO circuit was 2.2 to 2.6 L/min per m2, and we had excellent perfusion. The patient made urine
throughout the procedure. When the bleeding seemed better, I felt we should move back to the intensive care unit. Therefore,
we packed the anterior mediastinum and placed drainage tubes in both pleural spaces and in the mediastinum. A surgical
pause confirmed that all needle, sponge, and instrument counts were correct. The patient was in critical condition but did exit
the operating room and was returned to the intensive care unit.
19. LVAD – Heartware
Michael Tong MD, MBA
Cleveland Clinic, Cleveland, OH

2. General endotracheal tube anesthesia
3. Intraop TEE
4. Consider inhaled prostacyclin for prophylaxis against RV failure
5. Median Sternotomy
6. Open pericardium
7. Create tunnel for driveline with endoscopic tunneler
8. Systemic heparin
10. 2 stage single venous cannulation
11. Check ACT (>480)
12. Initiate CPB (CI 2.2)
13. Lift the apex of heart and identify the apex
14. Sew the HVAD ring into place with 12 pledgeted 2-0 Ethibond sutures
15. Perform ventriculotomy with coring knife
16. Bring a primed pump onto the table and place the inflow cannula through the HVAD ring
17. Externalize the driveline
18. Size the outflow cannula
19. Place a partial cross clamp on the ascending aorta and sew on the outflow graft.
20. Place a deairing vent in the aorta and deair the heart
21. Come off bypass and turn on pump and titrate to appropriate flows
22. Decannulate
23. Give protamine and assure hemostasis.
24. Close chest.

2. The tunneler for the driveline has potential to hit bowel, liver, vessels, etc.
3. Fragile LV apex that can tear
4. Outflow graft too long/short
5. Pump sitting in a poor position
6. Cannot adequately deair the pump
7. Bleeding
8. RV failure
9. Suction event
Template Dictation
Preoperative diagnosis: [Indication: e.g. ischemic cardiomyopathy]
Procedure(s) Performed: Implantation of HeartMate II left ventricular assist device as (INDICATION: destination
therapy or bridge to transplant)
Assistants: [BLANK]
Anesthesia: [BLANK]
Drains: [BLANK]
Specimen: [LV core]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT]. Preoperative
workup showed severe cardiomyopathy and end-stage systolic and diastolic congestive heart failure. Patient is status
[INTERMACS LEVEL] with [JUSTIFICATION OF STATUS]. Patient taken to the OR today for implantation of LVAD.
Description of Procedure: The patient was taken to the operating room on [DATE]. Preoperative huddle and preincision
timeout was performed. Patient was in supine position. General anesthesia was obtained. A right internal jugular central
venous line, pulmonary artery catheter and radial arterial line were inserted. Transesophageal echocardiogram was performed.
Patient was prepped and draped in normal fashion.
A midline sternotomy was performed and the pericardium was opened and mobilized all the way to the left to create space for
the HVAD device. The patient was heparinized and arterial cannula was placed in the ascending aorta and 2-stage venous
cannula was inserted in the right atrial appendage. Once ACT was >480, patient was placed on cardiopulmonary bypass and
normothermia was maintained.
The HVAD ring was then sewn on to this region with a 12 pledgeted 2-0 Ethibond sutures. Subsequently, a circular
ventriculotomy was performed. Within the ventricle, all scarring and fibrosis and thickened trabecula were resected to ensure
that our inflow cannula would be unobstructed. At this time, the LVAD pump was placed in and secured. The heart was then
placed back into the pericardium and the driveline of the device was brought out through the right upper quadrant of the
abdomen. At this time, we checked the inflow cannula position and it was positioned perfectly, directed toward the mitral.
Subsequently, the outflow graft was measured to the ascending aorta and cut to length. A partial cross-clamp was placed over
the ascending aorta and after aortotomy was created, the graft was sewn on with 4-0 Prolene suture in an end-to-side fashion.
A deairing vent was placed in the ascending aorta. The partial cross-clamp was then removed. The heart was gradually de-
aired. We gradually increased the flow on the HVAD and came off cardiopulmonary bypass.
We were able to achieve flows of over 5 L/min and the right ventricular function was excellent. Postop TEE demonstrated no
residual TR or MR and no PFO. The patient continued to remain stable. At this time, we decannulated the patient and
administered protamine. Subsequently, chest tubes were placed and the sternum, subcutaneous tissue, and skin were closed in
the usual fashion. The patient continued to remain well and was taken to the ICU in stable condition.
All instruments, sponges and needles counts were confirmed to be correct x 2 at the end of the case.
20. LVAD – Heart Mate II

3. Intraop TEE
4. Consider inhaled prostacyclin for prophylaxis against RV failure
6. Pump pocket creation in the preperitoneal space
7. Open pericardium
8. Create tunnel for driveline with endoscopic tunneler
9. Systemic heparin
11. 2 stage single venous cannulation
12. Check ACT (>480)
14. Lift the apex of heart and identify the apex
15. Core the LV apex and place basket vent into the LV
16. Sew a strip of felt along anterolateral apex of the LV
17. Place a circular strip of felt on the apex and place annuloplasty sutures circumferentially along the LV cavity.
18. Place the annuloplasty stitches through the sewing ring
19. Bring a primed pump onto the table and place the inflow cannula through the sewing ring and secure.
20. Place the pump in the pump pocket and externalize the driveline
21. Size the outflow cannula
22. Place a partial cross clamp on the ascending aorta and sew on the outflow graft.
23. Connect the outflow graft to the pump
24. Place a deairing vent in the ascending aorta and deair the heart
25. Come off bypass and turn on pump and titrate to appropriate flows
26. Decannulate
28. Close chest.

2. The tunneler for the driveline has potential to hit bowel, liver, vessels, etc.
3. Need to create pocket large enough and lateral enough to sit properly
4. Fragile LV apex that can tear
5. Bleeding from the pump pocket
6. Outflow graft too long/short
7. Pump sitting in a poor position. Inflow cannula not directing towards the mitral valve
9. Bleeding
10. RV failure
11. Suction event
Template Dictation
Preoperative Diagnosis: [Indication: e.g. Ischemic cardiomyopathy]
Procedure(s) Performed: Implantation of HeartMate II left ventricular assist device as (INDICATION: destination therapy
or bridge to transplant)
Assistants: [BLANK]
Anesthesia: [BLANK]
Drains: [BLANK]
Specimen: [LV core]
[INTERMACS LEVEL] with [JUSTIFICATION OF STATUS]. Patient taken to the OR today for implantation of LVAD
Description of Procedure: The patient was taken to the operating room on [DATE]. Preoperative huddle and preincision
A midline sternotomy was performed and a pocket was created in the left upper quadrant of the abdomen in the preperitoneal
space for the HeartMate II LVAD. At this time, the pericardium was opened. The patient was heparinized and arterial cannula
was placed in the ascending aorta and 2-stage venous cannula was inserted in the right atrial appendage. Once ACT was >480,
patient was placed on cardiopulmonary bypass and normothermia was maintained.
The apex of the heart was subsequently elevated and a core ventriculotomy was performed. A basket sucker was placed in the
LV cavity and any residual obstructing bands of muscle within the LV were resected. Subsequently, a strip of felt was sewn
onto the anterolateral apex of the heart with a running Prolene suture. A strip of doughnut shaped felt was then placed on top of
this and twelve 2-0 Ethibond mattress sutures were placed circumferentially. The annuloplasty sutures were then placed
through the inflow cannula and then sewn in. The pump was brought to the table and connected to the inflow cannula and
secured with plastic tapes. The body of the pump was then placed in the previously created pump pocket. The driveline was
exited initially through a right upper quadrant and subsequently into the left upper quadrant in a double tunneling technique.
The VAD was then placed in the proper position and the inflow cannula position was excellent. Hemostasis at the inflow
cannula was assured. At this time, the outflow graft was measured to the mid ascending aorta. A partial cross-clamp was
placed and the aortotomy was performed. The outflow graft was sewn in an end-to-side fashion with 4-0 Prolene suture.
Subsequently, a vent was placed in the aorta, and after the de-airing procedure was done under TEE guidance, the patient was
gradually separated from cardiopulmonary bypass and went onto the HeartMate II LVAD support. We were able to achieve
flows of over 5 L/min and the right ventricular function was excellent. Postop TEE demonstrated no residual TR or MR and
no PFO. The patient continued to remain stable. At this time, we decannulated the patient and administered protamine.
Subsequently, chest tubes were placed and the sternum, subcutaneous tissue, and skin were closed in the usual fashion. The
patient continued to remain well and was taken to the ICU in stable condition.
21. Minimally Invasive Directed Coronary Artery Bypass
M. Scott Halbreiner MD and Joseph Sabik MD

2. Selective right lung ventilation
4. left anterolateral thoracotomy
5. LIMA takedown
6. Systemic heparinization (ACT > 400)
7. Opening pericardium
8. Placement of stabilizers
9. Proximal LAD occlusion or shunt placement
10. Perform anastamosis
11. Securing LIMA pedicle
12. Protamine administration
13. Doppler flow check of anastamosis
16. Reinflation of left lung (assess tension of graft with inflation)
17. Rib reapproximation and soft tissue/skin closure

1. Incorrect rib space for entry
2. Injury to LIMA
3. Inadequate right lung isolation
4. Phrenic nerve injury when opening pericardium
5. Insufficient graft length
6. Subclavian vein injury
7. Kinking of graft
8. Fibrillation
9. Need to go on CPB
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. isolated single coronary artery disease of LAD]
Procedure(s) Performed: Minimally invasive directed coronary artery bypass [DETAILS – e.g. LIMA to LAD]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of symptomatic coronary artery
disease and [COMPLAINT – e.g. increasing shortness of breath, angina, etc]. Preoperative coronary angiography reveals
[FINDINGS – e.g. 90% stenosis of mid-LAD and ejection fraction of 50%].
Description of Procedure: The patient was taken to the operating room on [DATE]. An appropriate review was performed
verifying the patient’s identity and planned procedure. While supine on the operating room table, general endotracheal
anesthesia was administered without difficult. Single right-sided lung ventilation was achieved with a [double-lumen tube or
bronchial blocker] and confirmed by bronchoscopy. A [right/left] internal jugular central line and a [right/left]
[radial/axillary/femoral/brachial] arterial line were placed. A pulmonary artery catheter [was/was not] placed.
Preoperative transesophageal echocardiogram was performed to evaluate cardiac and valvular function. The patient was then
prepped and draped in a sterile fashion including the chest, abdomen, groins and bilateral lower extremities. A time-out was
performed. A [BLANK]cm anterolateral skin incision was made in the [4th/5th] intercostal space at the inframammary fold.
Dissection was carried down to the intercostal space with minimal division of the pectoralis muscle. The thoracic cavity was
then entered in the standard fashion with care to avoid injury to the left internal mammary artery (LIMA). The patient was
heparinized with [BLANK]units and ACT verified. The LIMA was then divided distally and carefully dissected from the
intrathoracic fascia up to the level of the subclavian vein. The pericardium was then opened. The diseased left anterior
descending artery was identified and location of acceptable target was decided upon. There was adequate length of the
LIMA. A coronary artery stabilizing device was then placed through a small port incision in the chest to stabilize the LAD
target. [Proximal LAD occlusion was achieved with a 4-0 felt-pledgeted suture / An arteriotomy was performed in the
LAD and an intravascular shunt was used to prevent ischemia and] to achieve hemostasis. The LIMA was then
anastamosed to the LAD in an end-to-side fashion with a running 7-0 Prolene suture. Prior to completing the anastamosis the
[occlusion suture / intravascular shunt] was removed. At the completion of the anastamosis the pedicled LIMA was suture
fixated to the epicardium with interrupted sutures. Protamine was administered to reverse the heparin effects. The flow down
the bypass graft was checked and confirmed using a doppler flow probe. The coronary stabilizing device was removed and
hemostasis was achieved. A total of [BLANK] chest tubes were placed in the left pleural space and [BLANK]chest tube(s)
were placed in the mediastinum. [Atrial/Ventricular] pacing wires were placed in the standard fashion. The thoracotomy
was reapproximated with rib sutures and prior to closure the left lung was observed to reinflate completely and imposed
minimal tension on the LIMA graft. The subcutaneous tissues and skin were closed in the standard fashion and sterile
dressings were applied. The patient tolerated the procedure well and was [extubated in the operating room and then]
brought to the intensive care unit in stable condition.
All instrument, sponge and needle counts were confirmed to be correct following skin closure.
22. Aortic Valve Surgery with Upper Hemisternotomy Approach
Narongrit Kantathut, MD and Stephanie Mick, MD
Cleveland clinic, Cleveland, OH

1. Lines and Monitoring, external defibrillator pads
4. Upper hemisternotomy (to level of right 4th intercostal space and taken transversely through this space)
5. Open pericardium, pericardial well, survey ascending aorta for plaque burden (consider epiaortic ultrasound)
7. Arterial cannulation (Ascending aorta or femoral artery)
8. Venous cannulation (Right atrial appendage, SVC or Femoral vein)
9. Myocardial protection cannula placement (antegrade cannula in ascending aorta +/-retrograde cannula in coronary
sinus)
11. Initiate CPB
12. Aortic cross clamp (reduce CPB flow rate, apply cross clamp, return to full CPB flow)
13. Antegrade cardioplegia +/- topical cooling with ice for cardiac arrest (+/-
14. retrograde cardioplegia)
15. Aortotomy (transverse, oblique)
16. Excision of aortic valve cusps and decalcification
17. Aortic valve replacement
18. Aortotomy closure
19. Warm blood cardioplegia “hot shot” administration for rewarming
21. Deairing
22. Placement of pacing wires (ventricular +/- atrial)
23. Chest tube placement while on CPB
24. Wean from CPB
26. Protamine test and administration for heparin reversal

1. Make sure that the sternotomy is absolutely midline and that the midline sternotomy is not carried beyond the level of
the transverse part. Otherwise it will result in a lateral fracture, resulting in three sternal fragments, or a continued
lower extension of the midline fracture with retraction that produces severe intraoperative bleeding and difficulty in
closure.
2. Care must be taken not to cut too deeply when the sternotomy is continued into the right fourth intercostal space to
avoid injury to mediastinal pleura, right internal mammary artery and pericardium
3. Care must be taken when bringing up the pericardium and reopening the retractor, as sudden retraction with elevated
cardiac structures could impede venous return causing a sudden drop in cardiac output.
4. Cannulation catastrophe (Aortic dissection/bleeding, Right atrial tear)
drainage)
7. Incomplete decalcification of the aortic valve and annulus resulting in paravalvular leak and dehiscence
8. Perforation of the aorta and anterior leaflet of Mitral valve while calcific deposits are debrided
9. Deep debridement in the area below the junction of the right and non-coronary cusps in the membranous septum or
deeply placed valve sutures in this region, resulting in permanent heart block (bundle of His injury)
10. Not capturing debris during procedure or forcing debris into the left ventricle while the aortic root is flushed with
saline, this debris may embolize and lead to stroke
11. Incomplete deairing prior to removal of aortic root vent
12. Not recognizing bleeding from aortotomy (particularly at extremes of aortotomy)
14. Placement of the drains while the heart is full; this must be done on bypass with the heart decompressed or injury to
the heart can occur.
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. Severe AR, Severe AS]
Procedure(s) Performed: Upper hemisternotomy and AVR (DETAILS – e.g. Tissue valve or Mechanical valve)
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT – e.g. chest pain,
syncope and shortness of breath]. The preoperative echocardiography revealed [FINDINGS - e.g. severe AS, mean
gradient across aortic valve(mmHg), peak jet velocity(m/s), Aortic valve area (cm²), severe AR , LV end-diastolic
diameter(mm) , LV end-systolic diameter(mm), estimated ejection fraction, morphology of aortic valve – bi-leaflet or tri-
leaflet , calcified]. The preoperative coronary catheterization revealed [FINDINGS - e.g. No significant coronary artery
disease].
External defibrillator pads were attached. Preoperative transesophageal echocardiogram was performed to evaluate cardiac
function and valve function. The patient’s chest, abdomen, groins, and lower extremities were prepped and draped in standard
sterile fashion. A time out was performed.
A 8-10 cm. vertical midline incision was made [Potential additional details: starting at 2-3 cm. inferior to sternal notch or just
above the level of the manubriosternal angle]. An upper hemisternotomy was performed from the sternal notch to the level of
fourth intercostal space with the standard sternal saw and continued into the right fourth intercostal space using a narrow blade
oscillating saw. The sternal retractor was inserted, the thymus divided and the pericardium opened. Pericardial stay sutures
were placed and the retractor was removed. The stays were tacked to the subcutaneous tissues and the retractor replaced.
[Note: This facilitates exposure by elevating the pericardial contents forward to the operative field.]
The ascending aorta was palpated [and/or epiaortic ultrasound was used] and found to be free of calcification. The patient was
heparinized. The [ascending aorta or proximal aortic arch] was cannulated. [Alternative cannulation site for the arterial line is
the femoral artery by a small incision at the groin. The arterial cannula can be place via femoral artery by Seldinger technique.]
A two stage venous cannula was inserted via the [right atrial appendage/superior vena cava]. [Alternatively, a peripheral
venous cannula can be placed via the femoral vein by Seldinger technique and under TEE guidance. The cannula is guided into
the right atrium and the tip is placed in the superior vena cava.] Cardiopulmonary bypass was initiated.
An antegrade cardioplegia/vent cannula was placed in ascending aorta and a retrograde cardioplegia catheter was placed in
the coronary sinus via the right atrium under TEE guidance. [Alternative: this catheter can be placed by the anesthesiologists
via the transjugular route prior to the incision). [A right superior pulmonary vein or a left atrial dome vent can be placed.]
The aorta was crossclamped and and the heart arrested with first antegrade and then retrograde cardioplegia. During the
remainder of the surgery, cardioplegia was given every 15-20 minutes.
[Oblique /Transverse] aortotomy was performed 10-15 mm above the origin of right coronary artery and extended anteriorly
and posteriorly. [Additional [ml] of cardioplegia was delivered directly into the [right and/or the left] coronary arteries.] The
aortic valve was exposed, examined and found to be [trileaflet, bileaflet, heavily calcified, etc.]. The valve was excised and
the annulus decalcified. The [valve company] sizer was used and the outflow tract/annulus found to accommodate a [size]
valve. A series of [2-0, type of suture] pledgetted valve sutures were placed around the annulus with the pledgets on the
[aortic or ventricular] side. The valve sutures were taken sequentially around the sewing ring of the [company name] valve
and the valve was seated, then tied in place. The valve was seated and the sutures tied. The left and right coronary ostia were
visualized to be [e.g., well away] from the valve annulus and posts. The aortic root and aorta were again irrigated with normal
saline. The aortotomy was closed with two layers of running 4-0 prolene and the aorta was deaired.
The heart and ascending aorta were deaired and aortic cross-clamp was removed. Pacing wires [can specify type] and chest
drains [specify site – mediastinal/pleural] were placed. When the patient's heart was adequately recovered and thoroughly
deaired, [s/he] was weaned from cardiopulmonary bypass without difficulty. Intraoperative transesophageal echo
demonstrated [e.g. a well seated valve with no paravalvular leaks]. All cannulas were removed and the heparin effect was
reversed with protamine. Hemostasis was obtained and the wounds were closed in standard fashion. The patient tolerated the
procedure well and was brought to the Intensive Care Unit in [e.g. stable] condition.
23. Mitral Valve Replacement
Franjo Siric, MD and A. Marc Gillinov, MD

5. Open pericardium, elevation of the right side of the pericardium with stay sutures, survey ascending aorta for plaque
burden and cannulation site
6. Systemic heparinization (400 U/Kg)
7. Aortic cannulation
8. Venous cannulation- Bicaval
9. Aortic root vent
12. Maintain normothermia
14. Antegrade cold blood cardioplegia (1000-1200 ml)
15. Dissect Sondergaard’s groove
16. Standard left atriotomy
17. Expose and assess the mitral valve (fill left ventricle with cold saline to identify the mechanism of regurgitation)
18. Excise portion of anterior leaflet, preserving subvalvular apparatus
19. Size valve
20. Place annular valve sutures (pledgits on the left atrial side)
21. Implant valve
22. Check valve struts with a dental mirror
23. Left atriotomy closure
24. De-airing maneuvers
27. Place epicardial atrial and ventricular pacing wires
29. Evaluate mitral valve with transesophageal echocardiogram
31. Ensure adequate de-airing of the heart prior to removal of aortic root vent

2. Avoid injury to the innominate vein while making pericardial well
3. Cannulation catastrophe (aortic dissection/hematoma, right atrial tear)
4. Poor choice of location of aortic cannula/cross clamp (risk of stroke)
5. Injury of the pulmonary artery during cross clamp application
6. Insufficient myocardial protection and cardiac arrest (cross clamp not across, aortic regurgitation with secondary
ventricular distension)
7. Feel the left ventricle during administration of antegrade cardioplegia to ensure absence of ventricular distension and
uniform cooling of the ventricle with cardioplegia
8. Poor venous drainage (incorrect choice of cannula size, advancing the two-stage cannula too far in so it is obstructing
hepatic veins)
9. Failure to dissect Sondergaard’s groove
10. Improper dissection of the Sondergaard’s groove with inadvertent opening of the right atrium close to the inferior
vena cava
11. Opening the left atrium close to the right superior pulmonary vein with subsequent difficulty in exposing the mitral
valve
12. Retractor injury with subsequent shearing tear of the left atrial wall edges which complicates closure
13. Failure to recognize important vital structures in relation to the mitral valve: atrioventricular node, coronary sinus,
aortic valve and circumflex coronary artery
14. Improper placement of the annular sutures with misidentification of the mitral annulus and subsequent placement of
the sutures in the left atrial wall
15. Deep placement of annular sutures with subsequent injury to the circumflex coronary artery in a left dominant system
16. LVOT obstruction by the valve strut
17. Improper de-airing prior to removal of aortic root vent
18. Lifting the heart with the prosthesis in place causing AV disruption
20. Improper closure of sternotomy
Template Dictation
Preoperative Diagnosis: Severe mitral valve regurgitation/stenosis
1. Intraoperative transesophageal echocardiography
2. Mitral valve replacement
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE]year old [GENDER]with [DURATION]history of [COMPLAINT–e.g. increasingly
shortness of breath]. Preoperative transthoracic echocardiography reveals [FINDINGS -e.g. severe mitral valve regurgitation
and stenosis due to advanced rheumatic disease].
Description of the Procedure: After satisfactory general endotracheal anesthesia was induced, a right internal jugular central
venous line, pulmonary artery catheter and brachial arterial lines were inserted. Transesophageal echocardiogram was
performed to evaluate the mitral valve and cardiac function. The patient was prepped and draped in the supine position.
A standard median sternotomy was performed and sternal retractor was placed. We opened the pericardium in an inverted T-
shape fashion and pericardial stay sutures were placed on the right side. Heparin was given systemically and an aortic cannula
was inserted through two pursestring sutures in the distal ascending aorta, secured and de-aired. Bicaval cannulation. An
aortic root cardioplegia/vent was then inserted. After confirming ACT of more than 480 seconds, cardiopulmonary bypass was
commenced at 2.4 L/min per m2. We maintained normothermia during perfusion. The aorta was cross clamped. After
administering 750ml of Buckberg cardioplegia antegrade we administered 500ml of cardioplegia in the retrograde fashion.
Thereafter cold blood cardioplegia was given retrograde very 15 to 20 minutes. Simultaneously we developed Sondergaard’s
groove between left and right atrium and opened the left atrium about 1-2cm away from the orifice of right upper pulmonary
vein to decompress it. A self-retracting Cosgrove retractor was applied to sternal retractor. Once cardioplegia was given, the
self-retracting arms of Cosgrove retractor were placed starting cranially to visualize the mitral valve. Once we confirmed that
the valve could not be repaired we incised the anterior leaflet in its mid-portion. Before we cut it all out we started placing
everting, interrupted #2-0 ethibond pledgeted stitches on anterior annulus gently lifting the anterior leaflet to facilitate
visualization. We made our way to both commissures, detached the remainder of the anterior mitral leaflet and divided it in the
middle and brought the segments to the left and right to preserve chordae. Preserved portions of the anterior leaflet were sewn
to the annulus towards the left and right commissures, away from central portion of the inflow, with double armed interrupted
#2-0 ethibond pledgeted mattress stitches. Appropriately sized [Valve type and size] valve was selected and sutures were
placed through sewing cuff orienting the struts in a way to avoid obstructing the left ventricular outflow tract. Atrial closure
was completed after deairing. Retrograde and antegrade hot-shot was given and the aortic crossclamp was released. Following
thorough deairing we removed the aortic vent. The IVC cannula was removed while still on partial bypass, the cannulation site
was reinforced and CPB weaned off. Ventricular and atrial pacing wires were placed. Every attempt was made not to lift the
heart with the bioprosthesis in place given the possibility of posterior LV wall rupture. A test dose of protamine was
administered and the patient was monitored for adverse reaction before the protamine was resumed. The aortic cannula was
then removed. Adequate hemostasis was then confirmed within the mediastinum. The sternum was then closed with a total of
[NUMBER] stainless steel sternal wires. The wound was irrigated with antibiotic solution. The fascia was then closed with
#1 Vicryl suture in running fashion. The deep dermal layer was then closed with #2-0 Vicryl suture in running fashion. The skin
and subcuticular layer was closed with #3-0 Monocryl in running fashion. The skin of the wound was cleansed with sterile
saline and dressed with antibiotic ointment and a Primapore dressing.
subsequently transferred to the postoperative cardiac surgical intensive care unit in critical condition.”
24. Minimally Invasive Mitral Surgery
Brian Solomon, MD and Eugene Grossi, MD
New York University Langone Medical Center, New York, NY

2. General endotracheal anesthesia +/- Right Lung Isolation
3. Intraoperative trans-esophageal echocardiogram (Evaluation of Aortic atherosclerotic disease)
4. Femoral vessel dissection and palpation of cannulation sites
5. Purse-string of femoral artery and vein
6. Right anterior thoracotomy – 4th intercostal space
7. Chest wall retraction, soft tissue retractor, and exposure
8. Open pericardium, survey ascending aorta and right atrium
9. Carbon dioxide line
11. Femoral arterial cannulation
12. Long venous cannulation through femoral vein – placement under TEE guidance
13. Lines tested
15. Initiate CPB
16. Myocardial protection cannula placement (DLP in aortic root, +/-retrograde cannula in coronary sinus)
17. Flexible aortic cross clamp placed (reduce CPB flow rate, apply cross clamp, increase CPB flow to 2.0-
2.5L/min/m2)
18. Antegrade cardioplegia (20 cc/kg initial dose) and (+/- retrogrograde cardioplegia)
19. Incision in Sondergaard’s groove. Intra-atrial septal retractor blade and handle placed.
20. Valve inspected. Saline distention test. Reconciliation with TEE pathology
21. Triangular resection of posterior leaflet, re-approximation with primary sutures
22. Valve measured along base and size of anterior leaflet
23. Ethibond sutures placed in posterior annulus from anterior to posterior trigone
24. Sutures passed through annuloplasty band
25. Annuloplasty band seated along annulus and secured
26. Saline distention test
27. Left ventricular vent placed
28. Closure of atriotomy – 2 rows running 4-0 prolene
29. Cross-clamp removed with root and LV vents on suction
30. Heart defibrillated
31. De-airing confirmed with TEE
32. Removal of vents and over-sewing of vent sites, tying LA closure sutures
33. Temporary epicardial pacer wire placement
34. Removal of arterial and venous cannulae
35. Reversal of heparinization
36. Hemostasis obtained
37. Blake drain placed in pericardium
38. Loose closure of pericardium
39. Pleural chest tube placement
40. Intercostal block
41. Closure of thoracotomy and groin incision

1. Entering incorrect intercostal space – resulting in poor exposure
2. Avoid injury to IMA when performing thoractomy
3. Avoid damage to femoral vessels or profunda when dissection groin vessels
6. Insufficient myocardial protection and cardiac arrest (cross clamp not completely across aorta, unrecognized aortic
insufficiency, insufficient venous drainage)
7. Coronary sinus injury with retrograde cardioplegia cannulation – if used
8. AV groove dissociation if dissecting posterior annulus
9. Incomplete coaptation of valve with residual mitral insufficiency
10. Valve sutures placed excessively deep, risking damage to circumflex artery
11. Valve sutures placed excessively deep, risking damage to conduction system / AV block
12. Valve sutures placed too deep causing injury to left cusp aortic valve – resultant aortic insufficiency
13. Mitral annular calcification with resultant annular disruption for valve sutures
14. Postoperative systolic anterior motion of the anterior mitral leaflet.
15. Bleeding
Template Dictation
Preoperative Diagnosis: [INDICATION– e.g. Mitral Valve Insufficiency, Mitral Valve Prolapse, Ischemic Mitral Valve
Disease]
Procedure(s) Performed: Minimally invasive mitral valve repair (DETAILS – e.g.resection of posterior leaflet prolapse,
suture valvuloplasty, annuloplasty with #30 Medtronic Future band).
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER]with [DURATION]history of [COMPLAINT–e.g. congestive
heart failure and shortness of breath]. Preoperative evaluation revealed [PRE-OPERATIVE FINDINGS e.g. - torn chordae
in the posterior mitral valve leaflet and severe mitral valve insufficiency with normal ventricular size and function, but
pulmonary hypertension in response to exercise].
Operative Findings: Fibroelastic deficiency of the valve with ruptured chordae in the P2 segment of the posterior leaflet. Left
ventricular systolic function was normal.
Wound Classification: Clean.
Specimens: Segment of posterior mitral valve leaflet was sent to Pathology.
Implant: Mitral valve annuloplasty – [Make, Model, Size, Serial Number]
Pump Data:
Cross-clamp time: [TIME]
Bypass time: [TIME]
Blood: None
Description of Procedure: The patient was taken to the operating room and general anesthesia was induced without
hemodynamic change. A central venous catheter and an arterial pressure measuring lines were placed. Trans-esophageal
echocardiography was performed and pre-operative pathology was confirmed. TEE was used to monitor throughout the case.
Patient was prepped and draped in the usual sterile fashion. Evaluation confirmed that patient was good candidate for
retrograde arterial perfusion. A 4 cm transverse small incision was made in the right groin, inferior to the inguinal ligament.
The common femoral artery and vein were exposed. The artery was palpated. It was noted to be soft, without visible or
palpable calcifications. A purse-string suture was then placed in the anterior wall of the femoral vein. An 8 cm right anterior
thoracotomy incision was performed at the level of the 4th intercostal space, adjacent to the right sternal border. The fourth
intercostal space was entered using electrocautery. A skin retractor was secured within the incision and a soft tissue retractor
placed in the intercostal space using the [Color] blades, to expose the underlying pericardium. The pericardium was
visualized and opened, exposing the lower ascending aorta and right-sided cardiac structures. The field was flooded with
carbon dioxide throughout the case to minimize intracardiac air.
The patient was systemically heparinized. Next, an arterial cannula was placed in the right common femoral artery over a
guidewire, using the modified Seldinger technique, within the arterial purse-string. A long venous cannula was placed through
a purse-string suture in the right common femoral vein, also using the modified Seldinger technique. The long venous cannula
was positioned in the right atrium with the tip in the superior vena cava, confirmed by echocardiography. The cannulae were
attached to cardiopulmonary bypass and the lines tested. Cardiopulmonary bypass was begun and the patient was systemically
cooled to 32 degrees centigrade. A cardioplegia catheter was placed into the aortic root. The ascending aorta was occluded
with a flexible cross-clamp through the thoracotomy. Cardioplegia was then re-injected part way through the cross-clamp time
and myocardial protection was excellent.
In the event of concurrent aortic insufficiency: The heart became somewhat distended, due to a degree of aortic
insufficiency. A small atriotomy incision was made and under direct vision, a retrograde cardioplegia catheter was placed in
the coronary sinus. The atriotomy was closed and cardioplegia was reinitiated with retrograde cardioplegia.
An incision was made in the left atrium posterior to the interatrial septum in Sondergaard’s groove. Septal retractor blade was
placed nicely exposing the mitral valve. It was secured to a “iron intern” retractor through a 0.5 cm separate incision placed
just medial to the thoracotomy. The valve was carefully inspected, comparing all leaflet to P1. Valve were inspected for
deformity, coaptation, ruptured chordae, and prolapse. Cold saline was gently instilled into the left ventricle and the valve
was assessed for regurgitation. The following findings were observed: [Findings - e.g. - P2 segment of the posterior leaflet
had several ruptured chordae and was flail in its midportion, with intact chordae on each side]. The decision was made to
repair the mitral valve.
In the event of a mitral valve repair: The flail leaflet was excised in a triangular V-type fashion. A primary repair was
performed with figure-of-eight 4-0 Ethibond sutures. The mitral valve was measured using mitral valve sizing tools. It was
measured from along the anterior leaflet from anterior to posterior commissure and a [size] annuloplasty ring was selected.
Next, 2-0 Ethibond sutures were placed in each trigone. Additional 2-0 Ethibond sutures were placed along the annulus
posteriorly. The sutures were placed through the sewing ring of the annuloplasty. The annuloplasty device was seated on the
mitral valve annulus and each suture was tied using [extracorporeal knot pusher or Core Knot] and cut.
In the event of a mitral valve replacement: The mitral valve was measured using mitral valve sizing tools. It was measured
from along the anterior leaflet from anterior to posterior commissure and a [size] mitral valve prosthesis was selected. The
anterior leaflet of the mitral valve was excised sharply from the posterior to anterior commissure. The posterior leaflet was
left in situ to protect the AV groove. Next, 2-0 Ethibond sutures were placed in each trigone. Additional 2-0 Ethibond sutures
were placed along the annulus posteriorly. Finally 2-0 Ethibond sutures were placed along anterior annulus. The sutures were
placed through the sewing ring of the valve prosthesis. The prosthesis was seated on the mitral valve annulus and each suture
was tied using [extracorporeal knot pusher or Core Knot] and cut.
Gentle distention of the left ventricle with cold saline revealed a competent valve in all zones. A vent was placed through the
atriotomy incision across the valve and the left ventricle. The atriotomy incision was closed with double layer of 4-0 prolene.
With the left ventricular vent and the aortic root vent on suction, the cross-clamp was removed and the heart re-perfused. It
was subsequently defibrillated and returned to normal sinus rhythm. The vents remained on suction until all micro-bubbles
were cleared from the circulation and cardiac tone returned. This was confirmed on echocardiography. The vents were then
removed. The vent sites were securely sutured with 4-0 prolene.
Temporary right atrial and right ventricular pacemaker wires were placed on the heart. Left ventricular function was
[description of EF] and the echocardiogram confirmed no residual mitral valve insufficiency. The venous cannula was
removed and bleeding was controlled by tying the purse-string suture in the anterior wall of the femoral vein. It was then
oversewn with 5-0 prolene. After obtaining proximal and distal control of the femoral artery with vascular clamps, the arterial
cannula was removed. The arteriotomy was then closed with a running 5-0 prolene suture. Distal pulses were confirmed and
the femoral artery was palpated to assure no residual thrill in the artery. Heparin was reversed with protamine.
Hemostasis was obtained at all operative site. A 24 Fr Blake drain was placed within the pericardium. The pericardium was
partially closed over the ascending aorta and the right atrium. A 28 Fr straight chest tube was placed in the right pleural cavity.
An intercostal block was performed using 0.25% Marcaine. The intercostal space was then closed with blunt #2 Vicryl
sutures. The fascia was closed in 3 layers with vicryl suture. The skin was then closed with 4-0 monocryl sutures in a running
subcuticular fashion. The groin incision was also closed in layers with vircyl and monocryl suture. The patient was brought to
the recovery room in stable condition without complication.
25. Mitral Valve Repair for Bileaflet Prolapse
Sameh M. Said, MD, and Hartzell V. Schaff, MD

5. Open pericardium, elevation of the right side of the pericardium with stay sutures, survey ascending aorta for plaque
burden and cannulation site
8. Venous cannulation-single two-stage right atrial cannula
9. Aortic root vent/cardioplegia needle
12. Maintain normothermia
13. Aortic cross clamp (reduce pump flow rate, apply cross clamp, increase pump flow rate to 2.0-2.5 L/min/m2)
14. Antegrade cold blood cardioplegia (1000-1200 ml)
15. Dissect Waterston’s groove
16. Standard left atriotomy
17. Expose and assess the mitral valve (fill left ventricle with cold saline to identify the mechanism of regurgitation)
18. Triangular excision or plication of the prolapsed posterior leaflet
19. The remaining edges of the posterior leaflets are sewn together in two layers with 4-0 Prolene suture or plication
with figure of-eight 4-0 Prolene
20. For anterior leaflet repair, artificial chordae (Gore-Tex) are used to correct prolapse
21. Posterior annuloplasty band (63 mm in length) is placed from trigone-to-trigone secured with interrupted 2-0
Ethibond, usually 7 or 8 sutures
22. The mitral valve is checked with cold saline injection into the left ventricle, ensure aortic root vent is off
23. Left atriotomy closure
25. Lowering pump flow rate and removal of aortic cross clamp
27. Placement of epicardial atrial and ventricular pacing wires
30. Evaluate mitral valve with transesophageal echocardiogram
34. Aortic decannulation (systolic blood pressure 90-100 mmHg)

2. Avoid injury to the innominate vein while making pericardial well
3. Cannulation catastrophe (aortic dissection/hematoma, right atrial tear)
4. Poor choice of location of aortic cannula/cross clamp (risk of stroke)
6. Insufficient myocardial protection and cardiac arrest (cross clamp not across, aortic regurgitation with secondary
ventricular distension)
7. Feel the left ventricle during administration of antegrade cardioplegia to ensure absence of ventricular distension and
uniform cooling of the ventricle with cardioplegia
hepatic veins)
9. Failure to dissect Waterston’s groove
10. Improper dissection of the Waterston’s groove with inadvertent opening of the right atrium close to the inferior vena
cava
11. Opening the left atrium close to the right superior pulmonary vein with subsequent difficulty in exposing the mitral
valve
12. Retractor injury with subsequent shearing tear of the left atrial wall edges which complicates closure
13. Failure to recognize important vital structures in relation to the mitral valve: atrioventricular node, coronary sinus,
aortic valve and circumflex coronary artery
14. Excessive excision of the prolapsed leaflet tissue which may compromise the repair
15. Poor judgement of the neochordal length with either persistence of leaflet prolapse or poor leaflet coaptation
16. Improper placement of the annuloplasty sutures with misidentification of the mitral annulus and subsequent placement
of the sutures in the left atrial wall
17. Deep placement of annuloplasty sutures with subsequent injury to the circumflex coronary artery in a left dominant
system
18. Improper de-airing prior to removal of aortic root vent
19. Failure to recognize systolic anterior motion (SAM) of the mitral valve anterior leaflet postrepair by transesophageal
echocardiogram
21. Improper closure of sternotomy
Template Dictation
1. Severe mitral valve regurgitation
2. NYHA class II
3. Prolapse of the middle scallop of the posterior leaflet
4. Prolapse of the middle segment of the anterior leaflet
1. Mitral valve repair with triangular excision of the unsupported lateral half of the middle scallop of the posterior
leaflet
2. Placement of two artificial Gore-Tex chordae to the middle segment of the anterior leaflet
3. Insertion of C-shaped posterior annuloplasty band (63 mm)
4. Establishment of temporary extracorporeal circulation using the FX15 membrane oxygenator with 3000-ml reservoir
with 3/8 loop to 37 degrees
5. Cardioplegic arrest (blood) 4:1
Assistants: [BLANK]
Anesthesia: [BLANK]
Drainage: 2 No. 32 Argyle chest tubes
Indication(s) for Procedure: [AGE] year old [GENDER]with [DURATION]history of [COMPLAINT–e.g. increasingly
shortness of breath]. Preoperative transthoracic echocardiography reveals [FINDINGS -e.g. severe mitral valve regurgitation
secondary to bileaflet prolapse, rupture chord of the middle scallop of the posterior leaflet with estimated ejection fraction of
50-55%], and preoperative coronary angiography revealed non-significant coronary artery disease.
Description of the Procedure: After satisfactory general endotracheal anesthesia was induced, a right internal jugular central
venous line, pulmonary artery catheter and radial arterial line were inserted. Preincision transesophageal echocardiogram was
then performed to evaluate the mitral valve and cardiac function. The patient was prepped and draped from chin to knees while
in the supine position. A standard median sternotomy was performed and Morse sternal retractor was placed. We opened the
pericardium in an inverted T-shape fashion and pericardial stay sutures were placed on the right side. Heparin was given
systemically and a 20-French DLP cannula was inserted through two pursestring sutures in the distal ascending aorta, secured
and de-aired. A two-stage cannula was placed in the right atrium for venous return and was secured. An aortic root
cardioplegia/vent was then inserted. After confirming ACT of more than 400 seconds, cardiopulmonary bypass was
commenced at 2.4 L/min per m2 for 41 minutes. We maintained normothermia during perfusion. The aorta was cross clamped
and 1 L of antegrade cold blood cardioplegia was administered. Waterston’s groove was dissected and an incision was then
made posterior to the interatrial groove to expose the mitral valve. There was redundancy of the valve, and the appearance
was typical for a myxomatous mitral valve disease. The prolapsing portion of the posterior leaflet was the lateral half of the
middle scallop and the medial half of the lateral scallop. We excised this area in a triangular fashion and sewed the middle
scallop to the lateral scallop in two layers with 4-0 Prolene. The middle segment of the anterior leaflet was noted to prolapse
as well, and we placed two 2/0 Gore-Tex sutures to this prolapsed segment passing each limb of the suture twice through the
free edge of the leaflet. One mattress suture was anchored to the anterolateral papillary muscle and one was anchored to the
posteromedial papillary muscle. The valve was tested with saline infusion to facilitate adjustment of the Gore-Tex suture
length, and the sutures were tied with multiple knots. Next, seven interrupted mattress sutures of 2-0 Ethibond were placed
along the posterior circumference of the valve beginning at the right and ending at the left fibrous trigones. These sutures were
passed through a 25 Medtronic annuloplasty band (63 mm in length) and tied securely. We tested the valve, and there was no
leakage. The left atrial incision was closed with 3-0 Prolene. Air was evacuated from the heart and the aortic cross-clamp
was released after 30 minutes. Sinus rhythm was restored with a single countershock. We de-aired the heart thoroughly and
discontinued bypass easily. No inotropic agents were required. Postprocedure transesophageal echocardiography confirmed
absence of mitral regurgitation, good ventricular function and absence of SAM.
The right atrium was decannulated and confirmation of adequate de-airing of the heart, the aortic root vent was removed.
Protamine was administered followed by removal of the aortic cannula. All cannulation sites were reinforced with 3-0 and 4-0
Prolene sutures. Two atrial pacing wires were attached to the heart. Two No. 32 Argyle chest tubes were led into the
mediastinum through stab wounds inferior to the incision. After adequate hemostasis was obtained, we closed the chest using
interrupted stainless steel wire for the sternum and Vicryl for the subcutaneous and subcuticular layers.
All instrument, sponge and needle counts were confirmed to be correct x 2 at the end of the operation. The patient tolerated the
procedure well and was transferred to the intensive care unit in a stable hemodynamic condition.
Intraoperative autotransfusion was present.
26. Orthotopic Heart Transplantation
Jose P. Garcia, MD and Tae H. Song, MD
Massachusetts General Hospital, MA

1. Communication with procurement team throughout procedure
4. Intraoperative transesophageal echocardiogram (TEE)
5. Median sternotomy after confirmation from procurement team
6. Dissection to free up heart / ventricular assist devices if present
7. Creation of pericardial well
8. Proceed with cardiopulmonary bypass once donor heart close to arrival
9. Systemic heparinization 350-400 units/kg
11. Bicaval venous cannulation
12. Check activated clotting time (ACT) > 400-450 secs
14. Aortic cross clamp, tighten caval snares
15. Cardiectomy
16. Left atrial anastomosis
17. Inferior vena cava (IVC) anastomosis
18. Superior vena cava (SVC) anastomosis
19. Pulmonary artery (PA) anastomosis
20. Start rewarming
21. Aortic anastomosis
25. Atrial and ventricular epicardial pacing wire placement
27. Check for hemostasis, inspect suture lines

1. Difficult redo sternotomy, cardiectomy
2. Inadequate communication with procurement team
3. Prolonged donor heart ischemic time due to above issues
4. Cannulation issues (aortic dissection/bleeding, caval injury)
5. Inadequate cuffs for anastomosis
6. Kinking of anastomoses and/or insufficient length resulting in tension
7. Sinoatrial node injury
8. Improper deairing
9. Bleeding from anastomoses
10. Inadequate control of hemostasis prior to sternal closure / bleeding from cannulation sites
11. Coagulopathy
12. Right heart failure
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. End-stage heart failure]
Procedure(s) Performed: Orthotopic heart transplantation
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: The patient is a [AGE]-year-old [GENDER] with a [DURATION] history of [COMPLAINT
– e.g. ischemic cardiomyopathy, idiopathic dilated cardiomyopathy, end-stage heart failure secondary to amyloid deposition].
The patient had previously undergone placement of a left ventricular assist device (LVAD) as a bridge to transplant, and an
organ appropriate for implantation became available.
Description of Procedure: The patient was taken to the operating room on [DATE]. After identification of the patient and
verification of informed consent, the patient was placed on the operating room table in supine position. General anesthesia was
administered after endotracheal intubation. A right internal jugular central venous line and a PA catheter was placed, and a
right radial arterial line was inserted. The chest, abdomen, and groins were prepped and draped in sterile fashion. A timeout
was performed, including confirmation that preoperative antibiotics had been given. Aminocaproic acid was also started. A 5
French right femoral artery catheter was then placed to provide quick access if needed during the procedure.
After confirming with the procurement team that the donor organ was suitable for implantation, median sternotomy was
performed. Communication with the procurement team was continued throughout the case. The heart and LVAD was dissected
free while being careful not to disrupt the conduit from the LVAD to the ascending aorta and avoiding injury to the right
ventricle. Careful dissection was continued to free up the native heart and great vessels. Aortic cannulation sutures were then
placed in the distal ascending aorta close to the arch. Bicaval cannulation sutures were placed in the SVC and IVC / right
atrium junction. With the donor heart near the hospital, intravenous heparin was given. The aortic cannula was then inserted,
secured and de-aired. The PA catheter was withdrawn into the sheath. SVC and IVC venous cannulas were then placed and
secured. Umbilical tape snares were passed around the SVC and IVC. After verifying adequate ACT, cardiopulmonary bypass
was initiated, and the patient was cooled to 28 degrees celsius.
The aortic cross-clamp was applied, and the caval snares were tightened. The proximal aorta and PA was transected, and the
left atrium was incised along the atrioventricular groove, leaving an adequate cuff. The SVC and IVC was also divided,
leaving sufficient length for anastomosis. The heart and LVAD was explanted. Hemostasis was achieved, and the vessels and
atrial cuff were examined and trimmed in preparation for anastomosis. During this time, the donor heart had been brought into
the room and was prepared at the back table. This was done by Dr. [BLANK]. A patent foramen ovale was found in the donor
heart and was closed. ABO compatibility was verified and documented in the chart. The donor heart was then brought onto the
field. We first performed the left atrial anastomosis using a double-armed 3-0 Prolene suture. A catheter was placed in the
right superior pulmonary vein and fed into the left ventricle just before closing the anastomosis. After this anastomosis was
completed, we then gave 500 mL of cold blood cardioplegia down the cardioplegia catheter in the donor aorta. We then turned
our attention to the vena cava. First the IVC, then the SVC anastomosis was performed using 4-0 Prolene suture. We made sure
that there was no narrowing at the caval anastomoses, and used locking technique so as not to cause the anastomosis to
pursestring. We were also careful not to injure the sinoatrial node during manipulation of the SVC. Another 400 mL of cold
blood cardioplegia was given. Next, the PA anastomosis was performed after it had been cut to size. This was done using 4-0
Prolene suture. Rewarming was started, and then the aortic anastomosis was completed using 4-0 Prolene suture.
The aortic cross-clamp was removed after giving 1 gram of Solu-Medrol. The heart was allowed to re-perfuse for an
appropriate amount of time before attempting to wean from bypass. The lungs were suctioned and ventilation was started. The
caval snares were released. The heart chambers were checked for air on TEE, and deairing maneuvers were performed.
Inotropes and pressors were started by anesthesia, and the patient was weaned off cardiopulmonary bypass. TEE showed good
biventricular function, and widely patent anastomoses. The venous cannulae were removed, and the PA catheter was re-
advanced into the main PA. Protamine was administered and hemostasis was achieved, and the suture lines were inspected
carefully. Atrial and ventricular pacing wires were placed, and atrial pacing was started. After ensuring hemodynamic
stability, the aortic cannula was removed. Two 28 French chest tubes were placed in the mediastinum, one curved tube at the
diaphragm, and one straight tube anteriorly. 19 French Blake drains were placed in the right and left pleural spaces. The
sternum was closed with a total of [BLANK #] stainless steel sternal wires. The fascia was closed with number 1 PDS suture
in running fashion. The deep dermal layer was then closed with running 2-0 Vicryl suture. The skin was closed with 4-0
Monocryl in running fashion, and sterile dressing was applied. All sponge and needle counts were correct times two. The total
cardiopulmonary bypass time was [NUMBER] minutes. The total ischemic time of the donor heart was [NUMBER] minutes.
The patient tolerated the procedure well, and was taken to the cardiac intensive care unit in stable condition.
27. Thoracoabdominal Aneurysm Repair
Zarrish S. Khan, MD and Leonard N. Girardi, MD

1. Preoperative workup- CTAngiogram, cardiac catheterization, lung function tests, room air ABG, bowel preparation.
3. General anesthesia, endotracheal intubation with bronchial blocker
4. Spinal drain
5. Right lateral decubitus position
6. Thorocoabdominal incision (5th IC thoracotomy with paramedian extension into abdomen)
7. Take down diaphragm circumferentially.
8. Expose the entire extent of diseased aorta and identify sites for clamping-take down attachments from lung, medial
visceral rotation in abdomen.
9. Have a plan for clamping, extent of resection, spinal and visceral protection and monitoring. Be ready to change the
plan.
10. Systemic heparinzation
11. Cannulation for left atrial-femoral artery bypass
12. Prioxal and distal clamps
13. Aortotomy
14. Oversew briskly backbleeding intercostals, plan to re-anastomose large intercostals with no back bleeding
15. Transect proximal aorta and end-to-end anastomosis with 3-0 prolene.
16. Move down cross clamp and check hemostasis
17. Come off partial bypass
18. Balloon tip catheters placed in mesenteric and renal arteries and selective perfusion initiated.
19. Reattach intercostals arteries
20. Reattach renal and visceral arteries as an island or individually as buttons.
21. Reclamp below this anastomosis
22. Distal anastomosis
23. Trendelenburg position. Remove clamp
24. Check for backbleeding intercostals
25. Reverse heparin. Assess hemostasis
26. Wrap the graft with native aorta
27. Close diaphragm
28. Place anterior and posterior chest tubes and abdominal closed suction drains
29. Incision closed in layers.
Potenital Complications and Pitfalls

1. Have an efficient team-limit cross clamp time
2. Use systemic cooling if unable to cross clamp or anticipate long cross clamp.
3. Failure to adequately protect spinal cord. Paraplegia/ paraparesis. Strategies to protect include ensuring adequate
cerebral perfusion with MAP goal 85-90, CSF drainage at L3-L5 level, distal aortic perfusion, intercostal / lumbar
artery re-attachment, intrathecal vasodilator, deep hypothermic circulatory arrest, monitoring including transcranial
Doppler ultrasound (TCD), electroencephalogram (EEG) and motor-evoked potentials (MEP).
4. Inability to keep up with hemodynamic and metabolic effects of clamping and blood loss.
5. Inadequate exposure from incision that is placed too low
6. Left vagus, left phrenic and left recurrent nerves injury during placement of proximal clamp
7. Iatrogenic injury –rib fracture, chyle leak, esophageal injury, spleen laceration, bowel/ureter injury
8. Embolization-stroke, visceral , extremity/visceral ischemia
9. Renal failure
10. Failure to leave adequate diaphragmatic cuff for closure-potential for diaphragmatic herniation
11. Inadequate fascia closure-herniation
Template Dication
Preoperative Diagnosis: [Indication eg size and Extent (I/II/III/IV/V) thoracoabdominal aortic aneurysm, dissection,
coarctation, traumatic injury].
Procedure(s) Performed: Repair of thoracoabdominal aortic aneurysm with reimplantation of the visceral and renal vessels
utilizing left atrial to distal aortic bypass utilizing a 26 mm(size) woven Dacron graft.
Assistants: [BLANK]
Anesthesia: [BLANK]
Cross clamp time: [NUMBER]
Pump time: [NUMBER]
Renal Ischemia Time: [NUMBER]
Urine Clearance Time: [NUMBER]
Blood Products: [NUMBER] units packed red blood cells, [NUMBER] units FFP, [NUMBER] units platelets.
Pulse Status: 2+ femoral, SMA and celiac axis.
Drains: chest tubes, 36-French times 2, Reliavac in abdomen.
Complications: [BLANK].
Indication(s) for Procedure: [AGE] year old [GENDER] with history of [PMH] who was found to have [S IZE]
thoracoabdominal aortic aneurysm extending from the left subclavian artery down to the bifurcation [EXTENT]. It was
thrombus filled. His [BRANCH VESEEL STATUS] eg left renal artery was occluded, had stenosis of the celiac axis and and
mild stenosis of the right renal artery,iliac arteries were patent and non aneurysmal.
In preparation for surgery, cardiac catheterization was performed which showed [[BLANK] egno significant coronary
disease. PFTs were obtained that showed FEV1 of[BLANK], DLCO of[BLANK]. His kidney function was adequate with
baseline Cr [BLANK]. He is able to walk 5 city blocks without any symptoms (Exercise capacity). He was advised to undergo
the aforementioned procedure. Risks, benefits and alternatives were explained to the patient and family including the risk of
paraplegia, paraparesis, stroke, respiratory failure, renal failure, infection, myocardial infarction, hemorrhage, recurrent nerve
palsy and death. He expressed understanding and agreed to proceed.
Description of Procedure: The patient was brought into the operating room and placed on the operating table in supine
position. General endotracheal anesthesia was induced without difficulty. Right radial arterial line, right internal jugular Swan-
Ganz catheter and foley catheter were placed. Right groin cordis was placed for rapid infusion during operation. Bronchial
blocker was placed for single lung ventilation. The patient was placed into the right lateral decubitus position with bean bags
and pressure points padded. Spinal drainage catheter was placed in the L3-L4 interspace. Shoulders were supported at 60
degrees. Hips were rotated posteriorly 45 degrees and he was prepped and draped in the usual sterile fashion using betadine
solution.
Sigmoid thoracoabdominal incision was made behind scapula to mid-axillary line than angled toward umbilicus. Fifth
intercostals space was entered and costal margin divided The 6th rib was excised. Inferior pulmonary ligament was taken
down. The diaphragm was taken down circumferentially and a medial and visceral rotation was performed for retroperitoneal
approach. Proximal control of the aorta was obtained just beyond the left subclavian artery. The left vagus, left phrenic and left
recurrent nerves were identified and preserved. 6000 units of heparin were given. A cannula was placed in the left inferior
pulmonary vein (or left atrium) . Return cannula was placed in the aorta at the level of the diaphragm (distal aorta/ femoral
artery). Flows were initiated at 3 L/minute at a temperature of 32 degrees Celsius.
The proximal and distal clamps were applied. The aorta was opened longitudinally. A large volume of thrombus was
evacuated. Small intercostal arteries were oversewn with 2-0 silk sutures. (plan to reimplant large intercostals without brisk
bleeding). The aorta was then transected circumferentially and dissected off the esophagus. End-to-end anastomosis was
carried out with a running 3-0 Prolene suture and a 26 mm graft. This was reinforced with pledgeted Prolene sutures. The
crossclamp was moved down below this anastomosis which was checked for hemostasis.
Partial bypass was discontinued. The aorta was opened down to just above the bifurcation. If selective perfusion is planned
celiac, superior mesenteric and renal arteries are cannulated with balloon perfusion catheters and selective perfusion is
initiated. [Number eg two] pairs of intercostal arteries were selected for reattachment and sutured to an opening in the side of
the graft.
The right renal artery, superior mesenteric,celiac, left renal arteries were then reattached with running 3-0 Prolene suture as an
island. This was reinforced with pledgeted Prolene sutures. Clamp was moved down below this anastomosis. Renal ischemic
time 19 minutes. [This can also be done as separate anastomoses by tailoring buttons out of aorta at each vessel orifice,
mobilizing proximal portion and anatomizing to an 8mm limbs of a four branch Dacron graft]
The aorta was reconstructed just above the bifurcation with a running 3-0 Prolene suture and a 26 mm graft. The patient was
placed in Trendelenburg position. Crossclamp was removed. Graft was de-aired. Crossclamp time was 44 minutes. Methylene
blue was administered and appeared in the urine in 10 minutes. There were no other intercostals that were backbleeding.
Protamine sulfate was administered to reverse the heparin. All cannulas were removed. The aneurysm sac was then wrapped
around the graft with 3-0 Prolene suture. Diaphragm was reapproximated with running 1-0 Prolene suture.
Relia-Vac drain (closed suction) was placed in the retroperitoneum and the abdomen was closed with running #1 Prolene
suture. Two chest tubes were placed one anteriorly and one posteriorly. The chest was reapproximated with interrupted #2
pericostal Vicryl sutures. Chest wall musculature was closed with PDS sutures and the skin with skin staples. Sterile dressing
was applied.
The patient was placed back in the supine position. All instrument, sponge and needle counts were confirmed to be correct x 2
at the end of the operation. The patient was subsequently transferred to the postoperative cardiac surgical intensive care unit in
critical condition.
28. Permanent Pacemaker Insertion
Jonathan C. Hong, MD and Jamil Bashir, MD
Division of Cardiovascular Surgery, St. Paul’s Hospital
University of British Columbia, Vancouver, BC

1. Peripheral venous access and monitoring
2. Prophylactic antibiotics
3. Local anesthetic +/- conscious sedation
4. Incision along the deltopectoral groove
5. Formation of a subcutaneous pocket
6. Cephalic vein cut down
7. Central venous access
8. Lead placement
9. Pacing parameters testing (sensing, impedance, and pacing threshold)
10. Connect leads to generator and placement of generator into pocket
11. Wound closure

1. The pocket is created before lead placement, thus reducing the chance of inadvertently displacing the leads once they
are positioned.
2. The usual course of the cephalic vein is in the delto-pectoral groove, penetrating the clavi-pectoral fascia to join the
axillary vein medial to the pectoralis minor muscle. A variant of the cephalic vein runs over the superficial surface of
the clavicle to join the external jugular vein.
3. When encountering difficulty obtaining central venous access, a venogram can be performed using the peripheral
intravenous line in the antecubtial fossa to visualize the course of the vein. Increasing venous filling (intravenous
fluids and elevating the legs) may also help.
4. A hydrophilic guide wire can be used when the venous valves obstruct the passage of a lead.
5. If there are poor pacing parameters despite good visual anatomic position, troubleshoot systemically by checking all
connections from the analyzer to the lead. If there no correctable problems and the pacing parameters are still poor,
then the lead will need to be repositioned.
6. The RV lead can be inadvertently placed into the coronary sinus. Identification of coronary sinus placement includes:
the lead coursing more posterior than expected in the LAO projection, lack of ventricular ectopy, and a right bundle
branch block pattern when pacing on the lead.
7. If pacing parameters suddenly worsen, perforation may have occurred. Monitor for hemodynamic stability and
consider echocardiogram to rule out pericardial effusion.
8. The RA lead in the right atrial appendage should course anteriorly in the LAO projection. The classical “figure-of-
eight” movement of the lead tip suggests the lead is in good position in the right atrial appendage.
9. When checking the pacing parameters in bipolar leads, the black clip goes to the distal ring and the red to the
proximal. If using monopolar leads (rare, but may be seen in older generator changes), the black clip goes to the ring
and the red clip is attached to the subcutaneous tissue.
10. Pacing parameter testing:
1. Sensing (mV) should be P wave > 1.5 mV, R wave > 5.0 mV. If the R wave is too small, there is a risk of R-on-
T arrhythmias and inappropriately sensing ventricular artifact as activity. For the RA lead, it is also important to
consider the “far field” sensing of ventricular activity at the atrial lead. If the far field activity is high, then the
atrial lead may inappropriately sense the ventricular activity as atrial.
2. Impedance ( ) should 400-1000 .
3. Pacing threshold (V) should be <1 V at 0.5 ms. The lower the value, the less energy is required to pace each
beat. Maximal output pacing at 10 V should also be performed to ensure there is no stimulation of the diaphragm
or any extra cardiac structures.
11. When securing the cephalic vein to the proximal end of the leads with a silk tie, ensure it is not too tight as to damage
the insulation of the lead.
12. Ensure that the correct lead is placed in the correct port by checking serial numbers. Confirm that the lead is placed
completely into the generator and that all screws are tightened appropriately.
13. All extra length from the leads are looped and placed posterior to the generator to prevent damage to leads when
performing subsequent generator changes.
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. syncope secondary to sinus bradycardia, etc.]
Procedure(s) Performed: Permanent pacemaker insertion [DETAILS – e.g. programmed mode of pacemaker at the time of
insertion, manufacturer/model of leads and generator]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [COMPLAINT – e.g. syncope] and electrocardiographic
evidence of [FINDINGS – e.g. sinus bradycardia < 40 beats/minute].
Leads Implanted: [Manufacturer/Model/Serial number] of right atrial and right ventricular leads
Device Implanted: [Manufacturer/Model/Serial number]
Fluoroscopy Time: [Minutes]
Pacing parameter characteristics: [Sensing (mV), Impendence ( ), and Threshold (V) of RA and RV leads]
Description of Procedure: The patient was taken to the operating room/electrophysiology suite on [Date]. The patient’s
identity, consent, and planned procedure were verified. The patient was placed on the operating table in the supine position. A
peripheral venous line was obtained in the left antecubital fossa. Prophylactic antibiotics, analgesia and sedation were
administrated to the patient as per hospital protocol. We then proceeded to prep and drape the left chest and neck. A time out
was performed. [Amount] of [Local anesthetic] was infiltrated along the planned incision and pocket.
A 5 cm incision along the deltopectoral groove was made. A combination of electrical cautery and blunt dissection was used
to create a subcutaneous pocket at the level of the prepectoral fascia. The deltopectoral groove was dissected to identify the
cephalic vein and 2 cm of the vein was freed from the surrounding tissue. Distal and proximal control of the vein was obtained
with #3-0 silk ties. The distal end of the vein was tied off. A venotomy incision was made with Iris scissors. A vein lifter was
used to insert the RV lead and a guide wire for the RA lead. Using fluoroscopy, the RV lead was advanced through the
tricuspid valve and positioned in the [RVOT/high septum or RV apex] using [Active/passive] fixation. Anatomical
positioning was confirmed in the LAO projection. Pacing parameters for the RV lead were checked and documented above. An
introducer sheath was inserted into the cephalic vein using the guide wire for the RA lead. The introducer and guidewire was
removed. The RA lead was inserted through the sheath and was positioned into the right atrial appendage using fluoroscopy.
Anatomical positioning was confirmed in the LAO projection. The sheath was peeled away and removed. Pacing parameters
for the RA lead were checked and documented as above. The pacing parameters for the RV lead were rechecked. The RA and
RV leads were secured to the generator and anchored into place with #0 silk tie around their suture sleeve. The leads were
placed in loops underneath the generator in the subcutaneous pocket. The subcutaneous tissue was closed with two layers of
running #2-0 Vicryl. The subcuticular layer was closed with #4-0 Monocryl in running fashion. The patient was transferred to
the post anesthetic care unit in stable condition.
29. Repair of Post-Infarction Ventricular Septal Defect
Amit Pawale, MD, FRCS, Anelechi Anyanwu, MD, MSc, FRCS
Mount Sinai Medical Center, New York, NY

(This patient already had a pulmonary artery catheter, radial arterial line, intra-aortic balloon pump, and Foley catheter with
temperature probe)
3. Opening pericardium, pericardial well, epiaortic ultrasound
6. Right atrial cannulation
7. Checking ACT (>480 seconds)
8. Initiation of cardiopulmonary bypass
9. Aortic root vent and cardioplegia cannula
10. Systemic hypothermia 30 degree Celsius
11. Right ventriculotomy
12. Ventricular septal defect closure with two patch technique
13. Ventriculotomy closure
14. Rewarming
15. Deairing
16. Weaning from cardiopulmonary bypass
20. Hemostasis

1. In this technique left ventriculotomy is avoided to preserve as much left ventricular ejection fraction as possible.
2. Care should be taken not to make the right ventriculotomy too close to the left anterior descending (LAD) artery
3. The right ventriculotomy should also not be made far from the LAD so there is minimal compromise of right
ventricular function.
4. Adequate distance from the ventricular septal defect is very critical while taking the sutures to avoid bites through
fragile necrotic tissue.
5. Care must be taken to retrieve fragments of muscle and BioGlue from the ventricle to prevent embolization.
6. The LAD must not be compromised during closure of the ventriculotomy.
Template Dictation
Preoperative Diagnosis: Post myocardial infarction ventricular septal defect, cardiogenic Shock and multi-organ failure
Procedure(s) Performed: Repair of post-infarct ventricular septal defect
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [COMPLAINT – e.g. syncope] was transferred from an
outside hospital in cardiogenic shock, intubated and mechanically ventilated. He hadsustained an acute ST elevation
myocardial infarction one-week prior due to occlusion of left anterior descending artery to which a stent had been placed.He
developed a ventricular septal defect post myocardial infarction and had initially been supported with a percutaneous impeller
ventricular assist device, which stopped functioning yesterday and he progressed into advanced cardiogenic shock. He had
evidence of multiorgandysfunction and his neurologic status was unknown. An intraaortic balloon pump was placed in the
intensive care unit. Because of severe shock he was brought to the operating room for emergency closure of his ventricular
septal defect and possible ventricular assist device placement. Because of the patent recent stent, no coronary bypass surgery
was planned.Prior to taking him to the operating room, we made a check to confirm his readiness for surgery.
procedure was verified, and the patient was placed on the operating room table in the supine position. Patient already had
arterial monitoring line, pulmonary artery catheter. Preoperative trans esophageal echocardiogram was performed. It showed
severe biventricular dysfunction, an anterior ventricular septal defect with a large left to right shunt.
Median sternotomy was performed, the pericardium was opened. The right ventricle was distended and there was poor
biventricular contraction. There was also fibrinouspericarditis. Epiaortic ultrasound of the ascending aorta was performed.
[BLANK] units of heparin were administered intravenously. Ascending aorta and right atrium were cannulated.
Cardiopulmonary bypass was initiated when ACT was above 480. An aortic root vent was placed. Systemic cooling was
started aiming systemic temperature 30 degree Celsius. The aorta was cross-clamped and the heart was protected with cold
blood cardioplegia given in the antegraderoute, this was repeated every 20 minutes.
We decided to close the VSD via right ventricular approach and two-patch technique with one patch on either side of the
ventricular septum. With a number 11 blade a longitudinal right ventriculotomywas performed about one cm away from and
parallel to the left anterior descending artery, going from the apex ofthe right ventricle toward the right ventricular outflow
tract, adequate enough to expose the septum. Two 2-0 Ethibond pledgeted stay sutures were placed in horizontal mattress
fashion without tying on each lip of the ventriculotomy and clipped to the drapes for better visualization of the cavity and the
defect. The right ventricular trabeculations were excised as needed to expose the interventricular septum, a thrombus was
removed. A 3 cm diameter ventricular septaldefect in the mid-anterior septum was identified. The edges were friable and the
septum was thinned out with recentinfarct. The friable edges were trimmed. Two large bovine pericardial patches (A and B)
were rinsed in normal saline and trimmed to the size of about 6 cm diameter. A series of interrupted 3’0 prolene sutures with
SH needle were placed through the patch ‘A’ in horizontal mattress fashion, about 1-1.5 cm from the edge of the patch along its
circumference. These were passed through the interventricular septum about 2 cm from the margin of the defect from left
ventricular side coming out into the right ventricle. Same sutures were then passed through another bovine pericardial patch
‘B’ in a manner similar to patch ‘A’. Anteriorly, rather than passing sutures through the rim of the defect, plegeted sutures were
passed through the Left ventricle just to the left of the left anterior descending artery then thorough the Patches as previously.
Patch ‘A’ was placed into the left ventricle through the defect and these sutures were pulled so that the patch ‘A’ lies on the left
ventricular side of the defect, covering it nicely. The patch ‘B” was parachuted down and covered the right ventricular side of
the defect. All sutures were tied but the last two. The aortic root vent was switched off and the cardiopulmonary bypass flow
was lowered, BioGlue was placed within the space between these two patches to add some strength and hemostasis to
thesuture line, and the last two sutures were tied. The root vent and full flow was resumed. The ventricular septum was
therefore sandwiched betweentwo bovine pericardial patches.
The right ventriculotomy was closed with a double layer of 3-0 Prolenesutures (first layer horizontal mattress and second layer
running) with a strip of Teflon felt reinforcement on either side of the ventriculotomy, taking care to avoid compromising the
left anterior descending artery.
The heart was reperfused and thecross-clamp was removed. Pacing wires wereplaced on the right ventricle andright atrium.
Following a period of de-airing and reperfusion,cardiopulmonary bypass was weaned with the aid of high dose inotropes,
intra-aortic balloon pump and inhaled nitric oxide. Echocardiography confirmed absence of a residual ventricular septaldefect.
No step up of oxygen saturation was noticed by direct blood gas sampling of the right atrium and pulmonary artery. Patientwas
oxygenating well and the left atrial pressure ranged between 15 and 20 mm of Hg.,while the right atrial pressure ranged from
10 to 15 mm of Hg. A ventricular assist device was not placed due to stable hemodynamics.
Venous decannulation was performed, the heparin wasreversed and the aortic cannula was removed. Hemostasis was
secured from all the surgical sites. There were bilateral straw-colored pleural effusions, which were drained. Drains were
placed withinthe mediastinum and both pleural cavities. The sternum was reapproximatedwith stainless steel wires and the soft
tissues were closed with absorbablesutures.
All instrument, sponge and needle counts were confirmed to be correct twice at the end of the operation. The patient was
subsequently transferred to the postoperative cardiac surgical intensive care unit in stable but critical condition.
30. Repair of Post-Infarction Ventricular Aneurysm (DOR
Endoventricular Circular Patch Plasty (EVCPP))
James H. Neel, MD and Mark S. Slaughter, MD
University of Louisville; Louisville, KY

(Steps 1-14 are part of CABG portion of procedure)
3. Intraoperative TEE
5. Conduit choice
6. Pericardiotomy, pericardial well creation, assess ascending aorta for cannulation, anastomotic sites, etc.
7. Heparinization (400 U/kg)
8. Arterial/Venous cannulation (+/- LV vent)
9. Cardioplegia cannula placement (antegrade +/- retrograde)
10. Confirmation of ACT (> 400 sec)
11. Commencement of CPB
13. Cardioplegia (antegrade, topical, retrograde)
14. Distal anastomoses (proximal anastomoses to be performed after EVCPP)
15. (Proceeding w/ Dor procedure)
16. Ventriculotomy (into depressed aneurysmal portion of ventricular wall)
17. Removal of thrombus
18. +/- cryotherapy for VT therapy (if indicated)
19. Mitral repair/replacement (if indicated)
20. Purse string suture at margin of normal-fibrous muscle (2-0 non-absorbable monofilament)
21. LV sizing w/ balloon device (approximately 40-50 ml/kg)
22. Placement of patch (Gore-tex, Dacron, autologous, heterologous) at “neck”, secured with running 3-0 or 4-0
monofilament
23. Oversewing/resection of excess aneurysmal ventricular free wall
24. (Back to CABG procedure)
25. LIMA-LAD anastomosis
27. Warm antegrade blood cardioplegia (“Hot Shot”)
29. Removal of aortic cross clamp
30. Assessment of hemostasis
31. CPB weaning
33. Placement of A/V wires
37. Repeated hemostasis assessment

1. Paramedian sternotomy
2. Innominate vein injury
3. IMA injury
4. Problems with cannulation (bleeding, iatrogenic dissection, atrial tear)
5. Poor myocardial protection (malpositioned aortic cross clamp, AI, poor venous drainage)
6. Coronary sinus injury (retrograde)
7. Intramyocardial coronary arteries
8. Injury to coronary arteries (dissection, back wall puncture)
9. SVG length problems (too short = tension, too long = kinking)
10. Air embolism (ineffective/inadequate de-airing maneuvers)
11. Anastomotic bleeding
12. Poor hemostasis (anastomoses, LIMA bed, cannulation sites, ventriculotomy repair)
13. Arrhythmias
14. Dehiscence or bleeding from ventriculotomy repair
15. Low cardiac output from small residual LV volume
Template Dictation
Preoperative Diagnosis: [INDICATION: CAD with Post-infarction LV aneurysm, ventricular akinesia]
Postoperative diagnosis: Same
Procedure(s) Performed: Coronary artery bypass grafting [DETAILS: ] with
LIMA-LAD, SVG targets, etc.
endoventricular circular patch plasty (EVCPP) and EVH
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT]. Patient was
found on preoperative echocardiography to have a left ventricular aneurysm, specifically [DETAILS]. Preoperative
angiography revealed [FINDINGS].
procedure were confirmed. The patient was placed on the operating room table in the supine position. General endotracheal
anesthesia was induced per the anesthesia team. Arterial line(s) and central venous access were obtained [DETAILS:
location, type of access, etc.]. Pulmonary artery catheter was also placed. Preoperative TEE was performed to evaluate
cardiac function, valve function, as well as aneurysmal dimensions/characteristics. The patient was then prepped and draped
in the standard surgical fashion with all bony prominences padded appropriately. A pre-incisional time-out was performed.
Median sternotomy was performed. Simultaneously to this, saphenous vein conduit was harvested from the [Right/left leg]
utilizing [Open/Endoscopic] technique. Upon gaining entrance into the chest, the IMA retractor was placed in the chest and
the LIMA was harvested utilizing a pedicled technique. Once LIMA was dissected, 5000U Heparin was administered by
anesthesia prior to distal division. LIMA bed was then examined and confirmed to be hemostatic. The LIMA was then
wrapped in a papaverine soaked gauze sponge and placed back into the chest. CPB tubing was brought up onto the field and
passed off to perfusion in the standard fashion. At this point, the pericardial well was established by incising the anterior
pericardium utilizing electrocautery and tacking the pericardial edges up to the chest wall. Care was taken to avoid injury to
the innominate vein. Aortic cannulation stitches were placed in the ascending aorta below the innominate artery takeoff. Right
atrial cannulation stitches were next placed. The patient was then fully heparinized per anesthesia staff. The aortic cannula
was inserted into the aorta, secured, de-aired, and attached to the CPB arterial tubing. Venous cannula was inserted into the
right atrium, secured, and attached to the venous CPB tubing in the standard fashion. An aortic root vent was then placed into
the ascending aorta below the level of the proposed site of cross clamp application. The vent was secured with monofilament
suture and connected to the vent/cardioplegia tubing. SVG conduit was then checked for appropriateness and any needed
repairs made. CPB was initiated and proper flows confirmed with perfusion team. Aortic cross clamp was placed and [Total
volume] ml antegrade cardioplegia was administered causing rapid arrest of cardiac function.
Next, attention was turned to identifying suitable targets on distal coronary arteries [Specify sites/targets]. Arteriotomy was
performed in the standard fashion. SVG was trimmed, spatulated to the appropriate size to match the arteriotomy. The SVG
graft anastomosis was performed with running 7-0 Prolene suture in the standard end-to-side fashion. Antegrade flow through
the anastomosis was checked and hemostasis was confirmed. [Repeat for subsequent SVG target sites.] Following SVG
anastomoses, a suitable site on the LAD [Specify target site] was confirmed and the artery opened. Again, care was taken to
avoid injury to the back wall of the vessel.
Following completion of the distal anastomoses, attention was turned to the ventricular aneurysm. The heart was
decompressed and the area of ventricular wall defect was confirmed. A longitudinal ventriculotomy was performed utilizing a
#11 scalpel blade and lengthened encompassing the full extent of the defect. Care was taken to avoid injury to the surrounding
coronary vessels. All visualized thrombus was removed from the left ventricle. The endocardial scar was resected sharply.
A 2-0 Prolene purse string suture was passed along the surrounding border of the defect at the level of the junction of normal
and fibrous ventricular muscle. [May or may not measure appropriate ventricular volume with balloon-type device]
Next, a piece of [Specify graft material used] was selected and trimmed to appropriate size. The graft was secured in place
over the defect utilizing a running 2-0 Prolene suture. The extraneous ventricular free wall musculature was then re-
approximated and oversewn covering the defect utilizing pledgeted 2-0 Prolene suture.
Next, the LIMA was prepared, trimmed to appropriate length, and spatulated to match the arteriotomy on the LAD. The
anastomosis was performed in the usual end-to-side manner utilizing a running 7-0 Prolene. The bulldog clamp was removed
briefly to ensure forward flow through the anastomosis and check for hemostasis.
Attention was then turned to the proximal aorta. The [Specify graft target] SVG was brought up to the proposed site of
proximal anastomosis and measured to ensure appropriate length. The vein graft was then trimmed to correct length and the
end spatulated in the standard fashion. The site for proximal anastomosis was selected and an aortotomy was performed using
a #11 scalpel and enlarged utilizing a 4mm aortic punch. The proximal anastomosis was performed utilizing a running 6-0
Prolene in the standard end-to-side fashion. [Repeat for each proximal SVG anastomosis.]
Upon completion of the proximal anastomoses, a dose of warm blood (Hot Shot) cardioplegia was administered and the patient
was rewarmed. De-airing maneuvers were performed. The bulldog clamp was removed from the LIMA and the LIMA-LAD
anastomosis was re-checked to ensure adequate flow and hemostasis. The aortic cross clamp was removed and the aorta was
further de-aired utilizing the aortic root vent. Chest tubes were then placed [Specify number and location]. Pacing wires
were then inserted, secured, and tested for appropriate capture. TEE was utilized to confirm adequateness of de-airing and the
aortic root vent was removed and sutures secured. The patient was weaned from cardiopulmonary bypass. Aortic cannula
was removed and sutures secured. Protamine was administered. Venous cannula was next removed and sutures secured.
Hemostasis was ensured at all sites within the mediastinum as well as the LIMA bed. The sternum was then re-approximated
utilizing #7 stainless steel wires [Specify number and type of wire sutures]. The incision was then irrigated copiously with
antibiotic saline solution. The fascia was then closed with running 0 Vicryl followed by running 2-0 Vicryl for the deep
dermal layer. Skin was approximated with running 3-0 Monocryl suture. Sterile dressings were applied. Chest tubes were
connected to drainage canisters.
All sponge, instrument, and needle counts were correct x 2 at the completion of the case. The patient was then transferred to
the Cardiac ICU in critical but stable condition.
31. Pulmonary Embolectomy
Amit Pawale, MD, FRCS, Ramachandra Reddy, MD, MBA
Mount Sinai Medical Center, New York, NY, 10029

1. Internal Jugular triple lumen catheter, Radial arterial line, Foley catheter with temperature probe
(No pulmonary artery catheter)
4. Pericardiotomy, creation of pericardial well, epiaortic ultrasound
8. Initiation of cardiopulmonary bypass
9. Aortic root vent, Right superior pulmonary vein vent
10. Systemic hypothermia 30 degree Celsius
11. Pulmonary arteriotomy
12. Removal of saddle
13. Removal of segmental thrombi under direct vision using gall stone forceps
14. Caval tapes
15. Right atrial and right ventricular exploration
16. Rewarming
17. Closure of Pulmonary artery and right atrium
18. Inferior Vena Cava filter insertion
19. Careful de-airing
20. Weaning from cardiopulmonary bypass
21. Decannulation and heparin reversal
22. Hemostasis

1. Left ventricular distension can occur if heart fibrillates before left ventricular vent is introduced.
2. Pulmonary valve can be injured during pulmonary arteriotomy
3. Inadvertent branch pulmonary artery tear can occur during selective removal of segmental emboli
4. Since pulmonary artery is open and the left ventricular vent is in place, air can be sucked from pulmonary vasculature
into the left ventricular
5. Right atrium and right ventricle should be explored before closing the pulmonary artery as clots missed and left in
these chambers can lead to further pulmonary emboli
6. IVC filter should be placed during the same operative intervention, as further embolization to pulmonary artery from
lower extremities is possible awaiting IVC filter insertion.
Template Dictation
Preoperative Diagnosis: Acute pulmonary embolism with right ventricular strain
Postoperative Diagnosis: Same + transit thrombus in the right ventricle
Procedure(s) Performed: Pulmonary embolectomy, exploration of right atrium and right ventricle, removal of right
ventricular thrombus, insertion of IVC filter
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] who presented relatively bedridden due to gastrointestinal
bleeding for the last 2 weeks with progressive shortness of breath over the last week and a syncopal episode immediately prior
to admission. She was tachycardiac, tachypneic and hypotensive with systemic blood pressure 90 mm of Hg systolic. The CT
pulmonary angiogram showed a saddle pulmonary embolus with bilateral large emboli occluding 2/3 of segmental branches,
Echocardiogram showed evidence of right ventricular strain and troponins were elevated. Based on her presentation and
investigation findings, decision was made to proceed with a pulmonary embolectomy.
procedure were verified. The patient was placed on the operating room table in the supine position. A left radial arterial line
was inserted. General anesthesia was initiated. A right internal jugular central venous line and Foley catheter were inserted.
Preoperative trans esophageal echocardiogram was performed. It showed large embolus in distal main pulmonary artery and
right pulmonary artery, a clot in the right ventricle and severe right ventricular dysfunction. The left ventricular function was
preserved. Patient’s chest, abdomen, groins were prepped and draped in sterile fashion. A time out was performed.
Median sternotomy was performed, the pericardium was opened.
The right ventricle was found to be distended. Heparin was administered intravenously. Ascending aorta and both cavae were
cannulated. Cardiopulmonary bypass was initiated when ACT was above 480. A left ventricular vent via right superior
pulmonary vein was placed. An aortic root vent was placed at a level higher than the superior border of right pulmonary artery
(to avoid it getting in the way while retracting open the right pulmonary artery later). Systemic cooling to 30 degree Celsius
was initiated.
4’0 prolene stay sutures were placed on either side of the main pulmonary artery. The pulmonary artery was opened
longitudinally. The stay sutures were clipped to the drape with adequate tension to aid the visualization. A large thrombus was
seen in the main pulmonary artery. With a sponge holding forceps and a stone forceps the clot was pulled out as much intact as
possible like a rope pulling. Making sure the systemic temperature is at 30 degree Celsius; systemic flow was reduced to 500
cc/ minute. Two nerve root retractors were placed in the left main pulmonary artery and the walls retracted to expose all the
segmental artery origins. With a cell saver suction and gall stone forceps, clots from each segmental artery were removed
under direct vision. Guessing is strictly avoided as grabbing and injuring the pulmonary artery endothelium can lead to
pulmonary artery dissection or rupture. The low flow state is terminated in 2-3 minutes and repeated if necessary after 5
minutes of full flow. No clot was left in any segmental or sub-segmental branches.
Same procedure was repeated in the right pulmonary artery and the retraction was provided by long blade of army- navy
retractor lifting the anterior wall of right main pulmonary artery lifting partly along with it, the ascending aorta. A nerve root
retractor is placed in the right pulmonary artery to retract the inferior wall down.
After clearing both sides of clot, the caval tapes are passed around the cavae and snared. The right atrium was opened parallel
to the atrioventricular groove and inspected for any thrombus or patent foramen ovale. The right ventricle, its apex and the
outflow tract were inspected trough the tricuspid valve. A large thrombus was found in the right ventricular trabeculations and
was extracted. The main pulmonary artery incision was closed with 4’0 prolene, running suture, over and over, in two layers.
The right atrium was closed with double-layered running 4’0 prolene sutures. The caval tapes were then released. Systemic
rewarming was started. (The heart is defibrillated if fibrillating).
A purse string suture was applied to the right atrial appendage. A guide wire was introduced through the right atrium into the
inferior vena cava and passed distally into the left common iliac vein. A cavogram was performed. A ‘Cook’ IVC filter was
deployed below the renal veins in the inferior vena cava.
Milrinone infusion was initiated. Atrial and Ventricular pacing wires were placed. Ventilation was initiated and careful
sequential de-airing from right superior pulmonary vein vent and aortic root vent was performed. When rewarmed completely,
patient was weaned off the cardiopulmonary bypass. Venous decannulation was performed. Protamine was administered.
Aortic cannula was removed. Cannulation sites were reinforced. Hemostasis of the entire mediastinum was performed. Two
mediastinal chest tubes were placed. The sternum was approximated with four figure of eight sternal wires. Subcutaneous
tissue and skin was closed in layers.
subsequently transferred to the postoperative cardiac surgical intensive care unit in stable but critical condition.
32. Redo Sternotomy and Difficult Sternal Closure
George Makdisi, MD, Leker Locker, Chaim MD.

Redo Sternotomy:
1. Check preoperative imaging, including CXR PA & lateral (evaluate space between heart and sternum, and number of
wires), Chest CT and coronary angiogram (patent grafts, IMA position related to sternum, sternal adhesions), evaluate
also the patency of the femoral vessels for femoral cannulation if needed.
2. Defibrillation pads/external defibrillator in the room.
3. Excise previous scar, and expose well the sternal wires on both sides for the whole width of the wire.
4. Mark your definite midline with cautery! If needed undermine fascial tissue towards the intercostal spaces on both
sides.
5. Cut the wires at midline, and keep sternal wires in situ, apply 4 perforating towel clips; 2 on each side.
6. Prepare your plane at the xiphoid level under the sternum with gentle manual digital palpation and sharp dissection
with cautery and heavy scissors with the help of 2 racks one on each side of the xiphoid. Feel the RV with your finger
tip (risk of arrhythmias and RV perforation).
7. Start sawing the anterior plate at the level of the xiphoid with oscillating saw (very superficial at the xiphoid as
usually there is no wire protecting you!), with slight careful forward biting movement of the tip of the saw. When you
reach to the level above the very lowest wire, you can safely dig further into the bone until you feel the wire. (Stop
and knock with the tip of the saw on the wire, you know you’re at the right level when you get the definite metal
sound). Keep moving towards the next wire but more superficially. Complete the whole length of the anterior plate up
to the suprasternal notch level.
8. Start to dissect and divide the posterior sternal plate adhesions from the level of the Xiphoid by using heavy
Metzenbaum scissors, and remove wires as you advance. Your assistant needs to pull on the perforating towel clips
upward and lateral, keep the field dry by the tip of your scissors (don’t cut blindly!) Keep the lower half part of the
scissors always in parallel to the heart and sternum with the tip pointing upwards.
9. Be sure you’re not cutting any previous patent grafts, if any, with your scissors.
10. If the space between bones is very narrow, you can open it a bit more by moving your closed scissors right to left in
between the two sternal bone edges at horizontal plane.
11. Complete the whole length of the sternum.
12. Sometimes the area of the suprasternal notch is very stubborn adhesed, use you saw very superficially and carefully
or use heavy scissors to cut the bone or the thick band holding both sides. Make sure not to cut into the innominate
vein.
13. Apply hemostasis with electrocautery to the periosteum all around the sternal bone bilaterally and use bone wax if
needed.
14. When the sternum is completely opened and dry, lower cautery power to 30-40 at early dissection to avoid
fibrillation/perforation. Start always at the level of the xiphoid towards the left pleura. Your assistant needs to pull
up the left sternal edge with 2 racks/ hook (careful with this pulling, you may perforate the RV if too excessive).
15. Develop the plane underneath the sternum, stay just 1 millimeter below the sternal bone. Use your other hand to
gently press on the heart with a sponge at the point where you cauterize. Your goal is to reach and open the lower
part of the left pleura.
16. Keep moving upwards by sharp or electrocautery dissection. (Be careful as the LIMA, if patent, at the upper part of
your track of dissection. Keep opening to a point where you suspect the LIMA to be close. At this point, if you are
unable to dissect and discover it safely, leave it alone, and get back to it later after completing the rest of the steps
(you might need to go on bypass).
17. Open the right pleura all the way up starting at the xiphoid level. Be aware that the IMA bundle is crossing on the
right side more medially. Sometimes you have to further dissect above the innominate vein in order to be able to open
the sternum safely with the retractor.
18. Place the sternal retractor. Make sure not to disrupt the innominate vein.
19. Your first step in the dissection of the structures would be to free the aorta to be able to cannulate it in case of
emergency (You’ll be able to transfuse through the aortic cannulae and use your pump suckers for venous drainage).
Next, dissect the right atrium to be able to venous cannulate, and then, follow with complete dissection of the rest of
the heart and bypass conduits if applicable.
20. At any point if you’re unable to safely continue with your dissection, expose the groin vessels, cannulate and go on
bypass, and keep going with your dissection.
21. Injury to the innominate vein or brachiocephalic artery should be avoided by careful pulling the sternum upwards by
perforator towel clips or racks, and manual palpation to eliminate traction while spreading the sternal retractor, the
innominate vein needs to fall away in the chest as the injury most likely occurs with wide opening of the sternal
retractor (patch it if needed to avoid stenosis).
22. If femoral cannulation! Be aware of lower extremity ischemia and compartment syndrome.
23. Once you’ve completed your intrathoracic dissection on femoral bypass. You can switch to the aorta and right atrial
cannulation.
24. Be aware of potential air emboli in case of right to left shunt:
1. If R-sided structure injured use mild hypothermia.
2. If L-sided structure injured use profound Hypothermia.
Sternal Closure
1. Sternal closure and type of closure should be personalized to every case, evaluate all the risk factors and the situation
of the sternum after sternotomy.
2. Careful hemostasis before starting sternal closure.
3. Protect the heart, the vessels and the graft from injury by the wire needle by covering them with a sponge and/or using
bands to lift the sternal edges to insert the wire under direct vision.
4. Consider a 6 mm wire for every 10 kg of wight as a rule, put more if long sternum, you might use Myo double sternal
wires if indicated.
5. The first 2-3 wires are inserted in the manubrium.
6. The following wires are inserted in the intercostal spaces (enter and exit the intercostal spaces just lateral to the
sternal edges to avoid the IMA injury; and on the top of the lower rib to avoid the intercostal vascular bundle injury).
7. Make sure the lower part of the sternum and the xiphoid have enough wires as most of dehiscences start in this area.
8. Check for bleeding from the wire sites.
9. Accurate approximation of the bone edges, to reduce postoperative override and shift of the sternal verges.
10. Start twisting at the bottom wires while your assistant tightens the crossed upper 4 wires.
11. Make sure the wires are tight; you might need to re twist and tighten the previous wire.
12. Make sure the fascia at the very bottom of the sternal wound below the xiphoid, is tightly closed with interrupted
absorbable 1-0 sutures.
13. The sternal fascia is closed by interrupted or running absorbable 1-0 sutures.
14. Close the subcutaneous tissue by absorbable 2-0 sutures.
15. Close the skin by running absorbable 4-0 sutures.
16. You might use binder especially in obese patients and females with large breast size to decrease the tension on the
wires and suture closure.

1. Make every effort to open every patient in the midline of the sternum. Adequate identification of the midline is easy by
checking the lateral border by digital palpation or a mosquito (careful with the possibility of IMA injury), or if still
unclear; undermine and dissect using electrocautery to identify the edge of the sternum and the beginning of the
intercostal space.
2. Cutting the sternochondral cartilage or ribs will be difficult to repair and lead to complex wound complications and
inadequate blood supply to the bone for healing.
3. During sternal rewiring, avoid injuring the grafts, myocardium by covering them by sponge or using bands to elevate
the sternal edges.
4. Consider a 6 mm wire for every 10 kg of wight as a rule, but even if patient weighs 70kg and the sternum is long and
requires 10 wires, obviously put 10. You might use also Myo double wires (Only in very wide and large sternum and
in patients with high BMI, where the bone will tolerate and the wire won’t cut through the bone).
5. Accurate approximation of the bone edges is essential to minimize sternal dehiscence and postoperative pain. Make
sure the edges are fitting each other on both sides so there is no step or override in between the 2 verges. If so, push
the bone down to make it fits just after crossing but prior to twisting the wires.
6. Bleeding: When inserting wires in a parasternal fashion, one should be aware of the presence of the internal thoracic
pedicle. Any injury must be immediately recognized and controlled to avoid postoperative bleeding and tamponade.
Put stiches to the intercostal space or stitch the intrathoracic pedicle directly.
7. Skin erosion: Wires should be deeply embedded into the sternal periosteum to avoid progressive skin erosion, check
with your finger by the end of this stage.
8. Dehiscence: Sternal dehiscence is not exclusively the result of poor operative technique! Poor quality of the bone, as
with osteoporosis, is a classic cause of dehiscence. In these cases, careful tissue handling and very meticulous
closure is mandatory to prevent complications. The twisting of the wires in those cases needs to be very careful and
make sure you don’t cut into the bone with twisting the wire, on the other hand don’t leave it loose!
9. In order to prevent dehiscence in the lower sternum; be generous with the number of your wires, and make sure the
very lower part of the xiphoid area is tightly closed.
10. Start twisting at the bottom wires while your assistant tightens the crossed upper 4 wires. This will prevent creating a
step. After twisting a wire, go back and check the previous wire; it might need to be tightened a bit further.
11. If the sternum is osteoporotic and friable, the previous sternal closure has disrupted, or you are severely off midline;
Robicsek closure is successful in most of these patients.
12. Fracture of the sternum: Approximation of the fractured sternal edges is a difficult task. Wires are passed
parasternally above and below the fracture site (in a figure of eight configuration, to include the fracture well in) with
the costal margins intervening to stabilize the fracture.
13. After completing the wiring, make sure the fascia at the very bottom of the sternal wound below the xiphoid, is tightly
closed with interrupted sutures. Don’t leave any gaps as this may initiate infection and disruption of the wound
involving the rest of the wound upwards.
14. Apply generously antibiotic mixed saline solution and irrigate all edges to prevent infection.
Template Dictation
Preoperative Diagnosis: severe aortic stenosis
Postoperative Diagnosis: severe massive air embolism
Procedure(s) Performed: Aortic valve replacement with tissue valve
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure:[AGE] year old [GENDER] who presented [BLANK] Workup included [CXR, cardiac
angiography, TTE], [Mr/ Mrs.] [BLANK] is brought now for surgical replacement in satisfactory condition
Robicsek technique: The sternum was frail by the repeated sternotomy with some areas were off the midline. We decided to
proceed with Robicsek sternal closure to better stabilize the sternum, The mediastinum was washed with copious amount of
fluids and antibiotics, the mediastinal chest tubes were positioned correctly, the heart and vessels were protected by a sponge,
with the surgical assistant using 2 bands to raise the sternum. A No.6 stainless steel wire was inserted in the manubrium to exit
on the top of the 2nd rib just lateral to the sternal edge then we proceeded with parasternal woven running wire, with alternating
sutures passed anteriorly and posteriorly to the costal cartilages in a wavy shape, down to the xiphoid process level. The wire
was reversed and led in the cranial direction, passing the cartilage posteriorly where it had passed anteriorly and vice versa
ending by passing below 2nd rib to exit in the manubrium, the exit and the entrance to intercostal spaces was always lateral to
the sternal edges and on the top of the lower rib. Same process was repeated on the right side of the sternum. Then we put our
classic sternal closure by 3 wires inserted horizontally in the manubrium, followed by 6-8wiers between intercostal space just
lateral to the sternal edge and the top of the inferior rib. Care was taken to avoid the injury of the internal thoracic artery and
the intercostal bundle. The sponge was removed. A careful hemostasis was done with Bovie cautery and some absorbable 1-0
suture stitches used to stop bleeding from around the wires. The woven vertical wires of Robicsek technique were tightened
first followed by crossing and twisting the vertical wires from the lower end proceeding to the upper end. The sternal repair
was satisfactory and the sternum was stable. The abdominal fascia and the sternum were closed by interrupted suture of
Absorbable1-0 suture, followed by absorbable 2-0 suture. The skin was closed by a running subcuticular suture using
absorbable 4-0 suture. The patient tolerated the procedure well. No intraoperative complications. All needle, sponge, and
instrument counts were correct on two occasions. [Mr/ Mrs.] [BLANK] appeared to tolerate the procedure well and was
transferred to the ICU in stable condition.
Sternal fractures figures of eight: The sternum was frail by the repeated sternotomy with some areas of sternal fractures. The
mediastinum was washed with copious amount of fluids and antibiotics, the mediastinal chest tubes were positioned correctly,
the heart and the vessels were protected by a sponge. We started our sternal closure using No.6 stainless steel wires. 3 wires
were inserted in a transverse fashion in the manubrium, followed by a figure of 8 including the fractured area by and one rib
above and below the fractured area, the next wire was in the same intercostal space below the fracture followed by 6-8wiers
between intercostal space just lateral to the sternal edge and the top of the inferior rib. Care was taken to avoid the injury of the
internal thoracic artery and the intercostal bundle. The sponge was removed and careful hemostasis was achieved with Bovie
cautery and absorbable1-0 stitches needed to stop bleeding from around the wires. The wires were crossed and the
hemodynamics were stable, we started tightening the wires from lower proceeding to the top ensuring the sternal plates were at
the same level. The sternal repair was satisfactory and the sternum was stable. The abdominal fascia and the sternum were
closed by interrupted suture of absorbable 1-0 sutures, followed by absorbable 2-0 suture. The skin was closed by a running
subcuticular suture using absorbable 4-0 suture. The patient tolerated the procedure well. No intraoperative complications.
All needle, sponge, and instrument counts were correct on two occasions. [Mr/ Mrs.] [BLANK] appeared to tolerate the
procedure well and was transferred to the ICU in stable condition.
Sternal fractures plates: The sternum was frail by the repeated sternotomy with some areas of sternal fractures. The
mediastinum was washed with copious amount of fluids and antibiotics, the mediastinal chest tubes were positioned correctly,
the heart and the vessels were protected by a sponge. We started our slandered sternal closure using No.6 stainless steel
wires. 3 wires were inserted transverse way in the manubrium, followed by 4-6 wirers between intercostal space just lateral
to the sternal edge and the top of the inferior rib. Care was taken to avoid the injury of the internal thoracic artery and the
intercostal bundle. The sponge was removed. Careful hemostasis was done with Bovie cautery and absorbable 1-0 stitches
needed to stop bleeding from around the wires. The wires were crossed and the hemodynamics were stable, we started
tightening the wires from lower proceeding to the top. The presternal pectoral muscle tissue dissected off the anterior table of
the body of the sternum, and then we proceeded with rigid titanium plate fixation by using H shape plates [number of plates],
the plates were bent to the appropriate curvature and then secured to the fractures sternum above the fracture using
appropriately sized bicortical locking screws with [number of screws]. The sternal repair was satisfactory and the sternum
was stable. The abdominal fascia and the sternum were closed by interrupted suture of absorbable 1-0 sutures, followed by
absorbable 2-0 suture. The skin was closed by a running subcuticular suture using absorbable 4-0 suture. The patient tolerated
the procedure well. No intraoperative complications. All needle, sponge, and instrument counts were correct on two
occasions. [Mr/ Mrs.] [BLANK] appeared to tolerate the procedure well and was transferred to the ICU in stable condition.
Open chest: Considering the long procedure time and the continuous generalized oozing due to coagulopathy a decision was
made to keep the chest open.
The mediastinum was washed with copious amount of fluids and antibiotics, the mediastinal chest tubes were positioned
correctly. The chest was packed using two rolls of 6-inch Kerlix; the chest was covered with sterile Ioban dressing. The tubes
were hooked to suction, the patient tolerated the procedure well, remained intubated and moved to ICU.
33. Resection of Atrial Myxoma
Paul A. Perry, MD and J. Nilas Young, MD
University of California Davis, Sacramento, CA

5. Open pericardium, pericardial well, survey ascending aorta for plaque burden (consider epiaortic ultrasound)
8. Bicaval cannulation
9. Antegrade (+/- retrograde) cardioplegia catheter
10. Carbon dioxide diffusion into operative field
12. Initiate CPB
14. Cardioplegia and topical cooling for cardiac arrest
15. Atriotomy. For left atrial masses usually open right atrium and divide atrial septum at fossa ovalis (most tumors will
be located in left atrium along septum); alternatively, can expose and incise left atrium
16. Expose base of mass
17. Sharply excise mass off atrial wall en bloc with 1 cm margin
18. Irrigation of atrium/ventricle to remove any debris
19. Repair atrium. Patch closure of septum
20. Close right atrium with pledgeted running prolene suture (allow heart to fill with blood prior to completing suture
line)
22. Atrial and ventricular pacer wire placement
23. Vigorous deairing under TEE guidance
24. Wean from CPB
25. Check for normal sinus rhythm
27. Protamine
29. Meticulous hemostasis

1. Tumor embolization due to manipulation of the heart before cross-clamp
2. Phrenic nerve injury during dissection of SVC
3. Atrial incision site selection should be specified to the location of the mass, as indicated by pre-operative imaging
4. SA node, AV node, or conduction system injury during atrial exposure or mass excision
5. Valvular injury during atrial exposure or mass excision
6. Goal is to obtain negative margins
7. Resected tissue should be sent for pathologic evaluation
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. embolism, arrhythmia, obstruction]
Procedure(s) Performed: Resection of Left/Right Atrial Mass
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of atrial mass. Preoperative
echocardiogram reveals [FINDINGS - e.g. 2 cm pedunculated left atrial myxoma].
Outcome: TEE demonstrated preserved biventricular function and no ASD.
Description of Procedure: The patient was taken to the operating room on [DATE]. Identity and planned procedure were
verified, and the patient was placed on the operating room table in the supine position. General anesthesia was obtained.
Central venous and radial arterial lines were inserted. Preoperative transesophageal echocardiogram was performed and the
mass was identified. The chest, abdomen, groins, and lower extremities were prepped and draped in sterile fashion. A
surgical time-out was performed.
Median sternotomy was created and a sternal retractor placed. After identification of the innominate vein, the pericardium was
opened and a pericardial well was created. [UNITS] of systemic heparin were administered. The aortic cannulation sutures
were placed in the ascending aorta below the level of the innominate artery. The aortic cannula was then inserted, secured, de-
aired, and confirmed to have pulsatile flow by the perfusionist. Venous cannulation sutures were then placed and the SVC and
IVC cannulas were inserted and secured. The superior and inferior vena cavae were dissected out and encircled with umblical
tape. After placing a purse-string suture in the proximal ascending aorta, an aortic root vent needle was inserted for
administration of antegrade cardioplegia. Gas diffuser was placed along the wound edge and used to flood the operative field
with carbon dioxide. The aortic cross-clamp was placed. Antegrade cardioplegia was administered and there was rapid
myocardial arrest. A total of [BLANK] ml of cardioplegia was given. Ice was applied to the heart. For the duration of the
procedure, [BLANK] ml of cardioplegia was administered at 15-20 minute intervals.
The right atrium was exposed and atriotomy was made parallel to the atrioventricular groove. The fossa ovalis was identified
and atrial septotomy was performed. The atrial retractor was inserted, and the atrial mass was identified along the [BLANK].
A 15 blade scalpel was then used to excise the mass off the atrial wall, taking care to obtain an approximate 1 cm margin of
myocardial tissue. The excision site was then over-sewn with multiple interrupted 5-0 prolene sutures, resulting in excellent
approximation of endocardium. The left atrium was copiously irrigated with [BLANK] ml of saline. The atrial septotomy was
repaired with a patch of bovine pericardium, and the right atriotomy was then closed with pledgeted 4-0 prolene.
Hot shot cardioplegia was administered and the patient was rewarmed. The aortic cross-clamp was removed. Atrial and
ventricular pacing wires were inserted and tested for appropriate capture. Vigorous de-airing maneuvers were performed
under TEE guidance and the aortic root vent was removed. The patient was weaned from cardiopulmonary bypass. A normal
sinus rhythm was noted. The venous cannulae were removed. A test dose of protamine was administered and the patient was
monitored for adverse reaction before the protamine was resumed. The aortic cannula was then removed. A total of
[NUMBER] chest tubes were placed in the [LEFT/RIGHT] pleural space, and [NUMBER] chest tubes were placed in the
mediastinum. Hemostasis was confirmed. The sternum was closed with [NUMBER] stainless steel sternal wires. The wound
was irrigated with saline. The soft tissue was closed in layers and the skin approximated with staples. The wounds were
dressed.
subsequently transferred to the postoperative cardiac surgical intensive care unit with stable hemodynamics and [BLANK]
inotropic support.
34. Septal Myectomy
Michael P. Robich, MD and Nicholas Smedira, MD

1. TEE- have a clear understanding of septal thickness and length of hypertrophy toward apex
3. Pericardial cradle sutures only on the right
4. Standard aortic and single 2-stage venous cannulation
5. Left atrial vent
6. Transverse aortotomy- oblique, slightly closer to the sinotubular ridge than for aortic valve replacement, staying
above the sinotubular junction
7. Complete septal myectomy from trigone to trigone, excise hypertrophied septum beyond endocardial scar to mid-
papillary muscles (if there is not a proximal bulge)
8. Post TEE (off bypass) to assess adequacy of myectomy and residual mitral regurgitation (provocation with Isuprel to
ensure that outflow tract gradient is minimal and no SAM).

1. Damage to aortic valve
2. Damage to mitral valve, papillary muscles or chordea
3. Creation of VSD
4. Inadequate myectomy. You have to go deeper toward the apex than you think.
5. Overlooking abnormal papillary muscles or chordae
6. Post operative atrial fibrillation can look like ventricular tachycardia due to left bundle branch block
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. Hypertrophic Obstructive Cardiomyopathy (HOCM)]
Procedure(s) Performed: Septal Myectomy (DETAILS – e.g. Tissue valve or Mechanical valve)
Assistants: [BLANK]
Anesthesia: [BLANK]
Specimen: septal muscle
Counts: sponge, instrument, and needle counts correct
Drains: mediastinal x2
Skin incision: [TIME]
Closure: [TIME]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT – e.g. chest pain,
syncope and/or shortness of breath].
Patient presented with frequent syncopal episodes. There is no family history of HOCM or sudden cardiac death. The SBP
dropped during exercise. Preoperative echocardiogram demonstrated a 28mm septum (normal <13 mm). The resting gradient
was 36mm Hg, gradient on valsalva was 64mm Hg. With amyl nitrate the gradient increased to 110mm Hg. Systolic anterior
motion of the anterior mitral leaflet with septal contact was noted at rest with trivial mitral regurgitation and there was no
AS/AR. Preoperative cardiac MRI revealed asymmetric (basal and mid) septal hypertrophy (28mm) with a preserved EF
(65%). The papillary muscles are multiheaded without thickening. There appears to be an abnormal chordal attachment of an
accessory head of the anterolateral papillary muscle to the septum. Coronary arteries were free of disease.
Description of Procedure: After induction of general anesthesia and central line placement the patient was prepped and
draped. TEE was used to confirm the preoperative findings. Median sternotomy was made, heparin was given, and standard
aortic and a single 2-stage right atrial venous cannulation performed. A left atrial vent was placed in the left atrium just beyond
the entry of the right superior pulmonary vein. The heart was arrested with one liter of antegrade del Nido cardioplegia. A
transverse aortotomy was made and 2-0 silk retraction sutures x3 were placed in the aortic wall (one on the superior and 2 on
the inferior aspect of the aortotomy) and the aortic valve leaflets gently retracted to reveal the left ventricular outflow tract
(LVOT). A hand-held ribbon retractor was placed in the LV and upward traction applied. A sponge on a stick was used to
depress the left ventricle and to rotate the septum posteriorly.
Fibrosis from the contact of the anterior mitral valve leaflet septum was evident and the myectomy was initiated here. An
angled #10 scalpel was used to make a two incisions 5mm apart, 8mm in depth creating a strip of myocardium 2.5cm below
the nadir of the right cusp that was extended toward the level of the papillary muscles. The resection with the scalpel was
continued from the medial to lateral commissures of mitral valve taking segments of myocardium approximately 5mm thick,
10mm wide and 15mm deep. These two incisions were connected using a #15 blade, excising a 5mm x8mm x1.5- 3cm strip of
myocardium. Two similar strips of muscle were then excised; one medially to the right fibrous trigone and the next laterally to
the left trigone. These three resections have excised the basal portion of the septum, exposing the septum over the papillary
muscle heads. To treat concentric hypertrophy the myectomy continues into the ventricle to excise septum over the distal, mid,
and sometimes basal portions of the papillary muscle. Care was taken to avoid creating a VSD and the RV was observed for
dimpling to suggest collapse of the septum into the LV cavity. The accessory head of the anterolateral papillary muscle was
resected. The LV cavity was then irrigated with cold saline.
Once the resection was thought to be adequate the aortic valve leaflets were examined for any damage and the aortotomy was
closed with a running 4-0 prolene in the standard fashion. The LA vent was removed, but the pursestring left loose to allow
deairing. The pursestring was then tightened, the cross clamp removed, and TEE used to assess for intracardiac air. The
patient was separated from CPB. TEE was used to assess the adequacy of resection, presence of SAM and MR. Isuprel drip
(10-20 mcg/min) was started and LVOT gradient was reassessed. The gradient was less than 15mmHg. The heart was
decannulated. Protamine was given and the chest closed in the usual fashion. The weight of the removed septum was 8 grams
(normal 3-12 grams). The patient left the OR in stable condition with the expected left bundle branch block.
35. Endovascular Repair of Descending Thoracic Aortic Aneurysm
(TEVAR)
Mohiuddin Cheema, MD and Ali Khoynezhad, MD, PhD
Cedars Sinai Medical Center, Los Angeles, CA

1. Lines and Monitoring (make sure radial aline on right if left subclavian artery being covered)
2. Lumbar drain if high risk for spinal cord ischemia
3. General Anesthesia
4. TEE to make sure no aortic valve or root pathology and good LV function
5. Access artery exposure for delivery of stentgraft (open surgical cutdown of CFA vs iliac artery vs percutaneous
perclose technique)
6. Percutaneous access of brachial or contralateral femoral artery for diagnostic angiography
7. Systemic heparin bolus (100units/KG) to keep ACT above 250
8. IVUS (intravascular US) evaluation of aorta and iliac arteries to map out landing zones and assess diameters
9. Measure the aortic diameter at both proximal and distal intended landing zones (IVUS and CTA)
10. Measure the length of aorta that needs to be covered using sizing pigtail catheter
11. Choose the appropriate stentgrafts based on above measurements (refer to company’s sizing guidelines for different
stentgrafts)
12. Perform left carotid subclavian bypass if indicated for intentional coverage of left subclavian artery (consult vascular
surgery if needed)
13. Access the femoral artery using seldinger technique and exchange soft wire for a stiff guide wire parked in ascending
aorta
14. Advanced an appropriately sized large bore delivery sheath into the abdominal aorta for delivery of endoprosthesis
(be careful not to push too aggressively if iliac artery is tortuous or calcified)
15. Advance a sizing pigtail catheter from contralateral femoral artery for angiogram
16. Obtain thoracic arch aortogram in steep left anterior oblique projection (45 degrees or more) to splay open the arch
and brachiocephalic vessel s.
17. Advance endograft to appropriate location over stiff wire after device flushing to evacuate air from delivery system
(air embolism is a major cause for stroke).
18. Reimage with IVUS or angiogram to confirm location before final deployment
19. Deploy stentgraft per company’s guidelines with brief period of asystole (adenosine 12-24mg IV bolus) or with very
low systolic BP to avoid graft migration or wind socking effect.
20. Deploy additional stentgrafts as needed with adequate overlap (generally 3-5cm overlap recommended for most
stentgrafts) to coverage aortic pathology (up to the Celiac artery if necessary).
21. Ensure spinal drain pressure below 10cm H2O (drain additional fluid if necessary upto 20cc max/hr) and MAP
above 75-80 for adequate spinal cord perfusion
22. Balloon the proximal and distal attachment sites as well as stentgraft overlap sites with appropriate compliant
balloons as recommended by the manufacturers.
23. Final angiogram and IVUS to ensure no endoleak or migration
24. Remove all the wires, catheters and sheaths and close arteriortomies surgically or percutaneously as planned.
25. Reverse anticoagulation with protamine

1. Avoid accessing small and calcified ileofemoral arteries. Access iliac arteries directly or sew a conduit if necessary
for large bore sheaths (iliac artery rupture carries high morbidity and mortality and sometimes presents in delayed
fashion)
2. Size the aorta and pick stentgrafts appropriately using preop CTA and IVUS
3. Avoid left subclavian artery coverage if patent LIMA to LAD graft or if patient has large dominant left vertebral
artery with small or absent right vertebral (perform left CCA to SCA bypass preoperatively if necessary)
4. Use lumbar drain Judiciously in cases where the risk of spinal cord ischemia is high
5. Avoid deployment of stentgrafts at the distal curvature of the aortic arch as it bends into descending aorta to avoid
bird beaking and collapse of the stentgraft especially in younger patients with tighter aortic curvatures
6. Ensure at least 2 cm of normal healthy parallel aorta at the proximal and distal landing zones to avoid Type 1
endoleaks
7. Ensure at least 3-5 cm of overlap between stentgrafts to avoid graft separation and type 3 endoleaks
8. Choose the stentgrafts with 10-20% oversizing for native aorta
9. Inadvertent coverage of left carotid or subclavian artery requires urgent bypass or retrograde stenting to avoid
cerebral ischemia
10. Acute drop in BP after removal of a large bore sheath is concerning for iliac artery rupture and requires urgent
endovascular or surgical repairs to avoid catastrophe (so called “iliac on the stick”)
Template Dictation
Preoperative Diagnosis: Descending thoracic aortic aneurysm status post previous aortic valve replacement, ascending aortic
enlargement.
1. Endovascular repair of descending thoracic aortic aneurysm.
2. Percutaneous access of right femoral artery with iliac and femoral artery angiogram.
3. Intravascular ultrasound (IVUS) before and after stent grafting.
4. Angiogram before and after stent grafting.
5. Radiology interpretation and supervision of above-mentioned procedure.
6. Transcranial Doppler monitoring throughout the entire case.
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with history of aortic aneurysm pathology. He had an aortic valve
replacement in the past due to bicuspid aortic valve and came in with back pain to the emergency room over the weekend.
Evaluation of the descending thoracic aorta using an MRA revealed a 5.6 cm descending thoracic aneurysm. After discussing
risks and benefits, he wanted to proceed with endovascular repair.
Operative Findings: Enlarged aortic root. Descending thoracic aortic aneurysm from distal to the left subclavian artery
extending upto the mid descending aorta with at least 2 cm of normal aorta at proximal and distal attachment sites. Completion
angiogram revealed no evidence of endoleak.
Description of Procedure: After informed consent was obtained, the patient was taken to the operating room and placed
supine on the table. Groin was prepped and draped in standard sterile fashion. Percutaneous access using ultrasound guidance
was performed in the right femoral artery. This was confirmed using angiogram of the distal iliofemoral artery. Next,
percutaneous ProGlide was deployed and dilators used to increase the size of the femoral arteriotomy. Next, an 8-French
sheath was placed and the wire was advanced under fluoroscopic guidance into the ascending aorta. It was exchanged for a
stiff wire and intravascular ultrasound (IVUS) catheter was advanced. The evaluation of entire thoracic aorta and iliac arteries
was performed using IVUS. The sizing was confirmed, which was a[BLANK] (eg. Medtronic Valiant stent graft 46 x 46x 157
mm graft). An angiogram was performed to confirm the location of the aneurysm. The Medtronic Valiant stent graft was
advanced to the desired location and deployed without any problems. Subsequently, a 16-French sheath was placed in the
groin after removal of the delivery catheter and intravascular ultrasound confirmed a good location of the stentgraft. The
completion angiogram also confirmed no evidence of any endoleak. At this time, the catheter and the wires were all removed.
The femoral arteriotomy was percutaneously closed. Please note that the patient was heparinized prior to the intervention and
we confirmed the ACT to be above 250 throughout the case. The anticoagulant was reversed using protamine at the end of the
case.
CONTRAST USED: (Visipaque 320) 55 mL.
FLUOROSCOPY TIME: 5 minutes.
TOTAL RADIATION DOSE: -------mSV
36. Total Arch Replacement with Deep Hypothermic Circulatory
Arrest for Aneurysm
Sanford Zeigler, MD
Stanford University, Stanford, CA

1. Preoperative planning for CPB cannulation
2. Induction, intubation, lines, and monitoring
3. Right radial arterial pressure line
4. Neuromonitoring (cerebral oximetry, transcranial Doppler, EEG)
7. Divide thymus, encircle innominate vein
8. Dissect out innominate artery, encircle with silastic
9. Open pericardium, create pericardial well
10. 5000 IU IV Heparin
11. Satinski or dual Novare clamps on proximal innominate artery
12. 5-0 Prolene to sew 6-8mm knitted Dacron graft to proximal innominate in end to side fashion
13. De-air and connect arterial cannula
14. Dissect out Left Carotid, Left subclavian, and encircle with silastic
15. Mobilize PA from Aorta for cross clamp; completely encircle ascending aorta
16. Full heparinization (400 IU/kg)
17. 4-0 Prolene pursestring to RA; venous cannulation with two stage cannula; connect to circuit
18. Place cardioplegia cannulae – root vent to ascending, retrograde through coronary sinus
19. Confirm ACT >480sec
20. Initiate CPB
21. Initiate systemic hypothermia to 24 degrees Celsius (cooler depending on more distal work, degree of difficulty)
22. Place Right Superior Pulmonary Vein Vent
23. Aortic cross clamp, antegrade cardioplegic arrest with ~1L cold blood cardioplegia
24. CPB Flows 2-2.5L/min/m2
25. Insert temperature probe into RV free wall
26. Insert cooling jacket or apply topical cold
27. Maintain myocardial temp <10 deg C with retrograde cardioplegia through case
28. Resect diseased ascending aorta to crossclamp
29. Give Hydrocortisone, Phenobarbital, Mannitol, Lasix
30. Drop flow to 10mL/kg/min
31. Clamp innominate proximal to graft
32. Remove aortic crossclamp
33. Ensure back flow from Left carotid, clamp if adequate
34. Add arterial perfusion balloon (pediatric retrograde) to L carotid if inadequate flow
35. Check for L Subclavian backflow, clamp; Keep R arm MAP ~40
36. Resect aortic arch, leaving 1cm Carrel buttons around arch vessels
37. Size proximal descending aorta; open and prepare multi-branch Dacron graft
38. Running 5-0 Prolene for open distal anastomosis
39. Attach Y’ed arterial cannula to grafts’ perfusion sidelimb; clamp graft, resume full flow through body and innominate
40. Reimplant L subclavian with running 5-0 Prolene, deair, move distal clamp proximal to this anastomosis
41. Reimplant L common carotid, deair, move distal clamp proximal to this anastomosis
42. Reimplant Innominate , deair, move clamp proximal to innominate
43. Remove Innominate clamp (end SACP)
44. Begin rewarming (no greater than 2 degrees C temperature gradient)
45. Clamp, cut, and oversew perfusion sidelimb of graft
46. Check and repair anastomoses
47. Graft to Ascending aorta anastomosis with running 3-0 Prolene
48. Deair (pump down, clamp off); tie
49. Remove cooling jacket and temp probe
50. “Hot Shot” – Retrograde warm blood cardioplegia
51. Place ventricular pacing wires
52. Deep Trendelenberg position
53. Remove crossclamp
55. Place chest tube
56. Engage root vent as rhythm returns
57. Wean from CPB
58. Deair heart and aorta through root vent
59. Remove LV vent
60. Remove Retrograde and Venous cannulae
61. Give Protamine
62. Remove arterial cannula
63. Reinspect for bleeding, achieve hemostasis
64. Pack chest
65. Place Sternal Wires
66. Check wires for bleeding
67. close sternum
68. Close Skin
69. (close axillary incision)

2. Innominate vein injury
3. Brachial plexus injury during axillary exposure
4. Injury/delamination of arch vessels during dissection
5. Failure to protect recurrent laryngeal nerves
6. Failure of left arm arterial line
7. Tracheal injury during arch dissection
8. Failure to insulate phrenic nerves from cold
9. Innominate/axillary dissection or bleeding from perfusion limb graft
10. Improper Venous cannula positioning (hepatic vein, RV)
11. Bleeding complications from venous cannulation
12. Coronary Sinus Perforation
13. Poor right heart protection (poor retro position)
14. Air embolism from improper deairing of any arterial graft segment
15. Poor LV venting
16. Low outflow from perfusion graft
17. Air embolism during open distal
18. Unilateral cerebral perfusion 2/2 unrecognized Circle of Willis obstruction
19. Excessive or inadequate flow during SACP
20. Failure to recognize bleeding from distal anastomoses prior to proximal anastomosis
21. Reperfusion injury from excessively fast rewarming
22. Coronary air embolism during dearing
23. Unrecognized bleeding from sternal wires
Template Dictation
1. [expanding, symptomatic] Aortic Arch Aneurysm of [cm]
2. [connective tissue disorder]
1. Total Aortic Arch Repair with deep hypothermic circulatory arrest and selective antegrade cerebral perfusion
2. [axillary artery cutdown]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [relevant connective disorder,
autoimmune disease, or infection] presented with an aortic arch aneurysm that was [size] [+/- growth rate].
induced. Neurologic monitoring was set up using [BLANK]. A left radial arterial line was placed, as were right right internal
jugular central venous line. A transesophageal echo probe was placed and formal evaluation of the cardiac function was
performed. The patient was prepped and draped in the usual fashion, leaving both groins exposed. A time out was performed to
confirm the correct patient, site, and procedure. Prophylactic antibiotics were given.
[A right axillary artery cutdown was performed taking care not to damage the trunks of the brachial plexus. The axillary artery
was isolated and proximal and distal control were obtained with silastic loops. 5000 Units of IV Heparin were administered
and allowed to circulate for 3 minutes. An 8mm Dacron graft was sewed end to side onto the artery using 5-0 Prolene in a
running fashion. The graft was deaired as the vascular clamps were removed. A tubing connector was secured to the graft.]
Median sternotomy was then performed. The thymus was divided and a pericardial well was created. The innominate vein was
encircled with a silastic and the arch vessels were dissected free, taking care to protect the left recurrent laryngeal nerve
around the distal arch. The ascending aorta and arch were dissected free. [An 8mm Dacron graft was sewn to the proximal
innominate artery taking care to avoid the right recurrent laryngeal nerve near the takeoff of the right sublavian].[Total Units]
of IV heparin were administered and allowed to circulate.
A purestring suture was placed in the right atrial appendage and a [size] two stage venous cannula was placed into the IVC
through the right atrium and secured. The perfusion graft was deaired and connected to the CPB circuit. A small pursestring
was placed on the right atrium and a retrograde cardioplegia cannula was inserted into the coronary sinus. After confirmation
of proper ACT, cardiopulmonary bypass was initiated. A left ventricular vent was placed through the right superior pulmonary
vein through a pursestring and position confirmed with TEE. Retrograde cold blood cardioplegia were administered with the
heart vented. The aortic crossclamp was placed. After diastolic arrest was achieved, a cooling jacket and RV temperature
probe were inserted. Systemic hypothermia was initiated to [degrees] Celsius.
As the patient was cooled, the diseased ascending aorta was resected up to the crossclamp. The healthy ascending aorta was
sized at [cm] and the appropriate Dacron graft opened. The proximal graft to aorta anastomosis was constructed using two
running 3-0 prolene sutures. When systemic hypothermia was achieved, Mannitol, propofol, and hydrocortisone were
administered. CPB flow was stopped and the aortic crossclamp was removed. Flow was then increased to [10 mL/kg/min].
The innominate artery was clamped after backbleeding to deair. [Good retrograde flow was seen from the left common carotid
artery, and the artery was clamped.] [Poor retrograde flow was seen from the left common carotid artery, and a pediatric
retrograde cannula that was hooked to the arterial circuit was placed into its ostium. The artery was then clamped]. The left
subclavian artery [was/was not] clamped.
Carrel patches were fashioned out of each arch vessel. The aortic arch was resected to just past the left subclavian. The
proximal descending aorta was sized at [cm] and the appropriate multibranch arch graft was opened and trimmed. The distal
graft to aorta anastomosis was constructed with 3-0 prolene in a running fashion. The graft was deaired and clamped, and an
aortic cannula was placed in the graft’s perfusion sidelimb. Hemostasis was achieved. Normal CPB flow was reestablished
and circulatory arrest terminated. Anastomoses were then constructed to the left subclavian, the left common carotid, and the
innominate artery, in that order, using 5-0 Prolene in a running fashion. Hemostasis was assured each anastomosis
appropriately deaired. As each anastomosis was completed, vascular clamps were removed restoring flow to the respective
territory in a sequential matter. After the innominate anastomosis was complete, the aortic crossclamp was placed on the
proximal arch graft, and the small [innominate/axillary] perfusion graft was doubly clamped and divided. It was oversewn
with 3-0 Prolene in two layers, obliterating dead space.
Systemic rewarming was then begun. The proximal graft to graft anastomosis was completed using 5-0 Prolene in a running
fashion. The ascending aorta was deaired and a retrograde hotshot was administered. The crossclamp was removed and
ventricular pacing wires placed. Normal sinus rhythm was restored and the patient weaned from CPB. Ventilation was
restarted. The heart was deaired through a Cooley needle in the ascending aorta. The retrograde cardioplegia catheter was
removed.
Protamine was administered and the venous cannula was removed. The graft’s perfusion sidelimb was clamped, divided, and
oversewn with 5-0 prolene in two layers. All suture lines were inspected and hemostasis achieved. [# of chest tubes] were
placed. The sternum was then reapproximated with eight #6 steel sutures. The wound was irrigated and closed using 0 Vicryl
for the periosteal fascia, 3-0 Vicryl for the deep dermal layer, and 4-0 monocryl for the subcuticular layer. [The axillary
incision was closed in two layers].
At the end of the case all sponge and needle counts were correct. The patient was then transferred to the CVICU in stable but
critical condition. There were no complications.
CPB Time: [minutes]
Crossclamp Time: [minutes]
SACP Time: [minutes]
Lowest Temperature reached: [minutes]
37. Total Artificial Heart

3. Intraop TEE
5. Open pericardium
6. Systemic heparin
9. Check ACT (>480)
11. Insert aortic vent
12. Clamp the aorta and snare the cava
13. Perform the cardiectomy leaving the aorta, pulmonary artery and a 1cm cuff of LV and RV and 1cm of TV and mitral
valve.
14. Buttress the rims of the LV and RV +/- a strip of felt
15. Sew the inflow cuffs onto the LV and RV.
16. Set the outflow grafts on the aorta and PA
17. Tunnel the driveline and connect the main body of the pump to the inflow cuffs and outflow grafts.
18. Connect the left pump and then the right pump
19. Deair
20. Start the left pump and then the right pump
21. Come off bypass
22. Decannulate
24. Wrap the pump with Gore-Tex
25. Close chest.

2. Patient’s chest cavity too small to accommodate the TAH
3. Not enough valvular tissue resected which leads to inflow obstruction
4. Atrial cuffs too large or too small leaving gaps or dog-ears.
5. Drivelines externalized too medially causing the pump to be medial and compressing the IVC.
6. RV turned on first, causing pulmonary edema.
8. Bleeding
Template Dictation
Preoperative diagnosis: [Indication: e.g. Ischemic cardiomyopathy]
Procedure(s) performed: Implantation of Total artificial heart as a bridge to transplant
Assistants: [BLANK]
Anesthesia: [BLANK]
[INTERMACS LEVEL] with [JUSTIFICATION OF STATUS].Patient taken to the OR today for implantation of Total
artificial heart
Drains: [BLANK]
Estimated Blood Loss: [BLANK]
Specimen: [LV core]
Description of Procedure: The patient was taken to the operating room on [DATE]. Preoperative huddle and pre-incision
A midline sternotomy was performed and the pericardium was opened. The patient was heparinized and arterial cannula was
placed in the ascending aorta and bicaval venous cannula was inserted. Once ACT was >480, patient was placed on
cardiopulmonary bypass and normothermia was maintained. A vent was inserted on the aorta to be used later for deairing.
The heart was mobilized, encircling the superior, inferior vena cava. The aorta and pulmonary artery were also mobilized. We
then performed the cardiectomy specifically designed for the insertion of the total artificial heart. Starting from the RV, an
incision was made 1-2 cm below the AV groove. The Tricuspid valve was cut 1 cm below the annulus. The incision was
carried through the base of the RV, into the septum and the LV and the Mitral valve was cut 1 cm below the annulus. The aorta
and pulmonary artery are then cut at the level of the commissural attachments. The remaining attachments of the ventricles were
then excised. The left atrium and left atrial appendage was examined for thrombus and the left atrial appendage was oversewn
from within the right atrium. The coronary sinus was oversewn. This leaves us with the left atrium with a rim of left ventricle,
right atrium with a rim of right ventricle, aorta and pulmonary artery.
Then, the rim of right ventricle and left ventricles were buttressed with 1 cm of felt around the free edge of both ventricles
using 3-0 prolene. [If the ventricles are thick, the felt doesn’t have to be used but the edge of the ventricles should still be
buttressed with 3-0 prolene]
The quick connect atrial cuffs of the TAH were trimmed and inverted and sewn onto the rims of the left and right ventricles.
The atria were then pressure tested to ensure there were no leaks from the cuffs. The cuffs were then everted.
The outflow grafts were pre-sprayed with co-seal as the graft material is not impermeable to blood. We measured our outflow
graft 3 cm for the aorta, 6 cm through the pulmonary artery and sewed these to the respective great vessels. Prior to connecting
the bodies of the pump, a sheet of Gore-Tex is sewn to the posterior pericardium and was used later for wrapping of the
device.
We then tunneled our driveline in a left subcostal position to make sure the pump was on the left hand side of the pericardial
space. The left pump was inserted into the inflow cuff and outflow graft, trying to deair along the way. The right pump was
attached in similar manner. We then further de-aired the pump and then as soon as we removed the cross-clamp, we began
pumping the left ventricle followed by the right ventricle.
We were able to easily ramp up of the flow and then separate from bypass. Cannulas were removed, cannulation sites
oversewn. Once we were satisfied with the hemodynamics and hemostasis, the remainder of the Gore-Tex was wrapped
around the pumping chambers in the great vessel. Two chest tubes were inserted and then closure was commenced in usual
fashion. The patient was then transported to the Intensive Care Unit in stable condition.
38. Transcatheter Aortic Valve Implantation (TAVI): (Transfemoral-
Transapical Approach)
Dimitrios Topalidis, MD and Gabriel Loor, MD

4. Unilateral arterial and bilateral venous groin access
5. Pigtail catheter placement/advancement to the aortic root
6. Temporary pacemaker placement in the RV
7. Aortogram to determine optimal radiographic angles during valve deployment
8. Left anterior thoracotomy (5th-6th space depending on 3D CT and spot fluoroscopy)
9. Pericardial stay sutures and exposure of the LV apex (for redos the pericardium can be left intact with creation of
separate small slits for drainage later)
10. Radiographic and TEE confirmation of optimal LV puncture site
13. Double pursetring suture on the LV apex with pledgets
14. LV apex puncture with a guide needle and advancement of a soft access guide wire across the aortic valve and into
the descending aorta under fluoroscopic guidance
15. 12fr Sheath advancement into the LV
16. Float the Berman PA catheter through the aortic valve and into the descending aorta.
17. Amplatz wire through the Berman
18. Delivery of the device introducer sheath over the wire
19. Balloon aortic valvuloplasty with rapid ventricular pacing
20. Removal of the balloon and advancement of the deployment system with the valve across the annulus (50% above,
50% below)
21. Actual valve deployment under apnea, rapid RV pacing with simultaneous retrieval of the pigtail aortogram catheter
22. TEE confirmation of appropriate valve deployment and lack of significant AI.
23. Retrieval of the valve deployment system and guide wire.
24. Removal of the deployment sheath
25. Surgical hemostasis of the LV puncture site using rapid pacing
26. Administration of protamine for heparin reversal
27. Retrieval of the venous pacemaker and closure of the groin puncture sites

1. Vascular arterial and/or venous groin injury during access
2. Performance of thoracotomy at a level and position away from the LV apex
3. Lung Injury/ LV Injury during initial entry in the thoracic cavity
4. LAD injury during placement of puersetring sutures on the LV
5. Poor Choice of valve size resulting in aortic annulus disruption/VSD formation during valve deployment in case of an
oversized valve
6. Significant paravalvular AI after valve deployment
7. Valve dislodgement into the LV or distally
8. Obstruction/dissection of Coronary Ostia
9. Heart block
10. Bleeding at LV puncture site
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. Severe Aortic Stenosis]
Procedure(s) Performed: Transapical aortic valve Implantation
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE]year old [G ENDER]w i th [DURATIO N]history of [CO MPLAINT– e.g. ,
[FINDINGS - ].
Description of Procedure: Patient was taken to the hybrid operating room /cardiac catheterization lab. Patient was placed on
the fluoroscopy table in the supine position. After induction of general anesthesia, patient was intubated with a double lumen
endotracheal tube. Arterial, central venous, and pulmonary artery catheters were placed by anesthesia without difficulty.
Transesophageal echo probe was placed. The patient was positioned in the supine position with a bump under the left chest.
Chest and bilateral groin areas were prepped and draped in the usual sterile fashion.
Under direct fluoroscopic guidance, and using the micro puncture kit, 7F arterial and venous sheaths were placed into the right
common femoral artery and vein. A pigtail catheter was advanced into the aortic root and a trans venous pacemaker was
placed into the right ventricle. A contralateral 7F venous sheath was placed for possible CPB.
Next, a small left anterior thoracotomy through the fifth intercostal space was carried out. The wound protector was inserted.
The pericardium over the ventricular apex was incised and the adhesions were lysed. Pericardial stay sutures were placed.
Systemic heparinization was initiated. Double purse string sutures of 3-0 Prolene with pledgets were placed in the appropriate
site on the left ventricle apex. Next, the left ventricular apex was punctured with a needle and a soft guide wire was advanced
into the LV cavity towards the aortic valve. Over this guide wire, a 7 French sheath was placed. The wire was then exchanged
through the sheath with a Berman PA catheter to cross the aortic valve. An Amplatz wire was advanced through the Berman
into the descending aorta. The Edwards transapical deployment sheath was advanced over the Amplatz. Through this, a BAV
was performed under apnea and rapid ventricular pacing. The BAV balloon was withdrawn and a prepared Edwards Sapien
[BLANK] 26 or 23 mm valve oriented in the correct manner on its Ascendra deployment system was introduced. Under
radiological and TEE guidance the device was positioned across the aortic annulus. When the positioning of the valve was
found to be satisfactory, the valve was deployed under apnea and rapid ventricular pacing with balloon expansion. Echo and
fluoroscopy were used to document any AI or other valve-related issues. Next, the deployment system and guide wire were
removed. With rapid pacing the left ventricle sheath was removed and the purse string sutures were tied.
Heparin was reversed with protamine. General hemostasis was achieved. A #28 right angle chest tube was left in the pleural
cavity and a Blake drain in the anterior pericardium.
The ribs were re-approximated with a heavy Vicryl suture and the thoracotomy was closed in layers with running absorbable
sutures.
The patient tolerated the procedure well and was returned to the intensive care unit in stable condition. Sponge, needle and
instrument counts were correct prior to closing.
39. Valve Sparing Root Replacement
Walter F. DeNino, MD and John S. Ikonomidis, MD, PhD

2. Sternotomy and creation of pericardial well
3. Aortic and venous cannulation, placement of ante- and retrograde cardioplegia cannulae, LV vent
4. Antegrade arrest, topical cooling
5. RV/RVOT tacking
6. Coronary buttons, trimming aorta to annulus
7. Hegar sizing of outflow tract, graft size selection
8. Annular suture placement followed by placement through graft
9. Circulatory arrest and selection of distal graft including side branch
10. Distal hemiarch anastomosis performed, return to CPB and cannulation of side graft
11. Rewarming
12. Reimplantation of valve commissures
13. Reimplantation of the coronary arteries
14. Graft-graft anastomosis
15. De-air aortic root, place chest tubes/drains, assess repair by TEE, pacing wires, come off CPB, remove cannulae,
close chest

1. Thorough inspection of native aortic valve to ensure proper morphology and function adequate for valve-sparing
procedure.
2. Proper sizing of the graft utilizing the David Method (based on height of aortic valve leaflets) or that outlined here
using a Hegar dilator (Hegar size + 11).
3. Replacement of all ascending aortic tissue to the level of proximal hemiarch to prevent subsequent dilation of the
remaining distal ascending aorta and proximal hemiarch, potentially requiring a subsequent aortic replacement.
4. The graft used for the hemiarch replacement is smaller in diameter than the graft used for the valve-sparing aortic root
replacement so care must be taken to appropriately adjust the needle bites in the two grafts so that the larger proximal
graft will telescope down to create a uniform neo-sinotubular junction.
5. A careful inspection of the suture lines should take place while on CPB to eliminate any surgical causes of bleeding.
Following protamine administration, the repair is tightly packed for 5 to 10 minutes. During this time, appropriate
blood product infusion should be accomplished. On pack removal, the majority, if not all, of the suture lines should
have ceased bleeding. If the patient is coagulopathic, repacking and infusion of blood products may be appropriate. If
the patient is completely warm, if all laboratory values are normalized, if all surgical bleeding is controlled, and if
bleeding has still not ceased, it is appropriate at this point to consider infusion of recombinant activated factor VII
concentrate.
6. One should aim for a cusp coaptation length of 5 mm or more. When this can be achieved, this operation is likely to
be very durable. If any more than trivial insufficiency is encountered, consider re-arresting the heart and inspecting
the repair. If the reason for the insufficiency is not identified or not repairable, it may be necessary to excise the
leaflets and replace the aortic valve with either a mechanical or tissue prosthesis based on patient preference.
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. Aortic root dilation and aortic insufficiency, Type A dissection, etc]
Procedure Performed: Valve Sparing Root Replacement (DETAILS – e.g. 34 mm Dacron graft anastomosed to a 26 mm
Dacron graft)
Assistants: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT – Aortic root
aneurysm]. The patient was originally found to have an enlarged aortic root measuring XX cm. The patient's aortic root now
measures between XX and XX cm in diameter, depending on the imaging modality. A preoperative echo showed an ejection
fraction of XX% with an aortic root diameter of XX cm and moderate aortic insufficiency. Due to the findings of progressive
aortic root dilatation and aortic insufficiency, the patient was evaluated by CT Surgery and consented for a valve sparing aortic
root replacement.
Estimated Blood Loss: [NUMBER]
Urine Output: [NUMBER]
Total CPB time: [NUMBER]
Cross Clamp time: [NUMBER]
Circulatory Arrest time: [NUMBER]
Specimens: [BLANK]
Description of Procedure: Under general anesthesia, the patient was positioned in the supine position with the
chest/abdomen/pelvis and lower extremities prepped and draped in sterile fashion. A radial arterial line and central venous
line with pulmonary artery catheter were placed by anesthesia. Pre-operative IV antibiotics were administered. A median
sternotomy was performed and the pericardium opened widely in the usual fashion. The right portion of the pericardium was
suspended, allowing the ventricular mass of the heart to fall downward into the left chest and provide better exposure to the
aortic valve. Following systemic heparinization, standard aortic and two-stage right atrial cannulation was undertaken. A [XX
F] aortic cannula was used that would later accommodate the Dacron side arm of the graft used for the hemiarch replacement.
Both antegrade and retrograde cardioplegic catheters were placed to first arrest the heart antegrade with blood cardioplegia
and then switch to retrograde cardioplegia during the remainder of the procedure. This was supplemented with topical iced
saline for cooling of the heart. The myocardial temperature was monitored with a probe placed just right of the left anterior
descending coronary artery and angled into the interventricular septum. Interventricular septal temperature was maintained
between 10 and 15°C for the entire cross-clamp procedure with intermittent 250 to 500 mL retrograde cardioplegic infusions
every 20 minutes. For venting, a [14-F] vent is placed directly in the apex of the left ventricle. Once on bypass, the patient was
systemically cooled to a bladder temperature of [20°C].
The superior margin of the right ventricle and right ventricular outflow tract were retracted downward and to the left,
respectively, using needled silastic sutures anchored under a reasonable amount of tension. Following cardioplegic arrest, the
ascending aorta was transected and the aortic valve carefully inspected to ensure that it is a morphologically normal structure
with no significant calcifications, fenestrations, or tears.
The left and right coronary buttons were excised and gently retracted with 4-0 polypropylene sutures. Following completion of
this, the residual aorta was carefully trimmed, leaving the aortic annulus and valve encircled by approximately 7 to 8 mm of
native aorta. Next, careful dissection was completed separating the aortic root from the pulmonary artery, right ventricular
outflow tract, and the left atrium. Dissection proceeded down to the level of the aortic annulus circumferentially and slightly
below.
Hegar dilators were carefully placed across the aortic valve to a dilator size that fit comfortably in the outflow tract but not
tightly. Then 5 mm (accounting for 2.5 mm on either side of the outflow tract) was added to the dilator number and an
additional 6 mm to allow for billowing of the graft (11 mm total).
A total of [12 -15] multifilament 2-0 polyester sutures were placed in horizontal mattress fashion under the annulus such that
one horizontal mattress suture was placed under each commissure in planar fashion using an equal number of stitches per sinus.
Caution was employed to make sure that the sutures did not breach the aortic endothelium but all stay buried beneath it. Next,
the previously sized Dacron graft was brought into the operative field and a marking pen was used to mark the graft at
approximately 120° intervals. The horizontal mattress sutures were then placed sequentially through the graft. The graft was
lowered into position such that the valve and all of the aortic tissues sat firmly within the graft. Care must was taken to make
sure that all layers of the aorta were sitting inside the graft before the sutures were tied. The Hegar dilator that was used to size
the annulus was placed across the valve before tying the sutures. The three subcommissural sutures were tied first, creating a
small graft plication under each commissure to narrow the valvular commissural angle. The remaining sutures were then tied
firmly but not snugly all the way around, keeping the Hegar dilator in place to prevent narrowing of the left ventricular outflow
tract. Following suture tying, a small amount of resistance was felt when removing the Hegar dilator.
By this time, the bladder temperature reached 20C. The patient was placed in Trendelenburg position, the head was packed in
ice, and 15 mg/kg IV of sodium pentobarbital and 1 g IV methylprednisolone were administered. A woven Dacron graft sized 2
to 3 mm larger than the Hegar dilator used to size the graft for the valve-sparing root replacement was selected. A graft with a
10 mm sidebranch for later cannulation was chosen. The pump was discontinued and the aorta quickly resected. The trimmed
graft was brought into the operative field and the distal anastomosis performed with a running 3-0 polypropylene suture such
that the side limb of the graft pointed directly anterior. A small amount of biological glue was used to seal needle holes. Pump
flow was commenced at 1 L/min and the side limb of the graft cannulated. Circulatory arrest time was XX minutes. The side
limb, arch, and graft were carefully de-aired before the cross-clamp applied to the graft just proximal to the entrance of the
side limb. The hemiarch anastomosis was inspected for leaks as cardiopulmonary bypass was brought back up to full flow.
When surgical hemostasis was obtained, rewarming was begun and the residual graft folded under the innominate vein for later
graft-to-graft anastomosis. Attention was turned back to the valve-sparing aortic root replacement.
3-0 Polypropylene sutures were placed in horizontal mattress fashion from inside to out anchoring the tops of the valve
commissures to the graft at 120° intervals. To achieve the appropriate graft height, gentle traction was placed on the graft to
slightly unravel its corrugations before placing the sutures. It was verified at this point that these commissural attachment sites
would not obstruct the direct re-implantation of coronary arteries. The aortic root was irrigated with a small amount of cold
saline and the valve leaflets inspected to ensure coaptation on the same plane with no prolapse into the left ventricular outflow
tract. The commissural suspension sutures were then gently tied with three knots, each leaving two equal lengths of suture
loaded with a needle.
One limb of one polypropylene suture was then brought from outside to in just over top of the aorta surrounding one
commissure. The aortic cuff around the valve was sutured carefully to the graft in running fashion. Care was taken not to take
excessive bites of the graft and that the bites were taken very close to the annulus of the aortic valve to prevent subsequent
dilation of both the annulus and the intervening aortic segment. Following complete running of one of the commissures, the
suture was brought outside and tied to one of the next Prolene commissure sutures. These were cut and the remaining suture on
that side used to run to the next commissure and so on circumferentially. [To deal with a prolapsing leaflet, a 6-0
polytetrafluoroethylene (Gore-Tex) suture is doubly run in continuous fashion along the free margin of the leaflet reinforced
with small pledgets placed on the outside of the graft. This suture is tied when traction on it pulls the free margin of the valve
leaflet up to the same level as the other two leaflets.]
Ophthalmic cautery was used to create appropriately sized defects in the left and right neo-sinuses of the graft for re-
implantation of the coronary arteries, performed with 5-0 polypropylene suture. Following completion of these two
anastomoses, the reconstructed root was carefully inspected from the inside to make sure that the suture lines on the coronaries
were uniform. Biological glue was applied to the anastomoses to seal needle holes.
Following completion of this portion of the operation, the graft was then trimmed to approximately 5 mm above the implanted
aortic valve commissures. The previous graft used for the hemiarch anastomosis was unraveled, measured, and trimmed
appropriately. The graft-to-graft anastomosis was then constructed with running 3-0 polypropylene suture.
Next, an ascending aortic vent with cardioplegia infusion line was inserted in the graft and 500 mL of warm cardioplegia given
with the first 100 mL used to de-air the root. The ventricular vent was removed and oversewn with a running 2-0
polypropylene suture. The retrograde cardioplegic catheter was removed. Ventricular and atrial pacing wires as well as a 36 F
mediastinal and 19 F left pleural Blake drain were placed. The cross-clamp was removed and sinus rhythm resumed. During
myocardial recovery, careful interrogation of the valve was undertaken by TEE to assess for any residual insufficiency and to
measure the coaptation distance of the valve leaflets. Following an appropriate period of rewarming (to at least 36.5°C) and
de-airing, the ascending aortic vent was removed and reinforced with 4-0 polypropylene suture. The patient was then weaned
from cardiopulmonary bypass. The venous cannula was removed. Protamine was administered directly down the side limb of
the hemiarch graft. Following completion of protamine administration, the side graft was tied at its point of insertion into the
larger graft with two #2 silk ties. The graft was then divided, resulting in arterial separation from bypass. Once adequate
hemostasis was ensured, the chest was closed in the usual manner.
III. Congenital Cardiac Surgery
1. Repair of Atrial Septal Defect- Secundum Atrial Septal Defect
Fahd Makhdom MD and Christo I. Tchervenkov MD.
McGill University, Montreal, Canada

1. Monitoring and central line.
2. General anesthesia with endotracheal intubation.
3. Intra-operative Transesophageal Echocardiogram (TEE)
4. Positioning; supine.
5. Median sternotomy (Variation: Right anterior thoracotomy, Ministernotomy, Submammary skin incision and
sternotomy).
6. Opening the pericardium
7. Preserve portion of the pericardium to use as a patch for closure (Optional), Other alternates include: Bovine
pericardium, or Gore-TEX patch.
8. Systemic heparinization (400 U/kg).
9. Ascending aortic cannulation.
10. Bicaval venous cannulation and caval snares.
11. Antegrade cardioplegia line.
12. Check ACT (greater than 400 seconds), initiate CBP.
13. Aortic cross clamp.
14. Antegrade cardioplegia with mild hypothermia.
15. Snare both cavae.
16. Right atriotomy; oblique incision from base of right atrial appendage towards the IVC.
17. Examination of the interatrial septum and identify the defect margins.
18. Structure to be identified upon examining the right atrium
19. Superior Vena Cava and Inferior Vena Cava to ensure that there is no anomalous pulmonary veins returning to the
right atrium or the SVC
20. Eustachian valve is identified to prevent baffling blood from the IVC to the left atrium
21. The coronary sinus is identified and must be protected from the suture line to avoid heart block
22. Closure of the defect (Variation: direct closure if defect is small. If the defect is large, a patch is used for closure)
23. The suture should be taken through a good tissue paying attention not to injure the surrounding structure.
24. De-airing of left side chambers.
25. Ventilate the lungs (Note: Avoid excessive suctioning of the left atrium to prevent air trapping in the left heart).
26. Tightening the suture line and tie.
27. Place additional interrupted sutures at several strategic places to further secure the closure.
28. Remove aortic cross clamp.
29. Start rewarming.
30. Fill the right atrium to perform deairing.
31. Close the atrial incision.
32. Temporary Pacing wires, atrial/ ventricular.
34. Transesophageal echocardiogram (TEE) to evaluate the repair and rule out residual shunt.
35. Heparin reversal; protamine (4 mg/kg).
36. Sequential decannulation.
37. Meticulous hemostasis.
38. Chest tube placement.
39. Sternotomy closure.

1. Bleeding from suture lines.
2. Improper de-airing can lead to systemic air embolism.
3. Pulmonary hypertension with right ventricular failure.
4. Injury to conduction system; heart block.
5. Residual shunting can occur in case of patch dehiscence, a suture line with pulmonary vein/veins draining into right
atrium or missed additional ASD.
6. Misidentifying the Eustachian valve can lead to closing the IVC to left atrium causing the post-operative cyanosis.
7. Post-operative cyanosis can also be due to missed PAPVC to right atrium or a coronary sinus ASD or the left SVC
draining into left atrium with an unroofing of the coronary sinus
Template Dictation
Preoperative diagnosis: Secundum Atrial septal defect
Postoperative diagnosis: Same.
Procedure(s) Performed: Repair of Secundum ASD with Gore-TEX patch
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE]year old [GENDER]with [DURATION]history of recurrent pneumonia. During the
workup she was diagnosed with atrial septal defect secundum type. On echocardiogram, the atrial septal defect was found to
be very large and missing an inferior rim precluding percutaneous device closure. A cardiac catheterization revealed a large
left to right shunt with a QP/QS ratio of 3:1. There are no other abnormalities diagnosed. The pulmonary artery pressures were
only mildly elevated. The patient was brought to the operating room for closure of the atrial septal defect.
Perfusion Data: For the purpose of the surgery, the patient was put on cardiopulmonary bypass. Following systemic
heparinization, we proceeded with cannulation the distal ascending aorta and of both venae cavae. The patient’s weight was
[BLANK]kilograms. The estimated flow optimal for this patient was at [BLANK]liters per minute. Following cross-
clamping of the aorta and arresting the heart with antegrade cold blood cardioplegia, both cavae were snared and the right
atrium was opened. The ASD secundum was closed with a Gore-Tex patch and the aortic crossclamp time was [BLANK]
minutes.
Operative findings: The patient had normal thymic tissue. The pericardium was not adherent to the heart. The great vessels
were normally situated. There was a large secundum atrial septal defect with no rim near the inferior vena cava. The systemic
and pulmonary venous drainage was normal.
Description of the procedure: After informed consent and patient identification the patient was brought to the operating room
and placed on the operating table in a supine position. After induction of general anesthesia with single lumen endotracheal
tube intubation, arterial and central venous monitoring lines were placed. A transesophageal echocardiogram (TEE) was
performed and the above findings were noted. The patient was positioned; chest, abdomen, groins and upper thigh were
prepped and draped in a surgical sterile fashion.
We proceeded with a median sternotomy by achieving careful hemostasis. The pericardium was opened and suspended. A full
dose of intravenous heparin was given to achieve the systemic anticoagulation. We proceeded with cannulation of the
ascending aorta as well as cannulation of the superior vena cava and inferior vena cava. After achieving an activated clotting
time above 450 seconds, cardiopulmonary bypass was initiated and the aortic crossclamp was applied. Antegrade blood
cardioplegia was used to arrest the heart. The right atrium was opened and the secundum atrial septal defect was visualized.
The coronary sinus and the ostia of both venae cavae were located. No anomalous pulmonary veins or additional defects were
identified. A Gore-Tex patch (0.6 mm) was tailored to fit the size of the atrial septal defect. Using a 5-0 polyproplyene, the
patch was sutured around the rim of the atrial septal defect in a continuous fashion. Excessive suctioning of blood from the left
atrium was avoided, in order to prevent trapping air on the left side of the heart. Just before completing the suture line, using
Valsalva maneuver, the left atrium was allowed to fill and air was expelled towards the right atrium. Then the suture was tied.
The suture line was reinforced in a few additional places with interrupted 5-0 mattress sutures. Next the patient was rewarmed
and the aortic crossclamp was removed. The right atrium was allowed to fill partially. The atriotomy was closed using running
5-0 polyproplyene suture and was reinforced by another layer. Temporary ventricular and atrial pacing wires were placed.
With the patient warm and normal sinus rhythm recovered, cardiopulmonary bypass was discontinued successfully.
Transesophageal echocardiogram confirmed a secure ASD closure, with no residual shunting, and no air on the left side of the
heart. After protamine administration, the heart was decannulated. One mediastinal drain was placed. Once hemostasis was
achieved the chest was closed in the usual fashion, sterile dressing was applied.
2. Ventricular Septal Defect: Perimembranous
Keerit Tauh, MD and Andrew I.M. Campbell, MD
Division of Cardiovascular and Thoracic Surgery, BC Children’s Hospital
University of British Columbia
Vancouver, BC, Canada

2. General anesthesia.
3. Intraoperative transesophageal echocardiogram.
4. Median sternotomy.
5. Open pericardium and inspect cardiac anatomy.
6. Right sided pericardial suspension.
7. Systemic heparinization.
8. Arterial cannulation.
9. Bi-caval cannulation.
10. Myocardial protection cannula placement (DLP Aortic Root Cannula)
12. Ensure ACT > 400
13. Systemic cooling to 34 degrees (Variation: For complicated cases requiring a longer cross clamp more significant
hypothermia may be necessary).
14. Consider ligation of ductus arteriosis (routine in infants)
15. Right superior pulmonary vein (RSPV) vent is placed in absence of a patent foramen ovale (Variation: If a PFO is
present, it may be used to directly vent the left side, once the right atrium is opened).
16. Encircle caval tourniquets around SVC and IVC.
17. Cross-clamp the aorta and administer cardioplegia.
18. Snare caval tourniquets and ensure aortic root is being vented.
19. Open and retract the right atrium to facilitate viewing of all borders of the VSD.
20. Cut an appropriately shaped patch.
21. Continous or interrupted closure of the VSD.
22. Place horizontal mattress pledgeted sutures starting at the inferior border of the VSD and moving in a counter-
clockwise fashion towards the superior margin of the defect and the antero-septal commissure.
23. Continue placing interrupted pledgeted sutures through the septal leaflet with the pledgets on the atrial side of the
tricuspid valve - starting at the anteroseptal commissure and running down to the posteroseptal commissure.
24. Close the inferior margin of the VSD with the other end of the running suture used to initially start the patch
(Variation: place additional horizontal mattress pledgeted sutures in the ventricular septum in a clockwise manner
beginning from the original starting point up until the posteroseptal commissure is again reached).
25. Pass the interrupted sutures through the patch to ensure closure of the defect.
26. Parachute the patch into place and the pledgeted sutures are tied down.
27. Inspect the ASD, if the PFO has been used to vent the left side it is closed with a 5-0 suture.
28. Closure of right atrium.
29. Rewarm to normothermia.
30. Heart is de-aired and cross clamp is removed.
31. Ensure adequate hemostasis.
32. Place atrial and ventricular pacing wires.
34. Wean from CPB.
35. Venous decannulation.
36. Administration of Protamine.
37. Aortic Decannulation.
38. Assess Hemostasis.
39. Close Sternotomy.
Note: - Similar Operative set up is utilized during repair of other types of VSD’s including Muscular VSD’s and
conoventricular VSD’s. Subpulmonic VSD’s are approached with similar principles except a transverse incision in the
pulmonary artery is utilized. Inlet VSD’s will be covered in a separate chapter.

1. Remaining midline during sternotomy is crucial.
2. Avoid injury to innominate vein during pericardial dissection and suspension.
3. Cannulation complications include aortic dissection, SVC/IVC tears, hepatic vein cannulation, azygous vein
cannulation, embolism with aortic manipulation.
4. Insufficient myocardial protection can occur due to the cross clamp not completely across the aorta, aortic
insufficiency and cardiac distension due to inadequate venting and should be avoided.
5. Failure to address the patent ductus arteriosus may lead to air embolism and flooding of operative field.
6. Failure to securely snare the caval tourniquets can result into venous air lock and flooded operative field.
7. Transection of SA nodal artery by too far superior extension of the atriotomy should be avoided.
8. Overly aggressive tricuspid retraction can lead to tricuspid regurgitation and conduction anomalies.
9. Poor exposure of the VSD can potentially result into incomplete closure of VSD, technical difficulty and injury to
conduction system or aortic valve.
10. Poor patch sizing can lead to a persistent VSD due to redundancy or insufficient patch material.
11. Careful attention must be paid to passing sutures near the posteroseptal commissure as damage to the bundle of His
and potentially the AV node can occur as the suture is transitioned onto and through the septal leaflet.
12. The aortic valve leaflets are situated below the superior margins of the VSD and can be caught into the deep needle
bites.
13. Sutures should be gently tied as excessive torque on the tissue can result into tearing of septum or septal leaflet when
tying the sutures.
14. Adequate warming, de-airing and obtaining a meticulous hemostasis prior to sternotomy closure are of paramount
importance.
Template Dictation
Preoperative Diagnosis: (INDICATION – e.g. Perimembranous VSD)
Postoperative Diagnosis: Same or other findings
Procedure(s) Performed: Repair of Perimembranous (Variation: type of VSD) VSD
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT – Failure to thrive,
Poor Feeding, Exercise intolerance, Shortness of Breath, Cyanosis etc]. Preoperative echocardiogram demonstrated a
(FINDINGS – e.g. 1.4 cm perimembranous VSD with a Qp: Qs ratio of[VALUE] and pulmonary pressures of [VALUE] mm
Hg.
Description of Procedure: After informed consent the patient was taken to the operating room on [DATE]. The patient’s
identity and planned procedure were verified, and the patient was placed on the operating table in a supine position. After
appropriate IV access, arterial lines were established and general anesthetic was administered with endotracheal intubation. A
central line was placed. Preoperative transesophageal echocardiogram was then performed to evaluate cardiac function and
anatomy. We then proceeded to prep and drape the patient in the usual sterile fashion. Time out was performed. Median
sternotomy was performed and the thymus [was/was not removed]. Following identification of the innominate vein, the
pericardium was opened and right-sided pericardial stay sutures were placed. Once dissected, intravenous heparin was
administered and an ACT was drawn. After the aorta was separated from the pulmonary artery and assessed, aortic cannulation
sutures using [SIZE] polypropylene were placed. The aortic cannula was then inserted, secured and de-aired. SVC cannulation
sutures were then placed and the right angle SVC cannula was inserted and connected to the bypass circuit. IVC cannulation
sutures were then placed and the IVC cannula was inserted. The IVC and SVC cannulas were then connected using a Y
connector to the common venous drainage line and tourniquets were encircled around each using umbilical tape. Once the ACT
was greater than 480 seconds, the patient was placed on bypass and gradual systemic cooling to 34 degrees Celsius was begun.
An aortic root cannula was then inserted into the ascending aorta for the cardioplegia administration and venting. The aortic
cross clamp was applied and antegrade cold cardioplegia solution was administered for arrest and myocardial protection.
Following cardioplegia administration, the caval tourniquets were snared and the aortic root vent was turned on.
An incision was then made in the right atrium starting at the right atrial appendage then moving obliquely towards the IVC.
Drop-in cardiotomy suction was used to aid in visualization of the tricuspid valve and right atrial retraction sutures were
placed. The inter-atrial septum was examined. The patent foramen ovale (PFO) was identified and used to vent the left side of
the heart. The tricuspid valve was then gently retracted using an aortic root retractor such that the circumferential border of the
perimembranous VSD could be clearly visualized and the repair could be planned. A double velour patch was then
approximated and cut to the size of the defect to ensure that there would be a sufficient overlap. Starting from the inferior
border of the VSD, pledgeted [SIZE] ethibond sutures were placed in a sequential interrupted manner using a mattress
technique progressing in a counter-clockwise direction. Care was taken to avoid the conduction system deep to the ventricular
septum. Once the antero-septal commissure was reached horizontal mattress sutures were then placed through the septal leaflet
in a similar fashion. Care was taken to avoid entering the tricuspid annulus. Once the interrupted sutures were run down to the
postero-septal commissure, sutures were then placed in a clockwise manner starting again from the inferior border of the
defect. Once the septal leaflet was met, a double pledgeted transition stitch was applied with one pledget adjacent to the
ventricular septum and one pledget on the atrial side of the septal leaflet. Cardioplegia was infused to help identify the aortic
valve to ensure that it was not entrapped by a suture. Once the sutures encircled the defect, they were then passed through the
pericardial patch. The patch was then parachuted down over the defect. In a sequential fashion, sutures were then gently tied
ensuring appropriate pledget orientation. Prior to tying the last set of sutures, cardioplegia was again instilled and gross de-
airing of the left ventricle was conducted. Once all sutures were secured, the patch and remainder of the interventricular
septum was inspected to ensure no residual or additional VSD was present. The atrial retraction sutures were then removed
and the tricuspid valve was interrogated using saline to assess for any signs of damage or new regurgitation. With the aortic
vent on high, deairing of the left atrium and ventricle was performed. The atrium was then closed using a 2 layer running
technique and [SIZE] polypropylene following gross de-airing. Once closed, the atrium was inspected for hemostasis and the
caval tourniquets were then released and removed.
Once gross de-airing was complete, the CPB flow was reduced, the root vent was placed on high, and the cross clamp was
removed. The patient was then rewarmed and further de-airing was conducted using transesophageal echocardiography and
pulmonary recruitment. Chest tubes were placed into the mediastinum. [ATRIAL/VENTRICULAR]pacing wires were then
inserted and tested for good capture. Once rewarmed to [NUMBER] degrees Celsius, the patient was slowly weaned from the
CPB circuit. The SVC cannula was first clamped then removed. The SVC suture was then tied in place and checked for
hemostasis. The IVC cannula was then removed. The IVC sutures was snared and left in place to allow reinstitution of
cardiopulmonary bypass if necessary. A test dose of protamine was given, and the patient was monitored for a hemodynamic
reaction. Protamine was then resumed and transfusion of pump blood via the aortic cannula was given as needed. Once the
protamine was complete, the aortic cannula was then removed and the aortic sutures were tied. Once de-airing was complete
the aortic root vent was then removed and the cannulation sutures were tied and assessed for hemostasis. The IVC purse string
was also secured. Hemostasis of all intra pericardial sites was assessed. The chest wall was then examined for hemostasis.
Sternum was then approximated using stainless steel wires. Hemostasis of wire sites was then assessed. The overlying fascia
and soft tissue and skin were approximated using absorbable sutures in a running fashion. The wound was then dressed with a
sterile dressing.
Instruments, sponges and needles counts were confirmed to be correct following conclusion of the operation. The patient was
then transferred to the Cardiac Surgery Intensive Care Unit in a stable fashion.
3. Partial AV Canal Repair
Sandeep Sainathan, MD, and Paul Kirshbom MD
Yale University, New Haven, CT.

1. Informed consent
2. Peripheral IV insertion and general endotracheal anesthesia.
3. Arterial line, central venous line, and urinary catheter insertion
4. Intraoperative Transesophageal echocardiogram (Avoid in infants less than 3 kg as the probe can cause
compression and distortion of the left atrium, interfering with the assessment and repair of the defect)
5. Median sternotomy with subtotal thymectomy
6. Asymmetric pericardiotomy to the left of the midline in order to harvest a pericardial patch.
7. Mobilization of aorta, ductus arteriosus and SVC.
9. Aortic and bicaval cannulation.
10. Initiate total cardiopulmonary bypass.
11. Ligation of PDA.
12. Snare the cavae.
13. Cool down to 34 degrees centigrade.
14. Apply aortic cross clamp with instillation of antegrade cardioplegia via the aortic root.
15. Right atriotomy parallel to the AV groove
16. Place left atrial vent via right upper pulmonary vein. (Rule out the presence of a small VSD under the septal leaflet of
the tricuspid valve).
17. Assess the mitral valve for morphology and competence through the atrial septal defect.
18. Close the commissure between the superior and inferior bridging leaflets on the left side with either interrupted or
running technique, typically with 5-0 or 6-0 monofilament suture. Commisuroplasties may be necessary in cases of
annular dilation causing residual regurgitation.
19. Repair the atrial septal defect with the native pericardial patch +/- with preservation with glutaraldehye, bovine
pericardium or PTFE patch.
20. Visualize the IVC orifice on right side of the patch.
21. Close of the atriotomy.
22. De-air the left heart via the aortic root and RSPV vent.
23. Remove the aortic cross-clamp.
24. Rewarm and remove the left atrial vent (Optional: Left atrial line, a LA line is generally not necessary).
25. Wean from CBP and decannulate.
26. Protamine administration.
27. Ventricular and atrial epicardial pacing wires
28. Place chest drains
29. Ensure adequate hemostasis.
30. Sternal closure.

1. The inferior vena caval cannula should be placed low enough to facilitate the adequate visualization of the inferior
aspect of the defect.
2. Excessive suturing of the free edges of the mitral cleft may cause the worsening of the mitral insufficiency. Hence, just
the opposing ‘Kissing edges’ should be approximated.
3. In order to carefully assess the mitral valve morphology and competence through the atrial septal defect, the defect
may need to be enlarged towards or into the fossa ovalis. The defect may range from a partial cleft in the anterior
leaflet to a complete cleft up to the base dividing the anterior leaflet into superior and inferior bridging segments.
Cold saline with a red rubber catheter is often used to test the mitral valve. The regurgitant jet either is through the
cleft or can be central after an adequate repair of the cleft due to annular dilation.
4. Central jet of mitral regurgitation from annular dilation after adequate repair of the cleft mitral leaflet can be treated
with either commisuroplasty or posterior annuloplasty.
5. Large bites taken on the anterior leaflet of the mitral valve or bites skewed towards the mitral valve side of common
annulus between the mitral and tricuspid valves may cause mitral insufficiency.
6. Repair of the atrial septal defect is done by placement of initial suture in the raphe between the mitral and tricuspid
valve orifices. After this is completed, the rest of the patch is trimmed and sutured to close the remaining septal
defect. The coronary sinus can be placed either on the right or left atrial side of the patch, but care must be taken to
avoid the conduction system as it crosses inferior to the coronary sinus. The coronary orifice needs to be kept on the
right side in presence of a left SVC.
7. Too much traction by the patch on the common annulus between tricuspid and mitral valve can potentially cause the
mitral annulus to tent up, resulting into mitral insufficiency. The patch should be tailored after completing the suture
line along the common annulus.
8. Friable tissue near the common annulus area can tear during suturing. Interrupted sutures reinforced with pericardial
strip pledgets should be used.
9. Insufficient tissue near the common annulus to suture the patch can be problematic. In such cases, the bites are taken
on the opposing leaflets of the tricuspid and mitral valve from the ventricular side near their insertion into the
common annulus. Deep bites should be avoided in the ventricular crest near the region of the conduction system.
10. Deep bites near the tricuspid annulus into the ventricular crest and in the region of the coronary sinus can potentially
cause AV block from injury to the conduction system. This can be avoided by taking superficial endocardial bites in
this region or suturing the right hand side of the patch over the coronary sinus.
11. Use of synthetic patch with residual mitral regurgitation may cause hemolysis, especially if the mitral regurgitation jet
impacts the patch.
12. Incorporation of the IVC on the left side of the patch can happen when there is a prominent Eustachian valve.
Similarly, when the defects extend high up superiorly or there is an associated secundum defect, the superior vena
caval orifice can be accidentally incorporated into the left atrium.
13. Deep bites in the superior aspect of the septal defect can cause the damage to the aortic valve
14. Deep commisuroplasty or annuloplasty stitches during mitral valve repair can potentially injure the circumflex
coronary artery.
Template Dictation
Preoperative Diagnosis: [INDICATION – Partial atrio-ventricular canal defect]
Procedure(s) Performed: Repair of partial atrio-ventricular canal defect
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT – e.g. - shortness
of breath]. Preoperative echocardiography revealed an atrial septal defect with left to right shunting and an associated
moderate to severe mitral regurgitation. The atrioventricular and arterioventricular concordance was normal with a normal
pulmonary venous drainage.
identity and planned procedure was verified, and the patient was placed on the operating room table in the supine position.
General anesthesia was administered via an endotracheal tube. A right internal jugular central venous line, radial arterial line,
and a urinary catheter were placed.
Preoperative transesophageal echocardiogram was then performed.
It confirmed the preoperative findings. We then proceeded to prep and drape the chest, abdomen, and groins in a sterile
fashion. A time out was performed.
Median sternotomy was then performed. A subtotal thymectomy was carried out. After identification of the innominate vein,
the pericardium was opened to the left of the midline. There were no pericardial adhesions .A pericardial patch of 3 by 4 cm
was harvested from the right half and pericardial stay sutures were placed. The ascending aorta, SVC and PDA were
mobilized. A total of [UNITS] of systemic heparin was administered. The aortic cannula was then inserted, secured and de-
aired. Bicaval venous cannulation was performed and caval snares were placed. Cardiopulmonary bypass was initiated. The
PDA was ligated with 6/0 polypropylene suture. Both the venae cavae were snared down. The patient was cooled to 34
degrees centigrade. The aorta was cross-clamped, antegrade cardioplegia was administered via the aortic root and a rapid
diastolic arrest was achieved. A right atriotomy was made parallel to the AV groove. A left ventricular vent was placed
through the right superior pulmonary vein with the help of a right angle clamp placed into it across the atrial septal defect. The
atrial septal defect was inspected and an associated VSD was ruled out by thoroughly inspecting under the septal leaflet of the
tricuspid valve. Through the atrial septal defect, the mitral valve was inspected. There was a cleft in the anterior leaflet of the
mitral valve extending up to its base, dividing it into superior and inferior bridging segments. On testing the valve, a regurgitant
jet through the defect was found. The defect was adequately repaired with simple interrupted 5/0 polypropylene with a
complete resolution of the regurgitant jet. The raphe between the mitral and tricuspid valve orifices was of sufficient strength
and amount to anchor the pericardial patch, in order to repair the atrial septal defect. The repair was started with a simple
continuous 5/0 double armed polypropylene suture at the base of the mitral cleft repair. The suture was run in a clockwise
fashion to the inferior aspect of the defect. In the region of the coronary sinus, the suture bites were kept superficial by taking
subendocardial bites. The coronary sinus was positioned to the right side of the patch in the right atrial cavity. The second arm
of the suture was run in an anticlockwise manner. After completion of the annular side of the repair, the pericardial patch was
carefully tailored and sutured to rest of the defect avoiding any tenting of the annulus. Both caval and coronary sinus orifices
were visualized in the right atrial cavity. The left atrium was purged of air before tying down the suture. The right atriotomy
was closed with a 5/0 polypropylene suture in a simple continuous fashion and the right atrium was purged of air before tying
the suture.
A hot shot cardioplegia was administered. The patient was rewarmed and caval snares were removed. The heart was de-aired
through the aortic root and LV vent. The aortic cross-clamp was then removed. A total 2 mediastinal drains were placed in the
mediastinum. Atrial and ventricular pacing wires were then inserted and tested for appropriate capture. The patient was
weaned from the cardiopulmonary bypass. Postoperative TEE showed no residual atrial septal defect and complete resolution
of the mitral regurgitation.
The venous cannulae were removed, and the cannulation sutures were secured. The LV vent was removed. A test dose of
protamine was administered and the patient was monitored for adverse reaction before the protamine was resumed. The aortic
cannula was then removed, and the cannulation sutures were tied.
An adequate hemostasis was then ensured within the mediastinum. All instruments, sponges and needles counts was confirmed
to be correct x 2.The sternum was then approximated with stainless steel sternal wires. There was no change in the
hemodynamics after sternal closure. The wound was irrigated with antibiotic solution. The presternal fascia was then closed
with absorbable sutures in a running fashion. The skin and subcuticular layer was closed with 5-0 polyglactin suture in a
running fashion. Sterile occlusive dressing was applied to the skin incision. The mediastinal drains were connected to bulb
suction.The patient was subsequently transferred to the postoperative cardiac surgical intensive care unit in a satisfactory
condition.
4. Complete Atrioventricular Canal Repair
Julia C. Swanson, MD and James J. Gangemi, MD

3. Intraoperative transesophageal echo (measure defect size, assess valvular pathology)
5. Prepare patch material
6. Pericardial well, circumferential dissection of superior and inferior vena cava
7. Systemic heparinization (300u/kg)
8. Single arterial cannulation, bicaval venous cannulation.
9. Place umbilical tape with snare around the SVC and IVC and test snare to ensure inferior cannula not in hepatic vein.
Leave tapes loose.
10. Confirm appropriate ACT.
11. Establish CPB and utilize moderate hypothermia (28-30C).
12. Place left ventricular vent (usually through right upper pulmonary vein).
13. DLP for antegrade cardioplegia.
14. Cross-clamp, give cardioplegia (single shot of Del Nido plegia 20ml/kg), ensure electromechanical arrest and then
apply ice for topical cooling.
15. Snare caval tapes.
16. Long, medial right atriotomy is made parallel to the right coronary artery extending to a point medial to the IVC
17. Place silk stay sutures x3 to allow for visualization as well as use of Regnel or similar retractors
18. Position LV vent into left atrium
19. Gently fill the ventricular chambers with cold saline to float the AV valve leaflets to their closed position. This
helps identify the line of apposition between the superior and inferior bridging components of the left AV valve
which is then approximated with a 6-0 polyproplyene suture.
20. Measure the extent of ventricular defect inferiorly and cut a half-circle shaped Gore-Tex patch.
21. Measure the extent of atrial defect superiorly and cut an appropriate bovine pericardial patch.
22. Examine anterior mitral leaflet cleft and decide on approach for closure.
23. The septal leaflet of the right-sided AV-valve may need to be mobilized to visualize the ventricular defect, if so this
will be closed at the completion of the repair.
24. Using a running 6-0 polypropylene close the VSD by placing the stitches on the right ventricular side of the crest of
the septum to avoid the left bundle and the AV node.
25. Use interrupted horizontal mattress suture coming from right to left through the Gore-Tex patch, the left-sided AV-
valve and the inferior aspect of the bovine pericardial patch and tie these down, thus recreating the AV valve
separation.
26. Close the mitral valve cleft with interrupted 6-0 polypropylene.
27. Ensure mitral (and tricuspid) valve is not stenotic (Note: Gently pass a Hagar dilator through the orifice, know the z-
score for the mitral and tricuspid valves in your patient)
28. Position the LV vent just across the valve into the LV.
29. Using the previous 6-0 polypropylene sutures complete the atrial defect closure.
30. De-air the left side of the heart as much as possible prior to completely closing the ASD.
31. Assess the right-sided AV valve; perform a valvuloplasty with 6-0 polypropylene.
32. Close the right atriotomy with 5-0 polypropylene while re-warming.
33. Institute inotropic support, suction lungs by anesthesia prior to instituting ventilation
34. Remove the cross-clamp and wean off bypass in concert with anesthesia
35. Ensure post-op echo shows acceptable valve function, cardiac function and no residual intra-cardiac shunts
36. Place atrial and ventricular pacing wires
37. Separate from bypass
38. Give protomine and ensure hemostasis and place a chest tube (consider 19 Fr round, fluted Blake drain circling the
chest and draining both thoracic spaces)
39. Close chest in standard fashion

1. Persistent left superior vena cava may be encountered. If present, this may need to be snared during the repair to
allow for visualization. Even in the absence of a bridging vein it may be safe to snare this, though some surgeons may
choose to cannulate this as well.
2. The conduction system can be injured and either temporary or permanent heart block may occur. Knowledge of the
location of the conduction system is imperative. Superficial bites need to be taken in this area.
3. Mitral stenosis needs to be avoided, thus it is important to ensure that appropriate orifice area is left after mitral cleft
closure.
4. The presence of a patent ductus arteriosus should be noted on pre-op TTE or TEE and if present should be dissected
carefully and then ligated prior to the induction of cardiopulmonary bypass.
5. The LVOT should also be assessed on pre-op TEE to ensure there is no narrowing.
6. These patients can have pulmonary hypertension that is reactive. This may result into right heart dysfunction and
difficulty in weaning from bypass. It should be diagnosed early and addressed. Nitric oxide (NO) should be in the
room and available when initiating ventilation if pulmonary hypertension has been diagnosed or his likely. In the
setting of pulmonary hypertension PO2 should be maximized and PCO2 kept low to optimize pulmonary blood flow.
Infants brought for repair at an older age are at greater risk for this.
7. There are multiple variations to the surgical management of complete AV canal. This operation can be
performed with deep hypothermic circulator arrest. A single patch technique can be used as compared to the
double patch technique described herein. The left AV valve (“mitral”) valve can be repaired to create a tri-
leaflet valve as compared to the bi-leaflet valve, as described herein. If sufficient tissue AV valve tissue is not
present, the valve may not be repaired, however this places the patient at risk for valve regurgitation and the
need for reoperation and higher long-term mortality.
8. A comment should be made about the appearance of the AV valve leaflets, the repair and the satisfaction with
the repair in the operative dictation.
Template Dictation
Preoperative Diagnosis: [INDICATION – Complete atrioventricular canal]
Procedure(s) Performed: Repair of complete atrioventricular canal.
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT – e.g. - shortness
of breath, COMORBIDITIES e.g.-Down– Syndrome]. The patient was discussed at cath conference and it was decided to
proceed with surgical intervention. After informed consent was obtained, the patient was set for surgery.
Description of the procedure: After informed consent the patient was brought to the operating room and placed in supine
position. After general endotracheal intubation occurred without difficulty, a (LOCATION) central line and the
(LOCATION) arterial line were placed. Systemic IV antibiotics were given. The chest was sterilely prepped and draped in
the usual sterile fashion. Standard median sternotomy incision was made. The thymus was removed and the pericardium
opened and standard pericardial well was made. At this point, the patient was systemically heparinized. A standard aortic and
bicaval venous cannulation were carried out. The patient was placed on cardiopulmonary bypass. An LV vent was placed the
right superior pulmonary vein and a cardioplegia needle was placed in midportion ascending aorta. The aorta was cross
clamped and cold blood antegrade cardioplegia was given with an excellent diastolic arrest. The caval tapes were snared and
the right atrium was opened and a right atriotomy was performed.
We then visualized the complete canal through the right atrium. We began by re-approximating the mid-point of the bridging
leaflet that would become the anterior leaflet of mitral valve with a #6-0 polypropylene suture. We then measured out the
ventricular septal defect and a half-moon patch of Gore-Tex was obtained. We then closed the ventricular septal defect portion
using a running #6-0 polyproplyene suture. At this point, we then obtained a piece of bovine pericardium and trimmed this
according to the size of the ASD. Next we placed multiple interrupted horizontal mattress sutures going through the tip of the
Gore-Tex patch then through the left-sided AV valve and then through the bovine pericardium. These were then subsequently
tied down thus creating the septum of the heart. We then addressed the cleft in the anterior mitral valve leaflet. This was then
closed using multiple interrupted #6-0 polypropylene sutures. (Note: Make a comment on the appearance and nature of the
cleft and the manner and satisfaction with which it was closed). The valve was then tested and did not appear to be stenotic.
We were able to put a (SIZE) mm Hegar dilator through the orifice. The ASD was then closed using bovine pericardium and a
running #6-0 polypropylene suture. Next we re-approximated the septal leaflet to the septal portion of the patch using a running
#6-0 polypropylene suture in 2 layers (Variation: There was small PFO, which was closed using a running #6-0
polypropylene suture.) The patient was rewarmed.
The right atriotomy was closed using a running #5-0 polypropylene suture. De-airing maneuvers were performed. The aortic
cross-clamp was removed and the patient was subsequently weaned off cardiopulmonary bypass on a (QUANTIFY) amount of
inotropic support and excellent hemodynamics. The patient's LV function was (QUANTIFY). The patient (DID/DID NOT
have heart block (Note: report the rhythm and rate coming off bypass).
Atrial and ventricular pacing wires were placed (Note: “subsequently atrial/AV pacing was/was not utilized). [Variation: We
did perform modified ultrafiltration for total of (DURATION) minutes with removal of (QUANTIFY) ml of volume taken off]
The protamine was given.
All cannulas were then removed and the purse strings tied and found to be hemostatic. A #19-French Blake drain was placed at
the inferior portion incision and sewn in place with #2-0 silk suture then positioned in the chest and subsequently connected to
Pleur-evac suction. Adequate hemostasis noted. We then re-approximated the sternum using several interrupted #1 stainless
steel wires. The wounds were closed in multiple layers of vicryl followed by monocryl suture followed by benzoin, Steri-
Strips and an occlusive dressing.
Instruments, sponges and needles counts were confirmed to be correct following conclusion of the operation. The patient was
then transferred to the Cardiac Surgery Intensive Care Unit in a stable fashion.
Dr. [BLANK] was present and scrubbed [BLANK] elements of this procedure.
5. Repair of Partial Anomalous Pulmonary Venous Return
Thomas Caranasos MD, Mark Bleiweis MD

1. Preoperative imaging to determine the type of PAPVR, directing repair.
2. Lines and monitoring.
3. General endotracheal anesthesia.
4. Intraoperative TEE to confirm diagnosis.
5. Median Sternotomy.
6. Pericardial well and harvesting of native pericardium (if elected to use pericardium).
7. Identify and dissect Right Sided Pulmonary Veins.
9. Arterial cannulation.
10. Bicaval venous cannulation (High SVC or Innominate vein and IVC cannulation).
11. Antegrade and/or retrograde cardioplegia (direct cannulation after atriotomy) for myocardial protection.
12. Opening the right atrium to allow for repair.
13. Evaluation of the location of the anomalous pulmonary veins and their draining location.
14. Enlarging the Atrial Septal Defect if needed.
15. Creation of a baffle from the ostia of the anomalous pulmonary veins to the left atrium through the Atrial Septal
Defect or if needed disconnection of the SVC and drainage of the anomalous pulmonary vein through the ASD and
attachment of the SVC to the Right atrium (Warden Procedure).
16. Closure of the right atriotomy.
17. Rewarming, Warm blood cardioplegia “hot shot”.
18. Deairing of the left side of the heart.
19. Removal of the aortic cross-clamp.
20. Hemostasis of the atriotomy and/or SVC to Right Atrial connection.
21. Pacer wire placement.
22. Separate from CPB.
25. Aortic decannulation.
26. Chest tube drainage.
27. Hemostasis and sternotomy closure.

1. Stay midline during sternotomy.
2. Cannulation catastrophe (aortic dissection/bleeding).
3. Insufficient myocardial protection (inappropriate aortic cross clamp, AI, insufficient venous drainage, persistent
LSVC)
4. Coronary sinus injury with retrograde cardioplegia cannulation.
5. Improper visualization of the draining veins.
6. Small ASD limiting flow and creation of a pressure gradient.
7. Improper size of the baffle limiting flow.
8. Patency of the SVC to right atrial connection.
9. Improper deairing.
10. Bleeding from atriotomy.
11. Inadequate control of hemostasis prior to sternal closure.
12. Late obstruction of the pulmonary venous circulation, pulmonary hypertension.
13. Post Operative arrhythmia.
Template Dictation
1. Partial anomalous pulmonary venous drainage of the right pulmonary veins to the right atrium.
2. Oval fossa atrial septal defect.
1. Repair of partial anomalous pulmonary venous drainage by tunnel repair of the right pulmonary veins through the
atrial septal defect using autologous pericardium.
2. Closure of atrial septal defect.
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT – e.g. - newly
discovered partial anomalous pulmonary venous drainage of the right pulmonary veins on imaging.] She has evidence of
drainage of all the right pulmonary veins directly into the right atrium. There is also a small atrial septal defect. She has a
history of polysplenia and developmental delay.
Description of Procedure: After informed consent and patient identification, the patient was brought to the operating room and
placed in the supine position. After single lumen general endotracheal tube anesthesia appropriate monitoring lines were
placed. Patient was then prepped and draped in the usual sterile fashion.
A median sternotomy incision was made, and dissection carried down to the level of the pericardium. The thymus was
subtotally resected. The pericardium was then opened on the left side to preserve the pericardium for baffle repair if
necessary. The aorta was separated from the pulmonary artery. The superior vena cava was dissected. A large azygous vein
was identified which came in relatively close to the innominate vein. There were no pulmonary veins draining into the superior
vena cava. We could identify the right pulmonary veins and they appeared to be in normal position, however they entered the
right atrium proper. The patient had one episode of rapid supraventricular arrhythmia and synchronized cardioversion was
necessary. The patient resumed a sinus rhythm at that point. Heparin was administered. After placing appropriate pursestring
sutures, aortic and superior vena caval cannulation was performed. Cardiopulmonary bypass was instituted and an inferior
vena caval cannula was added. An antegrade cardioplegia cannula was placed in the ascending aorta and this was also used as
a root vent later in the case. The patient was allowed to drift to a low temperature of 34 degrees centigrade. The aorta was then
cross clamped and a smooth diastolic cardiac arrest was achieved using antegrade cold potassium blood cardioplegia. Both
caval snares were then applied.
An oblique right atriotomy was made. The retrograde cardioplegia cannula was placed directly into the coronary sinus os and
held in place with polypropylene pursestring.
The retrograde cardioplegia was administered every 15-20 minutes during the cross clamp time. The pulmonary venous
drainage from the right lung was noted to be to the right atrium. We also ensured that there were no other veins draining on the
right side. The left veins drained normally into the left atrium. Since there was a small oval fossa defect, the remaining oval
fossa tissue was excised. This produced a widely patent atrial septum. A patch of untreated pericardium was fashioned for
baffling of the veins to the left atrium. This was then sutured in place using continuous fine polypropylene suture. The left side
of the heart was de-aired prior to tying the knot.
[Variation: For Warden Procedure: A superior vena caval snare was placed above the level of the azygous. The azygous
vein was controlled with a neurovascular clip. Clamps were placed at the SVC-RA junction. The patient remained in sinus
rhythm. The superior vena cava was divided above the level of the pulmonary veins. The cardiac side was over sewn using a
continuous polypropylene suture, in two layers, first a running horizontal mattress suture followed by simple continuous
technique. The sutures were tied before releasing the clamp to prevent the pursestring effect. This was noted to be hemostatic.
Next the aortic cross-clamp was applied, and a smooth diastolic cardiac arrest was achieved using a single dose of antegrade
cold potassium blood cardioplegia. The inferior caval snare was applied. An oblique right atriotomy was made, avoiding the
right atrial appendage. Superior sinus venosus defect was identified and defect was opened inferiorly and enlarged. We then
ran a polypropylene suture to endothelialize the cut surface. Next a patch of autologous untreated pericardium was fashioned
for the patch closure of the sinus venosus atrial septal defect and baffling of the pulmonary veins to the left atrium. This was
sutured in placed using continuous 5-0 polypropylene suture. The left side of the heart was deaired through this site before
tying the suture. Then the aortic cross-clamp was removed and deairing was performed via the root vent. Patient resumed
normal sinus rhythm spontaneously. Right atrial appendage was opened at its tip. The pectinate muscles were excised to ensure
that the right atrial opening was widely patent. The anastomosis between the SVC and the right atrial appendage was
constructed using continuous 5-0 polyproplyene suture. The anastomosis appeared to be widely patent and it was suture was
tied this over a 10 mm dilator, which was the size of the vena cava. The right atriotomy was closed in two layers. Caval snares
were removed and the patient was adequately rewarmed].
A hot shot was initiated in retrograde fashion. During this time, the left side of the heart was deaired. Next we completed the
hot shot in an antegrade fashion and removed the retrograde catheter. The right atrial closure was initiated with continuous
horizontal mattress polypropylene suture. Caval snares were then removed, the hot shot was completed, and the aortic cross
clamp was removed. The right atrial closure was completed with a simple continuous technique. The patient resumed a normal
rhythm spontaneously. He/She was rewarmed to normothermia.
An adequate deairing in the heart was ensured by the transesophageal echo. A double lumen right atrial catheter was tunneled
from the upper abdomen. It was placed it in the right atrium and fixed in place using two pursestring polypropylene sutures.
Patient was successfully weaned from the cardiopulmonary bypass. Post repair transesophageal echocardiogram revealed
good biventricular function and no pulmonary venous obstruction.
Modified ultrafiltration was then performed (Optional). The patient was decannulated while heparin was reversed with
protamine sulfate. Atrial and ventricular pacing wires were placed. A right pleural drain was placed. A mediastinal chest
drain was added. Excellent hemostasis was assured prior to closure. The sternum was reapproximated using interrupted #4
wires.
The presternal fascial, subcutaneous and cutaneous tissue layers were approximated with continuous absorbable sutures.
Sterile dressings were applied. Sponges, needles and instruments counts were correct. The patient was taken to the intensive
care in a stable condition. Cardiopulmonary bypass time was [BLANK] minutes and total clamp time was [BLANK] minutes.
6. Supra-Cardiac Total Anomalous Pulmonary Venous Return
(TAPVR)
Juan M. Lehoux, MD and Carlos M. Mery, MD, MPH
Texas Children’s Hospital/Baylor College of Medicine, Houston, TX
4. Perform partial thymectomy.
5. Open pericardium and set up pericardial well on stay sutures.
6. Dissect out the aorta, ligamentum arteriosum/PDA, SVC, and identify vertical vein.
7. Systemic heparinazation.
8. Bi-caval cannulation (may use single right atrial cannula).
9. Confirm ACT (>400).
10. Start cardiopulmonary bypass.

11. Ligate ligamentum arteriosum/PDA.
12. Cool to 18 degrees.
13. Dissect out the vertical vein.
14. Place apical stitch to aid in retraction of the heart.
15. Dissect out pulmonary venous confluence.
16. Cross clamp the aorta and instill cardioplegia once at desired temperature.
17. Start circulatory arrest.
18. Ligate the vertical vein.
19. Open the venous confluence widely with a longitudinal incision (may extend the incision into the vertical vein)
without entering the pulmonary vein orifices.
20. Inspect the pulmonary venous orifices.
21. Note: The rest of the procedure may be performed with a combination of circulatory arrest, low-flow
cardiopulmonary bypass, and full cardiopulmonary bypass if bicaval cannulation, or under circulatory arrest if
single venous cannulation.
22. Snare IVC and SVC if bicaval cannulation; remove atrial cannula if single atrial cannulation.
23. Oblique right atriotomy.
24. Identify ASD.
25. May enlarge the ASD in order to inspect the left atrium and choose the best site for anastomosis.
26. Make incision on the posterior wall of left atrium corresponding to the incision on the pulmonary venous
confluence (may include the left atrial appendage depending on the size and lie of the left atrium).
27. Perform anastomosis between pulmonary venous confluence and left atrium with 8-0 polypropylene in running
fashion.
28. Close the ASD using either a patch or primary closure of the septum primum.
29. If single venous cannulation, close the right atriotomy, replace the cannula, and restart CPB.
31. De-air the left sided chambers.
32. Remove the aortic cross-clamp.
33. Vent the left heart via the left atrial appendage (if not included in the anastomosis) or the patch (prior to
complete closure) until the left ventricle regains adequate function.
34. Close the right atriotomy (if bicaval cannulation).

35. May insert LA line through the left atrial appendage (if not included in the anastomosis). May insert PA line if
patient had significant obstruction and there are concerns for pulmonary hypertension.
36. Resume ventilation.
39. Place mediastinal tubes
40. May place peritoneal dialysis catheter to aid in postoperative fluid management
1. Avoid phrenic nerve injury during thymectomy.
2. Do not place too much tension on pericardial well in order to avoid worsening obstruction of the pulmonary
veins.
3. Do not ligate vertical vein until in circulatory arrest or after the pulmonary venous confluence is open in order to
avoid worsening pulmonary venous congestion.
4. Avoid right phrenic nerve injury when dissecting out the SVC.
5. Completely dissect SVC in order to avoid missing entry of a separate pulmonary vein
6. Make pericardiotomy towards the left side to allow for harvesting of patch material if autologous pericardium is
to be used.
7. Limit incision to the venous confluence. Avoid manipulating pulmonary veins.
8. Avoid twisting/kinking of anastomosis.
9. Make anastomosis as wide as possible.
10. Do not allow the left ventricle to distend. Vent heart thru left atrial appendage if possible.
11. LA and/or PA lines may help for postoperative monitoring.
12. Peritoneal dialysis catheter may facilitate postoperative fluid management.
Template Dictation
Preoperative Diagnosis: Obstructed supra-cardiac total anomalous venous return (TAPVR)
Procedure(s) Performed: Repair of obstructed supra-cardiac total anomalous venous pulmonary return via direct
anastomosis.
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT – e.g. - acute
desaturations into the 70’s soon after birth.] Patient was started on non-invasive respiratory support with no improvement. He
was emergently intubated and transferred to the NICU. An Echocardiogram was performed which revealed supra-cardiac total
anomalous pulmonary venous return with an obstructed vertical vein. Patient was taken urgently to the operating room for
repair.
Description of Procedure [using bicaval cannulation]: The patient was brought to the operating room and placed on the
operating table in the supine position. General anesthesia was induced. Monitoring lines were placed. The patient was
prepped and draped in the usual fashion.
A median sternotomy was performed. A subtotal thymectomy was performed. The pericardium was opened and set on stays to
create the pericardial well. A piece of autologous pericardium was harvested for future use. Dissection was performed around
the aorta, superior vena cava and the ductus arteriosum. The aorta, superior and inferior vena cava were cannulated for
cardiopulmonary bypass. After confirmation of adequate ACT, bypass was initiated. The ductus arteriosus was ligated. The
patient was cooled to 18 degrees. During cooling, the vertical vein was identified entering the innominate vein. The vertical
vein was dissected and followed inferiorly towards the pulmonary venous confluence. The confluence was dissected out by
incising the posterior pericardium. Once the patient was at 18 degrees, the aorta was cross-clamped and antegrade
cardioplegia was given. Smooth cardiac arrest was quickly achieved.
A pledgeted 6-0 polypropylene was placed on the apex of the heart to facilitate retraction upwards and rightwards. The
dissection of the pulmonary venous confluence was then completed. Circulatory arrest was started and the vertical vein was
ligated and divided at its entry point into the innominate vein. The venous confluence was incised longitudinally with care not
to incise the individual pulmonary orifices. The veins were individually inspected.
Cardiopulmonary bypass was re-started. The SVC and IVC were snared, the right atrium was incised in the usual fashion. A
large secundum ASD was identified. The left atrium was inspected through the ASD. The ideal area for the anastomosis was
identified by lining up the left atrial wall to the previously made confluence incision. Special care was taken to avoid torsion
at the site of the anastomosis by visualizing the area of the anastomosis from both inside and outside the heart.
The posterior wall of the left atrium was incised longitudinally up to the left atrial appendage mirroring the incision made in
the pulmonary venous confluence. Using a combination of circulatory arrest and low-flow cardiopulmonary bypass, the
anastomosis was performed between the pulmonary venous confluence and left atrium with 8-0 polypropylene suture in running
fashion. After completion of the anastomosis, all 4 pulmonary veins were probed through the ASD and were found to be
patent. Full cardiopulmonary bypass was restarted and the patient was rewarmed.
The ASD was closed (primarily/with a patch) using a running [Blank] polyproplyene (The left atrial appendage was incised to
vent the left heart.). After de-airing, the cross-clamp was removed. The patient regained a spontaneous sinus rhythm. The
right atriotomy was closed with running 6-0 polypropylene (Optional: A left atrial line was placed through the left atrial
appendage in the usual fashion. A pulmonary arterial line was placed in the main pulmonary artery for pressure monitoring).
Once the patient was warm, ventilation was re-started. Cardiopulmonary bypass was weaned with (careful assessment of left
atrial and pulmonary arterial pressures and) very judicious volume monitoring. The venous cannulas were removed. After
confirmation of adequate hemodynamics, protamine was given. The aortic cannula was the removed.
A temporary peritoneal catheter and mediastinal tube were inserted. After confirmation of hemostasis, the patient’s sternum
was closed with steel wire in the usual fashion. The fascia, subcutaneous planes, and skin were closed in layers. The patient
tolerated the procedure without complications and transported to the Pediatric Cardiac Intensive
Care Unit in a satisfactory condition. Sponge, needle and instrument counts were correct.
Cardiopulmonary bypass time was [BLANK] minutes. Hypothermic circulatory arrest time was [BLANK] minutes and cardiac
ischemia time of [BLANK] minutes.
7. Total Anomalous Pulmonary Venous Return (TAPVR) - Cardiac
Type
Amit Pawale, MD, FRCS (CTh), Khanh Nguyen, MD
Mount Sinai Medical Center, New York, NY, 10029

2. Median Sternotomy.
3. Partial thymectomy.
4. Opening pericardium, create pericardial well.
6. Aortic and bicaval cannulation.
7. Dissection of ductus arteriosus.
8. Initiation of cardiopulmonary bypass.
9. Ductus ateriosus ligation.
10. Perform right atriotomy.
11. Unroofing of coronary sinus.
12. Closure of atrial septal defect.
13. Weaning from cardiopulmonary bypass.
15. Protamine administration and aortic decannulation.
16. Ensure excellent hemostasis.

1. Perioperative pulmonary vasodilators are useful to reduce the risk of pulmonary hypertensive crises.
2. Care should be taken dissecting and ligating the ductus arteriosus, as it can rupture during these maneuvers. It should
be ligated as soon as initiating the cardiopulmonary bypass to avoid overflowing the pulmonary circulation.
3. A wide communication between the coronary sinus and left atrium should be ensured to prevent future narrowing.
4. During the atrial septal defect closure, care is taken to avoid the area anterior to the coronary sinus because it
contains the atrioventricular (AV) node.
5. Postoperative diuretics are given for several days to minimize the pulmonary edema
Template Dictation
1. Total anomalous pulmonary venous return (TAPVR), cardiac type
2. Patent foramen ovale
3. Patent ductus arteriosus
1. Repair of total anomalous pulmonary venous return (Cardiac Type) with unroofing of coronary sinus ostium.
2. Patch closure of the atrial septal defect.
Assistant: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: A five month old baby girl, who was born at full term with caesarian section, had an
echocardiogram for lower oxygen saturation after the birth. She was diagnosed to have an unobstructed total anomalous
pulmonary venous return, with all the pulmonary veins draining into the coronary sinus. She also had atrial septal defect and a
patent ductus arteriosus. Since the total anomalous pulmonary venous return was unobstructed type the baby was allowed to
grow with close observation over the last five months and an elective repair was performed today.
Operative Findings: The right heart was significantly dilated. The systemic venous drainage was normal. Within the heart
there was a small patent foramen ovale. The coronary sinus was severely dilated. After opening the atrial septum and the
coronary sinus all 4 pulmonary veins could be seen draining directly into the coronary sinus.
Description of Procedure: After informed consent and patient identification the patient was brought to the operating room and
placed on the operating table in a supine position. After induction of general anesthesia with single lumen endotracheal tube
intubation, arterial and central venous monitoring lines were placed. The patient was positioned, prepped and draped in
surgical sterile fashion. TEE was not performed.
A median sternotomy was performed and the partial thymectomy was undertaken. The pericardium was opened and a segment
was harvested for later use in cardiac repair. Intravenous heparin was administered. Ascending aorta and both vena cava were
cannulated. Having ascertained adequate ACT, total cardiopulmonary bypass was initiated. A small ductus arteriosus was
ligated with a silk ligature. The child's temperature is decreased to 22°C. The aorta was cross-clamped and cold blood
cardioplegia was given through the aortic root. A rapid diastolic arrest followed. The cavae were snared and the right atrium
was opened with an incision parallel to the atrio-ventricular groove and intracardiac anatomy was noted. The atrial septal
defect was found. The septum primum was resected. A vent was placed into the left atrium through the atrial septal defect to
decompress the left side of the heart. The coronary sinus ostium was incised and the coronary sinus was completely unroofed
to the left atrial chamber. Much of the superior margin of the coronary sinus was resected and the endocardium was
reapproximated over the exposed muscle with running fine polypropylele. A piece of autologous pericardial patch was used to
close this atrial septal defect with fine polypropelene running suture, such that the coronary sinus drains in to the left atirum.
The suture line in the area anterior to coronary sinus was moved away from the edge of the septum into the floor of the
coronary sinus to avoid injury to the atrioventricular (AV) node. The left atrial vent was removed and de-airing was performed
before tightening the last few sutures. Once the atrial septal defect was closed, the cross-clamp was removed. A normal sinus
rhythm returned rapidly. The right atriotomy was closed using running polypropelene suture.
The patient was weaned from cardiopulmonary bypass in sinus rhythm. Excellent hemodynamics were achieved. A left atrial
pressure monitoring line was placed via the appendage and a peritoneal dialysis catheter was placed (Optional). Modified
hemofiltration was carried out. Single Blake drain was placed in the pericardium. Atrial and Ventricular pacing wires were
placed. Sternotomy was closed in layers.
subsequently transferred to the postoperative pediatric cardiac surgical intensive care unit in stable but critical condition.
8. Infra-Cardiac Total Anomalous Pulmonary Venous Return
(TAPVR)
Muhammad Aftab, MD, Jeffrey S. Heinle*, MD
*Texas Children’s Hospital/Baylor College of Medicine, Houston, TX

3. Bilateral cerebral near-infrared spectroscopy sensors (NIRS)
4. Transesophageal Echocardiogram (TEE) not performed (concern of compressing pulmonary veins confluence
especially in small infants).
6. Sub-total thymectomy.
7. Open pericardium, pericardial well.
8. Minimal initial dissection.
9. Systemic heparinization (3-4 mg/Kg).
10. Direct aortic cannulation (Note: small aorta-cannulation needs to be precise).
11. Single right atrial venous cannula- for emergent cases; (Note: Bicaval cannulation with caval snares – for elective
cases)
12. Establish Cardiopulmonary bypass (CPB) circuit.
13. Check ACT >450
14. Initiate Cardiopulmonary bypass.
15. Immediately after initiation of CBP, dissect free and ligate the ductus arteriosus.
16. Slow cooling to 18oC (over 20-30 minutes) in anticipation of deep hypothermic circulatory arrest (DHCA).
17. Divide posterior pericardial attachments and mobilize pulmonary venous confluence while cooling.
18. Identify all four pulmonary veins and encircle the descending vein.
19. Once nasopharyngeal temperature 18oC, pack the head with ice.
20. Cross clamp ascending aorta.
21. Antegrade cold crystalloid cardioplegia with topical cooling.
22. Initiate deep hypothermic circulatory arrest (DHCA).
23. Remove right atrial cannula (If bicaval cannulation, snare both caval tapes.)
24. Rotate the apex of the heart towards patient’s right shoulder.
25. Enter the posterior pericardium.
26. Mobilize vertically oriented pulmonary vein confluence.
27. Identify all four veins (with limited dissection on the veins).
28. Suture ligation of the descending vertical vein (Optional).
29. Perform right atriotomy and inspect the intracardiac anatomy.
30. Identify the atrial septal defect (ASD).
31. Longitudinally open the pulmonary venous confluence (steps 32-34 working from outside the heart).
32. Make a corresponding vertically oriented incision on posterior wall of left atrium.
33. Create a left atrium-to-pulmonary venous confluence anastomosis with fine suture and small bites.
34. Ensure a wide open anastomosis and probe the pulmonary veins (looking through right atrium).
35. Resume cardiopulmonary bypass followed by another period of brief circulatory arrest.
36. Harvest the autologous pericardium
37. Clean the redundant tissue [Variation: treat the pericardium with 0.6% glutaraldehyde solution for 20-30 min
(optional).
38. Close the ASD with fresh autologous pericardium.
39. Resume bypass and de-air the left heart as ASD closure is completed.
40. Close the right atriotomy (either on pump sucker bypass or a brief period of DHCA).
41. Place the venous cannula (If single right atrial venous cannulation).
42. Resume full cold cardiopulmonary bypass.
43. Start re-warming after 5 minutes of reperfusion (remove the ice from head).
44. Perform de-airing of heart via aortic root.
45. Place patient in trendelenburg position and remove the aortic cross clamp.
46. Secure atrial/ventricular pacing wires (Optional: left atrial and PA lines, if needed).
47. Once re-warmed, resume the ventilation, fill the heart with blood and allow to eject.
48. Wean from CPB, inotropes and vasopressers as needed.
49. Ensure good gas exchange on 100% Oxygen, avoid hypercapnia (Optional: use of nitric oxide).
50. Goal of Pulmonary artery pressure < 2/3 to ½ of systemic pressures, within 15-30 minutes of weaning.
51. Administer protamine and sequential decannulation.
52. Assure excellent hemostasis.
53. Careful volume administration.
54. Place drain. Peritoneal dialysis catheter (Optional).
55. Sternal closure (temporary closure, if warranted).

1. Patient with obstructed TAPVR are critically ill, and sometimes in extremis, so an expeditious transfer to the
operating room is of paramount importance.
2. Special attention should be paid to avoid any inadvertent injury to the phrenic nerves during partial thymectomy and
dissecting the SVC.
3. Avoid rapid surface cooling in critically ill patients, as they may fibrillate at higher core body temperatures.
4. Special care should be exercised to avoid any disturbance to the myocardium after opening the pericardium, as any
minimal retraction of ventricle can result in ventricular fibrillation.
5. Injury of the pulmonary artery during the cross clamp application should be avoided.
6. Gentle handling of myocardium, while tilting the apex of the heart up and to the right, is essential to avoid any
crushing of myocardium (done after cross clamping).
7. Carefully matching incisions should be made on the pulmonary venous confluence and the posterior left atrial wall,
such that the atriotomy should fall directly on the common venous confluence opening once heart resumes its normal
position in the pericardium.
8. It is of paramount importance to insure a wide open left atrium-to-pulmonary venous confluence anastomosis.
9. To allow a widely patent anastomosis, the vertical incision on pulmonary venous confluence can be extended onto
pulmonary vein or alternatively vertical vein can be divided to better conform the anastomosis. Similarly, the
corresponding left atriotomy can be extended superiorly into the left atrial appendage. Left atriotomy should not be
extended too close to mitral annulus, as this can result in injury to the circumflex coronary artery.
10. In the presence of a wide patent anastomosis, initially elevated pulmonary artery pressure should drop to < 2/3 of
systemic pressures within 30 minutes of weaning from the CPB. Persistently elevated near systemic pulmonary artery
pressure should be concerning for an obstructed anastomosis.
11. A secure and well hemostatic anastomosis is critical. Any anastomotic reinforcements in this area are technically
very challenging and can also potentially distort the anastomosis.
12. Patients with TAPVR usually have small left heart chambers, so volume administration should be used judiciously
and large volume administration should be avoided post-operatively.
Template Dictation
1. Infra-cardiac total anomalous venous return (TAPVR), [Variation: Obstructed]
2. Secundum ASD (Variation: Patent foramen Ovale)

3. Patent ductus arteriosus
4. Cardiogenic shock

Drainage: Mediastinal chest tube(s).
Assistant: [BLANK]
Anesthesia: [BLANK]
1. Emergent repair of obstructed infra-cardiac total anomalous pulmonary venous connection.
2. Autologous Pericardial patch closure of secundum atrial septal defect.
3. Ligation of patent ductus arteriosus.
4. Placement of temporary non-tunneled peritoneal dialysis catheter (Optional)
5. Placement of temporary pulmonary artery pressure monitoring line (Optional)
6. Placement of temporary left atrial pressure monitoring line (Optional)
Indication(s) for Procedure: This is an eight hours-old infant who was transferred from [BLANK] hospital to the neonatal
intensive care unit at [BLANK] hospital [approximately one hour] prior to the initiation of this procedure. He/she was noted to
be in extremis with oxygen saturations in the 50s, profound hypotension, and severe metabolic acidosis. Chest x-ray
demonstrated severe bilateral pulmonary edema and echocardiogram showed obstructed infracardiac total anomalous
pulmonary venous return. The patient was emergently/urgently taken to the cardiac operating room for repair.
Operative Findings: A thymus was present and there was atrial situs solitus with normal systemic venous return. There was
severe pulmonary edema and hemorrhage. The pulmonary venous return was abnormal in that there was no direct pulmonary
venous connection to the left atrium. All 4 pulmonary veins were identified draining to a vertically oriented confluence in the
midline posterior to the pericardium. The confluence then drained inferiorly with a large descending vein traversing the
diaphragm. The confluence was dilated and severely thickened. The ascending aorta was relatively hypoplastic and there was
a patent ductus arteriosus. The right atrium was dilated. On intracardiac examination there was a large secundum atrial septal
defect [Variation: sometimes there is just a PFO).
Repair consisted of a direct anastomosis between the vertically oriented confluences to an incision in the posterior left atrium.
The atrial septal defect was augmented with an autologous pericardial patch. Post-repair pulmonary artery pressures were
approximately one-half systemic.
Description of the Procedure: After informed consent and patient identification the patient was emergently brought to the
operating room and placed on the operating table in a supine position. After induction of general anesthesia, the patient was
intubated. Additional arterial and venous access was obtained. Transesophageal echo study not performed. The patient was
then positioned supine, prepped, and draped in a standard sterile fashion. A complete median sternotomy was performed. A
subtotal thymectomy was carried out. The pericardium was opened and a pericardial well was created. [Variation: Patient
was in extremis, so monitoring lines were not obtained prior to sternotomy. An expeditious median sternotomy was performed
and the thymus was removed. The pericardium was opened and a 2.5F arterial pressure monitoring line was placed in the
aortic arch].
After preliminary dissection, pursestring sutures were placed in the ascending aorta and right atrial appendage. Heparin was
administered and the ascending aorta and right atrium were directly cannulated utilizing single right atrial cannula [Variation:
Bicaval cannulation was performed and both cavae were encircled with umbilical tapes]. These cannulae were secured, de-
aired and connected to the bypass circuit. Having ascertained an adequate anticoagulation bypass was initiated. The ductus
arteriosus was circumferentially dissected and ligated with a heavy silk ligature. A piece of fresh autologous pericardium was
harvested for future use. The patient was slowly cooled to a nasopharyngeal temperature of 18oC over approximately 30
minutes. As we were cooling, posterior pericardial attachments were divided and the pulmonary venous confluence was
mobilized. Then all four pulmonary veins were identified and the descending vein was encircled. After reaching a
nasopharyngeal temperature of 18oC, the head was packed in ice. The ascending aorta was then cross-clamped and the
myocardium was protected with cold crystalloid cardioplegia administered antegrade in the aortic root. A rapid diastolic
arrest occurred. Additional cardioplegia was given at regular intervals during the crossclamp period.
The child was exsanguinated into the venous reservoir initiating a period of deep hypothermic circulatory arrest (DHCA). The
right atrial cannula was removed, a right atriotomy was created and the intracardiac anatomy was inspected. [Variation: If
bicaval cannulation: The caval tapes were snare. An oblique right atriotomy incision was performed and the intracardiac
anatomy was inspected]. There was a large secundum atrial septal defect, which was further enlarged by incising the septum
primum. The left atrium was inspected and was relatively small. The apex of the heart was rotated to the right shoulder and the
vertically oriented pulmonary venous confluence was further mobilized. The descending vertical vein was suture ligated with
5/0 polypropylene, at the point where it pierces the diaphragm (optional).The vertically oriented pulmonary venous confluence
was opened longitudinally with the incision carried on to the descending vertical vein. A corresponding vertically oriented
incision was created on the posterior wall of the left atrium. Working from outside of the heart, a direct left atrium to
pulmonary venous confluence anastomosis was accomplished with running 7-0 Prolene. A large connection was created.
Looking back through the left atrium, the anastomosis was noted to be widely patent and the pulmonary veins were easily
probed.
The harvested autologous pericardial patch was used to close the atrial septal defect with a running fine polypropylene suture.
Cardiopulmonary bypass was resumed, on pump sucker bypass, and left-sided cardiac chambers were deaired as the atrial
septal closure was completed. [Variation: Another brief period of circulatory arrest was utilized to close the right atrium].
The right atriotomy incision was closed using running Prolene suture and the right atrial cannula was replaced [Variation for
Bicaval cannulation: Cardiopulmonary bypass was resumed. The harvested autologous pericardial patch was used to close the
atrial septal defect with a running fine polypropylene suture. Prior to completing the suture line, the left-sided cardiac
chambers were de-aired. Additional de-airing was carried out through the cardioplegia site in the ascending aorta. The right
atriotomy incision was closed using running 6/0 Prolene suture].
The patient was then reperfused on full cold cardiopulmonary bypass for five minutes, removed the ice from the head, and then
commenced rewarming. The heart was de-aired, patient was placed in trendelenburg position and the the aortic cross clamp
was removed. A normal sinus rhythm returned rapidly. Temporary atrial epicardial pacing wires were placed. Additional de-
airing was carried out through the cardioplegia site in the ascending aorta. [Variation: During rewarming, a left atrial
monitoring catheter was placed via the left atrial appendage. A temporary pulmonary artery monitoring catheter was placed].
After complete rewarming, the lungs were ventilated and the heart was allowed to fill and eject. Patient was weaned from
cardiopulmonary bypass without difficulty and with good hemodynamics. There was excellent gas exchange, and pulmonary
artery pressures were approximately one-half systemic with/without the use of inhaled nitric oxide]. Protamine was given and
the heart was sequentially decannulated. [Variation: A pressure monitoring line had been placed in the right atrial appendage
immediately after weaning from bypass. Note: If arterial monitoring lines were not obtained prior to sternotomy; A 2.5F left
femoral arterial catheter was replaced and the line in the aortic arch was removed.] A temporary non-tunneled peritoneal
dialysis catheter (Optional) and mediastinal chest drains were placed. Hemostasis was assured. The sternal edges were
reapproximated using stainless steel wires. The soft tissues were closed in multiple layers using running absorbable suture.
The skin edges were reapproximated using a running absorbable subcuticular stitch. [Variation: If temporary sternal closure
was performed: The sternum was supported in an open position with a strut fashioned from a 20 French chest tube and the skin
was closed with a Gore-Tex membrane and then a sterile occlusive dressing applied]. The patient tolerated the procedure
without complications. He was left intubated and was transported to the Pediatric Cardiac Intensive Care Unit in satisfactory
condition. Sponge, needle and instrument counts were correct.
Cardiopulmonary bypass time was [BLANK] minutes, with a cross-clamp period of [BLANK] minutes. There were two/three
periods of circulatory arrest of [BLANK] minutes each. The total circulatory arrest time was [BLANK] minutes.
9. Patent Ductus Arteriosus Ligation
John R Spratt, MA, MD and Robroy MacIver, MD, MPH

1. Ensure adequate anesthesia/ nursing/ OR staff support if performing procedure in NICU
2. General endotracheal anesthesia with single-lumen tube
3. Right-lateral decubitus postioning.
4. Posterolateral thoracotomy incision, sparing latissimus and serratus if possible.
5. Enter left chest via third or fourth intercostal space.
6. Retract left upper and left lower lobes laterally.
7. Identify takeoff of head vessels and descending aorta as landmarks for incision of parietal pleura.
8. Divide crossing vein if necessary.
9. Expose duct with pleural retraction sutures.
10. Apply clip across duct.
11. Alternatively, encircle and tie off ductus.
12. Ensure hemostasis.
13. Place left chest tube or JP drain.
14. Re-approximate ribs with single suture.
15. Closure of muscle, fascia scarpa and skin incision in layers.

1. Consider performing in the NICU if patient requires oscillatory ventilation.
2. Failure to completely dissect can lead to incomplete ligation of duct by hemoclip, causing persistent flow.
3. Large ductus may be confused for aortic arch, leading to inappropriate ligation.
4. Each element of the arch should be identified prior to ligation. A large ductus may cause the aortic isthmus to be
identified as the left subclavian and the left pulmonary artery as the ductus.
5. Division of periductal lymphatics may lead to chylothorax
1. Higher risk in patients with upper respiratory infections.
2. May benefit from the reapproximation of pleura.
6. Use of cautery around the ductus carries the risk of recurrent laryngeal nerve injury.
Template Dictation
Preoperative diagnosis: Patent ductus arteriosus
Procedure(s) Performed: Ligation of patent ductus arteriosus
Assistants: [BLANK]
Specimens: [BLANK]
Fluids: [BLANK]
EBL: [BLANK]
Drains: [BLANK]
Indication(s) for Procedure: Baby [NAME] is a [AGE/ GENDER]born at [GESTATIONAL AGE] with [HISTORY].
This child has been in the Newborn Intensive Care Unit with a persistent ductus arteriosus and pulmonary overcirculation, and
was referred for surgical therapy. A lengthy preoperative consultation was carried with the patient's parents detailing the
anatomy, planned surgery, and attendant perioperative risks. All of their questions were answered, and they were in favor of
proceeding with the operation.
Operative Findings: There was significant chest wall and soft tissue edema. The lungs were morphologically normal but stiff,
noncompliant and edematous. There was a moderate to large size patent ductus arteriosus with a normal-appearing aortic arch.
Description of Procedure: The patient was in the Newborn Intensive Care Unit intubated and sedated. After informed consent
and patient identification, the patient was then moved into a right lateral decubitus position and the left chest was prepped and
draped in the usual sterile fashion. A time out was performed, confirming the patient and procedure to be performed; all team
members were in agreement.
A posterolateral thoracotomy incision was made and carried down to the chest wall. The latissimus muscle was divided in the
line of the incision; care was taken to spare the serratus. The fourth intercostal space was identified and entered, taking care
not to injure the underlying lung. A small Finochietto retractor was placed and narrow malleable retractors were used to
retract the lung anteriorly and inferiorly, exposing the mediastinal pleura and aorta. The parietal pleura overlying the ductus
was carefully opened, taking care not to damage the recurrent laryngeal nerve. The ductus was then identified between the
aortic arch and the left main pulmonary artery and freed from surrounding structures. A single large hemoclip was applied
across the ductus, completing the ligation [Note: Mention any hemodynamic changes]. A Jackson-Pratt drain was placed in the
pleural cavity, brought out through the chest wall, and secured to the skin with nylon suture. The retractors were removed and
the left lung was noted to re-inflate appropriately. The ribs were re-approximated with a single 2-0 pericostal suture, which
was followed by reapproximation of the latissimus with running 4-0 vicryl. The skin was then closed using running
subcuticular stitch and Dermabond was placed on the wound. The sponge and needle counts were correct at the end of the
case. The patient will remain in the neonatal intensive care unit.
10. Aortic Coarctation Repair with Extended End-to-End Anastomosis
Muhammad Aftab, MD, Ismael Alejandro Salas De Armas, MD, Carlos M. Mery*, MD, MPH

3. Right arterial radial line.
4. Blood pressure cuffs and pulse oxymeter in all extremities.
5. Right lateral decubitus position (for left-sided aortic arch).
6. Serratus-sparing left posterolateral thoracotomy.
7. Enter left pleural space through the 3rd or 4th intercostal space.
8. Retract the lung anteriorly to expose posterior mediastinum.
9. Longitudinal incision on the posterior parietal pleura, posterior to the vagus nerve, to expose the descending aorta and
left subclavian artery. Ligate and divide the vein and lymphatic vessel that usually cross the base of the left
subclavian artery.
10. Ligate and divide or cauterize any lympathic channels encountered.
11. Dissect the ductus arteriosus.
12. Identify and protect the recurrent laryngeal nerve.
13. If non-patent, ligate and divide the ligamentum arteriosum. If there is a patent ductus arteriosus, preserve at this time.
14. Widely mobilize the aorta from the level of the innominate artery onto the mid descending thoracic aorta.
15. Identify and preserve the intercostals vessels (may need to be looped with atraumatic snares). Some intercostal
vessels in the area of the anastomosis may need to be ligated and divided.
16. Systemic heparinization (1 mg/Kg).
17. Allow the temperature of the child to drift down to ~35 C for additional spinal cord protection.
18. Ligate the ductus arteriosus (if left intact).
19. Place a C-clamp around the proximal aortic arch (just distal to the innominate artery), the left carotid artery, and the
left subclavian artery. The left subclavian artery may also be controlled separately with an atraumatic snare.
20. Clamp the descending thoracic aorta below the level of coarctation.
21. Excise the coarctation segment and all ductal tissue.
22. Extend the proximal aortotomy onto the undersurface of the arch - to a point opposite to the origin of left common
carotid artery.
23. Incise the distal aortotomy on its lateral aspect of to accommodate to proximal aortotomy.
24. Construct an extended end-to-end anastomosis.
25. De-air the aorta prior to completing the suture line with either heparinized saline solution or by unsnaring one of the
intercostal vessels on the field.
26. Remove clamps and check for hemostasis.
27. Check pressure gradient between upper and lower extremities.
28. Approximate the parietal pleura.
29. Place a pleural drain.
30. Chest closure

1. Neonates with critical aortic coarctation are usually critically ill. If possible, an appropriate resuscitation in the
Intensive Care Unit including prostaglandin to reopen the closing ductus arteriosus should be performed prior to the
surgery. If the child is older or the ductus arteriosus is not responding to prostaglandin, urgent surgical intervention
may be required.
2. Special attention should be paid to avoid any inadvertent injury to the vagus and recurrent laryngeal nerves during the
dissection of the aortic isthmus and ductus arteriosus.
3. Gentle handling of the tissue is necessary to avoid inadvertent injury to the pulmonary artery, the ductus, or the aorta
during ductus ligation.
4. The proximal aorta should be adequately mobilized. The proximal clamp onto the ascending aorta should be applied
just distal to the innominate artery, so that the incision on the lesser curvature of the aorta can be extended proximally
as far as the origin of the left common carotid.
5. Careful dissection should be performed during aortic mobilization, as intercostals arteries are usually enlarged and
bronchial arteries sometimes arise from the posterior surface of aorta. An inadvertent injury to these thin walled
vessels can result into the troublesome bleeding.
6. To prevent any tension on the aortic anastomosis suture line, the descending aorta should be mobilized as far distally
as possible and atraumatic snares should be used to control collateral vessels that will be in the field of the
anastomosis.
7. It is important to ensure that all coarctation and ductal tissue has been removed to prevent recurrent coarctation.
8. The descending aortotomy is enlarged laterally so that it will match to the size of proximal aortotomy.
9. Using absorbable suture or interrupted suture technique rather than a running monofilament non-absorbable suture
anastomosis has not been shown to decrease the incidence of recurrent coarctation.
10. To minimize the risk of paraplegia the core body temperature should be allowed to drift to or below 35 oC by keeping
the room cold, utilizing cooling blankets and irrigation of the surgical field with cold saline. The blood pressure
proximal to the clamp should be allowed to be slightly higher than normal during the clamping period to allow distal
collateral flow. Distal circulatory support (left heart bypass) should be used in older children if clamp time is
anticipated to be more than 30 minutes.
11. If the proximal aortic arch (between the innominate artery and the left carotid artery) is hypoplastic as defined by a Z-
score < -2 or an absolute size in mm less than the weight of the child in kilograms plus 1, consideration should be
made to doing the repair through a median sternotomy and under cardiopulmonary bypass.
Template Dictation
Preoperative Diagnosis: Coarctation of the aorta.
Procedure(s) Performed: Aortic coarctation repair with an extended end-to-end anastomosis.
Drainage: Left pleural chest tube.
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s): This is a [BLANK]-year/month/day old child who presented with [BLANK]. The workup revealed a moderate-
severe coarctation of the aorta [Variation: and patent ductus arteriosus/intracardiac anomalies]. He/She was referred for
surgical evaluation. The preoperative evaluation demonstrated an area of severe coarctation just distal to the isthmus with a
peak velocity of [BLANK]. In addition, the pulses on his/her lower extremities were significantly diminished and there was a
gradient on cuff pressures of [BLANK]. He/she was recommended surgical intervention.
Operative Findings: There was a left aortic arch with normal branching pattern. There was a severe juxta-ductal aortic
coarctation. The coarctation was repaired with resection and extended end-to-end anastomosis, taking the proximal extent of
the anastomosis into the distal aortic arch. Distal pulses were palpable and there was no blood pressure gradient between
upper and lower extremities at the end of the procedure.
Description of Procedure: After obtaining appropriate consent, the patient was brought to the operating room and placed in
supine position. Single lumen general endotracheal tube anesthesia was induced and necessary monitoring lines including a
right radial arterial line were placed. The patient was placed on right lateral decubitus position and the left chest was prepped
and draped. A serratus-sparing left posterolateral thoracotomy incision was performed and the left pleural space was entered
through the third/fourth intercostal space. The lung was retracted anteriorly to expose the posterior mediastinum. The
posterior mediastinal pleura was incised to expose the aorta. The aorta was then widely mobilized from the level of the
innominate artery onto the mid descending thoracic aorta. The ligamentum arteriosum/ductus arteriosus was dissected, with
care to avoid injuring the recurrent laryngeal nerve. [The ligamentum arteriosum was suture-ligated and divided to
facilitate mobilization.] The above findings were noted. During dissection, the patient's nasopharyngeal temperature was
allowed to fall to 35 degrees centigrade. Intravenous steroids were administered. The ligamentum arteriosum was suture
ligated. Systemic heparin was administered at 100 IU/kg (1mg/kg). [Variation: The first set of intercostal vessels below the
coarctation were suture ligated and divided.] All intercostal vessels expected to be within the clamped area were
controlled with atraumatic snares [Variation: The ductus arteriosus was suture-ligated]. The proximal aortic arch, left
carotid artery, and left subclavian artery were clamped with a Castaneda-type vascular clamp. The descending thoracic aorta
was clamped below the level of the coarctation. The coarctation segment was excised. All ductal tissue was removed. The
proximal aortotomy was extended onto the undersurface of the distal aortic arch to a point just opposite the distal left common
carotid artery. The descending aorta was spatulated appropriately and then a long, sliding, extended end-to-end anastomosis
was carried out with a fine running polypropylene suture. Prior to completing the suture line, the aorta was de-aired with
heparinized saline solution. The suture line was completed. The vascular clamps were sequentially removed and the snares
on the intercostal vessels were removed. There were excellent pulsations in the descending thoracic aorta. After the
completion of the anastomosis the blood pressure gradient between upper and lower extremities was assessed and there was
no significant gradient. Hemostasis was assured. The posterior mediastinum was irrigated with warm antibiotic saline
irrigation. The pleural edges were reapproximated using running polypropylene suture. A [BLANK] French chest tube was
placed through a separate incision and secured to the skin. The lung was re-expanded. The rib edges were reapproximated
using interrupted absorbable pericostal sutures. Serratus anterior fascia, latissimus dorsi muscle, and subcutaneous tissue
were reapproximated using running absorbable suture. The skin edges were approximated using a running absorbable
subcuticular stitch. Dermabond skin adhesive was applied. The patient tolerated the procedure without complications. He/She
was transported to the Pediatric Cardiac Intensive Care Unit in a satisfactory condition.
The aortic cross-clamp time was [BLANK] minutes. All instruments, sponges and needles counts were confirmed to be correct
x 2 at the end of the case.
Suggested Readings:
1. Khonsari S, Sintek CF. Cardiac Surgery: Safeguards and Pitfalls in Operative Technique. 4th ed. Philadelphia,
PA: Lippincott Williams & Wilkins; 2008, p 209-217.
2. E. L. Bove and J. C. Hirsch.Surgery for Congenital Heart Defects by J. Stark and M. de Leval, VT Tsang. John
Wiley & sons, Ltd; 2006, p 285-298.
3. Kaiser, Larry R.; Kron, Irving L.; Spray, Thomas L.Mastery of Cardiothoracic Surgery, 2nd Edition. Lippincott
Williams & Wilkins; 2007. P 769-778
4. Backer CL, Kaushal S, Mavroudis S.Coarctation of the Aorta. In: Mavroudis C, Backer CL (eds). Pediatric Cardiac
Surgery, 4th edition. Wiley-Blackwell; 2013, p 256-282.
11. Division of Vascular Ring
Wissam Raad, MD, MRCS1,2 and Samuel Weinstein MD, MBA1, 2
1. Montefiore-Einstein Center for Heart and Vascular Care, New York, NY
2. Albert Einstein College of Medicine, New York, NY

3. Appropriate positioning
4. Posterolateral thoracotomy
5. Identify aortic arch and descending aorta
6. Identify subclavian and carotid vessels, confirm presence of the ring
7. Confirm ligamentum arteriousm or patent ductus, if present
8. Divide the ring
9. Free the esophagus from adhesions
10. Chest tube
11. Close ribs, approximate the chest wall in layers

1. Avoid injury to the neurovascular bundle upon entering the chest
2. Identify and avoid injury to the vagus nerve
3. Identify and avoid injury to the recurrent laryngeal nerve
4. Avoid injury to the esophagus
Template Dictation
Preoperative Diagnosis: Vascular ring [INDICATION – e.g. stridor, dysphagia]
Procedure(s) Performed: Division of vascular ring (DETAILS – e.g. PDA ligation)
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT– e.g. increasingly
worse stridor and shortness of breath]. Preoperative CT scan or echocardiogram reveals [FINDINGS - e.g. a descending right
aorta with a rightward ductus] or barium swallow reveals [FINDINGS - e.g. posterior indentation of the esophagus].
identity and planned procedure were verified, and the patient was placed on the operating room table in a supine position.
General anesthesia was induced. A right/left internal jugular central venous line and a right/left radial arterial line were
inserted. The patient was then turned to the right/left, an axillary roll was placed underneath to protect the axilla and to prevent
brachial plexus injury. We then proceeded to prep and drape the chest in the usual sterile fashion. A time out was performed.
The right [Variation: in case of left arch and right ductus] or the left [Variation: in case of double arch with left-sided
ligamentum, or in case of a right arch with retroesophageal component] chest was opened through a posterolateral thoracotomy.
The latissimus dorsi was divided partially. Electrocautery was used for hemostasis. The serratus anterior muscle was spared,
and the fourth intercostal space was entered. The lung was held anteriorly with stay sutures.
Variation: Right aortic arch with retroesophageal component. The descending aorta, ligamentum and vessels were all
identified after opening of the chest. The ligamentum was mobilized from around the esophagus and divided. Clamping of this
vessel does not result at all in blood pressure change in the arterial line in the left subclavien artery, and there is no change in
the blood pressure cuff in the left arm. The vessel was then divided and ligated. Upon division it was obvious that there was
ductal tissue within the structure. After division of the vessel the esophagus is relieved of the tethering. The incidental
adhesions were taken down further to allow mobilization and freedom of the ring.
Variation: Left aortic arch and right sided ligamentum arteriosum. The descending aorta on the right was easily
encountered. The vessels branching from the aortic arch were mobilized and identified. There was an additional vessel that
leaves the aorta medially opposite the right subclavian branch and enters the pericardium towards the pulmonary artery. This
vessel encircles the esophagus and there is obvious tension upon it. This vessel was mobilized and was temporarily clamped.
Clamping of this vessel did not result in blood pressure change in the arterial line in the left subclavien artery, and there was
no change in the blood pressure cuff in the right subclavian artery. Temporary clamping of the right subclavian artery does
result in a blood pressure change in the blood pressure cuff in the right arm. The vessel was then divided and ligated taking
care to avoid injury to the recurrent laryngeal nerve. Upon division it was obvious that there was ductal tissue within the
structure [Note: This is the usual case for a vascular ring]. After division of the vessel the esophagus was relieved of the
tethering. The incidental adhesions are further taken down to allow mobilization and freedom of the ring.
Variation: Double arch with left-sided ligamentum arteriosum. The atretic arch was easily identified after the thoracotomy.
The arch vessels were identified from each limb of the aorta, and the posterior limb of the aorta was seen descending behind
the esophagus. The arch was then divided between clamps close to its junction with the descending aorta to maintain patency
of the arch vessels. Both ends were oversewn with two rows of 4-0 polypropylene sutures. Tissue bands were then divided
away from the trachea and esophagus. The ligamentum arteriosum is divided, taking care to avoid injury to the recurrent
laryngeal nerve.
A Marcaine block was given to the intercostal region. A 16-French straight chest tube was placed, and the ribs were
approximated with #1 Vicryl. The remainder of the chest wall was closed in layers in the usual fashion. The fascia was then
closed with #1 Vicryl suture in a running fashion. The deep dermal layer was then closed with #2-0 Vicryl suture in running
fashion. The skin and subcuticular layer was closed with #3-0 Monocryl in running fashion. The skin of the wound was
cleansed with sterile saline and dressed with antibiotic ointment and a sterile dressing. All instrument, sponge and needle
counts were confirmed to be correct x 2 at the end of the operation. The patient was subsequently transferred to the
postoperative pediatric cardiac surgical intensive care unit in critical condition.
12. Pulmonary Artery Banding
Raghav Murthy MD., Vinod Sebastian MD.
Children’s Medical Center of Dallas, Texas.

4. Total/subtotal thymectomy.
5. Ligation of patent ductus arteriosus, if present.
6. Dissection of the pulmonary artery from the aorta.
7. Placement of band at the proximal pulmonary artery.
8. Depending on the specific lesion being palliated, adjustment of the band until the pressure distal to the band is 1/3 to
½ systemic pressure with an arterial oxygen saturation no less than 75% on 40% FiO2.
9. The constriction site of the band is secured with a hemoclip or permanent sutures.
10. The band is secured to the adventitia of the main pulmonary artery.
11. Assess hemostasis.
12. Mediastinal blake drain placement and closure of the pericardium.

1. Excessive banding may result in unacceptable cyanosis and hemodynamic collapse.
2. Inadequate banding may lead to persistent pulmonary overcirculation, possible pulmonary vascular disease and
failure to thrive.
3. Placing the band too proximally can result into an incompetent pulmonary valve. This can also pose a problem during
the debanding procedure. The sinus portion of the pulmonary artery often needs to be patched during the de-banding
operation.
4. To avoid the band migration, the band should be sewn to the adventitia of the pulmonary artery. Band migration
causes narrowing of the bifurcation and/or kinking/obstruction of the right pulmonary artery.
5. Damage from the band: Band material can potentially cut through the pulmonary artery and produce hemorrhage.
6. In case of difficulty in passing the band around the pulmonary artery, the ‘subtraction technique’ can be used to
facilitate placement of the band around the pulmonary artery. The band is first passed around both the pulmonary
artery and the aorta through the transverse sinus and then passed between the pulmonary artery and the aorta. This
maneuver avoids passing a right angle solely around the friable pulmonary artery.
Template Dictation
Preoperative diagnosis: [Blank]
(Possible Indications –Swiss cheese ventricular septal defect, tricuspid atresia with normally related great vessels with
pulmonary overcirculation, multiple ventricular septal defects with coarctation)
Procedure(s) Performed: Pulmonary artery banding
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [Age] week old [Gender] with history of [Complaint/Diagnosis].
Description of the Procedure: The patient was brought to the operation room on [Date]. The patient’s identity and planned
procedure were verified and the patient was placed supine on the operating table. General anesthesia was administered.
Monitoring lines and foley catheter were placed. The chest and abdomen were prepped and draped in the usual sterile manner.
A time out was performed. A median sternotomy was then performed. A total/subtotal thymectomy was performed. The
pericardium was opened in the midline and a pericardial cradle created.
The patent ductus arteriosus was dissected out, ligated and divided (if present). The aorta and the pulmonary artery were then
separated with cautery. The main pulmonary artery was then encircled circumferentially by blunt dissection [Variation: If
difficulty is encountered while dissecting the main pulmonary artery the ‘subtraction technique’ can be used]. The banding
material [Options: Teflon impregnated Dacron, Silastic or 3mm ePTFE] is passed around both the aorta and the pulmonary
artery in the transverse sinus. The aorta is then dissected and the band was brought in between the pulmonary artery and the
aorta. The band is sequentially tightened using hemoclips or 5-0 prolene sutures [Note: The approximate circumference of the
band is determined using the Trusler’s formula: 20mm+child’s weight in kilograms]. Once the distal pulmonary artery pressure
was reduced to 1/3 to ½ systemic pressure and the systemic arterial saturation was greater than 75% on 40% inspired oxygen
the constriction site of the band was secured with a hemoclip or 5-0 prolene suture. With this a 10-15 mm of Hg rise in
systemic arterial pressure was seen. The band was then secured to the adventitia of the main pulmonary artery using 6-0
prolene suture.
Hemostasis was confirmed. A mediastinal blake drain was placed. The median sternotomy was closed with stainless steel
wires. The fascia was closed using 2-0 vicryl, the subcutaneous tissue using 3-0 vicryl and the skin was approximated using 4-
0 vicryl in a subcuticular manner. Sterile dressing was applied to the incision.
All the needles, sponges and instruments counts were found to be correct at the end of the procedure. The patient was
transferred to the intensive care unit in a stable condition.
13. Modified Blalock-Taussig Shunt (Using Interposition Gore-Tex
Tube Graft)
Muhammad Aftab, MD, Ismael Alejandro Salas De Armas, MD, Carlos M. Mery*, MD, MPH

3. Left radial/femoral/pre-existing umbilical arterial line.
OPTION A: RIGHT THORACOTOMY
A4. Left lateral decubitus position.
A5. Serratus-sparing right posterolateral thoracotomy.
A6. Enter left pleural space through 4th intercostal space.
A7. Retract the lung inferiorly and posteriorly for an optimal exposure.
A8. Doubly-ligate and divide the azygos vein.
A9. Open the mediastinal pleura posterior to the SVC and right phrenic nerve.
A10. Dissect behind the SVC until the right pulmonary artery and its branches are identified.
Circumferentially dissect the right pulmonary artery and its branches (perform the proximal dissection under the
ascending aorta).
A11. Identify the right subclavian artery on the apex of the pleural cavity and circumferentially dissect the
artery with care not to injure the right recurrent laryngeal nerve.
OPTION B: MEDIAN STERNOTOMY (NO CPB)
B4. Supine position.
B5. Median sternotomy and thymectomy.
B6. Open the superior portion of the pericardium and distract with stay sutures.
B7. Dissect the innominate artery, right carotid artery, and right subclavian artery with care not to injure the recurrent
laryngeal nerve.
B8. Dissect the right pulmonary artery under the ascending aorta and SVC. Continue the dissection to include the first
branches of the right pulmonary artery.
THORACOTOMY/STERNOTOMY
1. Select 3/3.5/4 mm Gore-Tex shunt and trim appropriately.
2. Systemic heparinization 100 IU/Kg (1 mg/Kg).
3. Control the right subclavian artery with atraumatic snares or a side-biting clamp. [If through a sternotomy,
control the innominate artery, the right carotid artery, and the distal right subclavian artery].
4. A longitudinal incision on the inferior surface of the right subclavian artery to correspond to the size of the shunt.
5. An end-to-side shunt to subclavian artery anastomosis with fine poplypropelene suture.
6. Deair the shunt with heparinized saline solution.
7. Control the shunt with a clamp.
8. Unclamp the subclavian artery [innominate artery/right carotid artery].
9. Assure hemostasis at the anastomotic site.
10. Snare the proximal right pulmonary artery with an atraumatic snugger and control the branches with Silastic
vessel loops or atraumatic snuggers.
11. Make a longitudinal incision on the superior surface of the right pulmonary artery with care not to enter the right
upper lobe branch of the artery.
12. Create an end-to-side shunt to pulmonary artery anastomosis with fine polypropelene suture.
13. Remove the pulmonary artery snare and vessel loops.
14. Remove the clamp from the shunt.
15. Ensure hemostasis and check for a thrill.
16. [If through a median sternotomy, may ligate the patent ductus arteriosus].
17. Irrigate with warm antibiotic saline irrigation.
18. Place an appropriate drain.
19. Chest closure

1. Modified Blalock-Taussig shunts can be performed through right or left posterolateral thoracotomies or through a
median sternotomy. The approach depends on the anatomy of subclavian and pulmonary artery, the presence and
location of the ductus arteriosus, the relationship of the great vessels, and surgeon/institutional preference.
Advantages of a thoracotomy approach include the ability to place the shunt more distally in the subclavian artery
potentially allowing for better control of pulmonary blood flow and the lack of mediastinal adhesions for future
operations. Advantages of a sternotomy approach include less technical challenge and the ability to control the ductus
arteriosus at the same time. If the patient is marginally stable, a median sternotomy approach with cardiopulmonary
bypass may be necessary.
2. Special attention should be paid to avoid any inadvertent injury to the phrenic and recurrent laryngeal nerves during
the dissection.
3. The right pulmonary artery should be clearly identified and circumferentially dissected. The right pulmonary artery
should be dissected medially up to the location of the main pulmonary artery and laterally onto the first branches.
The branches of the right pulmonary artery should be adequately identified in order to avoid placing the shunt into the
right upper lobe branch.
4. The size of Gore-Tex graft is determined based on the size of the patient, the length of the shunt, and its location.
Generally, when creating a shunt through a median sternotomy, a 3.5 mm shunt is used for most patients except for
those <2.5 kg (3 mm shunt) or >4 kg (4 mm shunt). When creating a shunt through a thoracotomy, a 4 mm shunt is
usually appropriate as the size of the subclavian artery will control the amount of flow into the shunt.
5. The graft should be trimmed to an accurate length. Too short of a graft will cause tension on the anastomosis leading
to bleeding along the suture line, distortion of the pulmonary artery with resultant stenosis and possible thrombosis.
Similarly, too long of a graft may cause kinking and distortion of the pulmonary artery and possibly compromise shunt
flow.
6. At the completion of anastomosis, oxygen saturation should increase and diastolic blood pressure should decrease. A
palpable thrill should be present in the shunt and the distal pulmonary artery. In patients with a very large ductus
arteriosus that are undergoing a shunt through a contralateral thoracotomy, there may not be marked changes in oxygen
saturation or diastolic blood pressure upon unclamping of the shunt.
7. Bleeding from the suture line is controlled by packing the anastomotic site lightly with Gelfoam soaked with topical
thrombin or Surgicel for a few minutes. Protamine administration to reverse the heparin is usually avoided, unless
there is excessive bleeding.
8. It is imperative to maintain an adequate systemic arterial pressure prior, during, and after the procedure to avoid early
shunt thrombosis.
9. Aspirin or low-dose intravenous heparin are routinely administered and continued postoperatively to prevent shunt
thrombosis.
Template Dictation
Preoperative Diagnosis: [BLANK]
Postoperative Diagnosis: [BLANK]
Procedure(s) Performed: Creation of right modified Blalock-Taussig shunt with [BLANK] mm Gore-Tex graft via right
thoracotomy/median sternotomy.
Drainage: Right pleural/mediastinal chest tube.
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: This is a [BLANK]-day-old, [BLANK]kilogram, full-term neonate with a pre-natal/post-natal
diagnosis of [BLANK]. He was started on intravenous prostaglandins and transferred to the Neonatal Intensive Care Unit. An
echocardiogram confirmed the diagnosis of [BLANK]. The branch pulmonary arteries were of good caliber and were
confluent. He was felt to be an appropriate candidate for staged single ventricle palliation and is put forward now for
placement of a systemic-to-pulmonary artery shunt.
Operative Findings: The right pulmonary artery and its branches were of adequate size. The right subclavian artery was of
adequate size. The oxygen saturation and blood pressure responded as expected after placement of the shunt. There was a
palpable thrill on the shunt and right pulmonary artery at the end of the procedure.
Description of the procedure: After obtaining appropriate consent, the patient was brought to the operating room and placed
in a supine position. Single lumen general endotracheal tube anesthesia was induced and necessary monitoring lines, including
a left radial arterial line, were placed (Variation: The patient was brought from the Intensive Care Unit with umbilical arterial
and venous catheters in place).
RIGHT THORACOTOMY:
The patient was turned into the left lateral decubitus position and the right chest was prepped and draped. A serratus-sparing
right posterolateral thoracotomy incision was performed and the pleural space was entered through the fourth intercostal space.
The lung was retracted inferiorly and posteriorly. The azygos vein was doubly ligated and divided. The right pulmonary
artery was identified and was circumferentially dissected distally onto the first branches. The right subclavian artery was
identified medial/lateral to the recurrent laryngeal nerve, and was circumferentially dissected.
MEDIAN STERNOTOMY:
The patient was prepped and draped. A median sternotomy was performed. A thymectomy was undertaken. The upper
pericardium was opened longitudinally and a series of pericardial stay stitches were placed in order to facilitate exposure.
The innominate artery, right carotid artery, and right subclavian artery were dissected with care not to injure the recurrent
laryngeal nerve. The right pulmonary artery was dissected up to its first branches.
THORACOTOMY/STERNOTOMY:
A [BLANK] mm Gore-Tex shunt was selected and tailored appropriately. Systemic heparin was administered at 100 IU/kg
(1mg/kg). The right subclavian artery [, right carotid artery and innominate artery] was/were controlled with a vascular
clamp/atraumatic snuggers. A longitudinal incision was made on the inferior surface of the right subclavian artery. An end-to-
side graft to subclavian artery anastomosis was performed using running fine polypropylene suture. The shunt was deaired and
controlled with a clamp. The clamp/snuggers was/were removed from the subclavian artery [, carotid artery and innominate
artery]. Hemostasis was assured at the anastomotic site. The proximal right pulmonary artery was snared with an atraumatic
snugger. The branches were controlled with silastic vessel loops. A longitudinal incision was made on the superior surface of
the right pulmonary artery and an end-to-side shunt to pulmonary artery anastomosis was performed using running fine
polypropylene suture. The pulmonary artery snare and the vessel loops were removed and the shunt was de-aired through the
suture line. The clamp was then removed from the shunt, and there was an appropriate fall in mean and diastolic arterial
pressure. There was a thrill in the shunt. Excellent hemostasis was assured. The incision was irrigated with warm antibiotic
saline irrigation. A single right pleural/mediastinal chest tube was placed. [The rib edges were re-approximated using
interrupted absorbable pericostal sutures. Serratus anterior fascia, latissimus dorsi muscle, and subcutaneous tissue
were re-approximated using running absorbable suture.] [The pericardium was loosely reapproximated. The sternum
was reapproximated with interrupted stainless steel wire. The fascia and subcutaneous tissues were re-approximated
with running absorbable suture] The skin edges were approximated using a running absorbable subcuticular stitch.
Dermabond skin adhesive was applied. The patient tolerated the procedure without complications. He/She was left intubated
and was transported to the Pediatric Cardiac Intensive Care Unit in satisfactory condition.
Needles, sponges and instruments counts were correct at the end of the procedure.
Suggested Readings:
2. C. van Doorn, and M. de Leval. Surgery for Congenital Heart Defects by J. Stark and, VT Tsang. John Wiley &
sons, Ltd; 2006, p 251-260.
3. Kaiser, Larry R.; Kron, Irving L.; Spray, Thomas L.Mastery of Cardiothoracic Surgery, 2nd Edition. Lippincott
Williams & Wilkins; 2007. p 694-707.
4. Backer CL, Mavroudis C. Palliative Operations. In: Mavroudis C, Backer CL (eds). Pediatric Cardiac Surgery. 4th
edition. Wiley-Blackwell; 2013, p160-163.
14. Norwood Procedure
Peter Sassalos, MD and Ming Si, MD
University of Michigan Health System, Ann Arbor, MI

4. Subtotal thymectomy
5. Pericardial well
7. Arterial cannulation of patent ductus arteriosus
8. Venous cannulation of right atrium
9. Full cardiopulmonary bypass
10. Cool to 18oC for deep hypothermic circulatory arrest
11. During cooling, dissection of ascending aorta, aortic arch , proximal descending aorta, head vessels, and pulmonary
artery branches with placement of unengaged snares
12. Snare arterial cannula to direct flow into systemic circulation
13. Division of main pulmonary artery proximal to bifurcation
14. Closure of distal main pulmonary artery with Gore-Tex patch
15. If right ventricle to pulmonary artery shunt performed, proximal anastomosis using 5 mm or 6 mm ringed Gore-Tex
graft with distal anastomosis performed following neoaorta construction
16. After cooling at least 20 minutes to 18oC, snare the head vessels
17. Cross clamp the descending aorta
18. Antegrade cold blood cardioplegia – 30- 40 cc per kg through arterial cannula.
19. Topical cooling of heart
20. Deep hypothermic circulatory arrest initiated and cannulae removed
21. Limited right atriotomy and atrial septectomy
22. PDA ligation and division
23. Aortotomy along lesser curvature on leftward side of aorta from level of divided proximal main pulmonary artery to
normal descending aorta distal to PDA with resection of ductal tissue
24. Approximation of proximal most extent of aortotomy and adjacent divided proximal main pulmonary artery
25. Neoaorta augmentation with pulmonary homograft patch
26. De-air the neoaorta
27. Remove the Aortic cross clamp
28. Recannulation with partial cardiopulmonary bypass
29. Right atriotomy closure with full cardiopulmonary bypass and removal of head vessel snares
30. Rewarm to 37oC
31. If systemic (innominate artery or aorta) to pulmonary artery shunt performed, proximal and distal anastomoses using
3.5 mm or 4.0 mm heparin bonded Gore-Tex graft
32. Resume ventilation
34. Modified ultrafiltration if <15 kg
35. Sequential decannulation
36. Right atrial transthoracic intracardiac line placement
38. Hemostasis
39. Atrial and ventricular pacing wire placement
40. Mediastinal chest tube placement
41. Sternum left open (or can be closed)
42. Skin closure with Silastic patch

1. PDA injury during arterial cannulation and dissection
2. Injury to pulmonary valve during placement of right ventricle to pulmonary artery shunt
3. Cooling less than 20 minutes prior to deep hypothermic circulatory arrest
4. Restricted atrial level shunting due to insufficient atrial septectomy
5. Insufficient length and/or spiraling of aortotomy
6. Distortion of native ascending aorta during creation of neoaorta
7. Bleeding from distal aortotomy suture line
8. Failure to de-air neoaorta prior to disengagement of head vessel snares
9. Overwarming with neurologic sequelae
10. Using innominate artery of unsuitable size for shunt rather than central aorta shunt
Template Dictation
Preoperative Diagnosis: Hypoplastic left heart syndrome (HLHS)
Procedure(s) Performed: Norwood procedure with [Variation: Right ventricle to pulmonary artery shunt or Modified
Blalock-Taussig Shunt OR Central shunt]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] day old [GENDER] diagnosed with the Hypoplastic Left Heart Syndrome (HLHS). The
procedure as well as its potential benefits, risks, and other treatment options were discussed with the patient's parents. They
consented to the above procedure.
Description of Procedure: After informed consent and patient identification, the patient was brought to the operating room and
placed in the supine position. After induction of general anesthesia, a single lumen endotracheal tube was placed. A central
venous catheter and arterial line were placed for the hemodynamic monitoring. An oropharyngeal tube, foley catheter and
rectal temperature probe were placed. Preoperative antibiotics were administered. The chest was prepped and draped in the
usual sterile fashion. A second time out was performed to identify correct patient, procedure and site.
A standard median sternotomy was performed. A subtotal thymectomy was carried out. The pericardium was opened and
marsupialized. The patient was systemically heparinized with 400 units per kg of heparin. Arterial cannulation was
performed in the patent ductus arteriosus. Venous cannulation was performed in the right atrium. After a satisfactory activated
clotting time, full cardiopulmonary bypass was initiated. Cooling to 18oC was begun for deep hypothermic circulatory arrest.
During cooling, dissection of the ascending aorta, aortic arch, descending aorta, head vessels and pulmonary artery branches
was performed with unengaged snares placed. The arterial cannula was then snared to direct flow into the systemic
circulation. The main pulmonary artery was then divided just proximal to the bifurcation. The distal main pulmonary artery
was closed with a Gore-Tex patch using running 6-0 Gore-Tex suture.
[If right ventricle to pulmonary artery shunt performed: A stab incision was made to create a right ventricular
infundibulotomy. A right angle clamp was carefully passed into the proximal main pulmonary artery through the pulmonic
valve to exit the infundibulotomy. A [5 MM OR 6 MM] ringed Gore-Tex graft was selected and passed with the right angle
clamp through the wall of the right ventricle. It was cut flush to a ring and pulled back such that one ring was inside the
ventricular wall and the other at the level of endocardium. The graft was then secured to the epicardium using two pursestring
polypropylene sutures. The distal end was left for anastomosis following neoaorta construction.]
At this point, the patient was cooled for greater than 20 minutes to a temperature of less than 18oC. A cross clamp was placed
on the descending aorta and the head vessels were snared. Antegrade cold blood cardioplegia was administered at a dose of
[30-40 cc] per kg through the arterial cannula. Topical cooling of the heart was achieved with ice slush. The pump was
stopped and deep hypothermic circulatory arrest was initiated. The cannulae were removed.
A limited right atriotomy was made and an atrial septectomy performed to allow unrestricted atrial level shunting. The patent
ductus arteriosus was then ligated and divided. An aortotomy was created along the lesser curvature on the leftward side of
the aorta from the level of the divided proximal main pulmonary artery to normal descending aorta distal to the patent ductus
arteriosus with resection of all ductal tissue. The most proximal extent of the aortotomy and the adjacent divided proximal
main pulmonary artery were approximated using three interrupted [6-0 or 7-0] polypropylene sutures. A pulmonary homograft
patch was then sewn with running [6-0 or 7-0] polypropylene suture to augment the arch from the proximal descending aorta
through the arch and down the ascending aorta with incorporation of the main pulmonary artery to form the neoaorta.
A pursestring suture was then placed in the neoaorta homograft to de-air the reconstruction. The aortic cross clamp was
removed. Recannulation with partial cardiopulmonary bypass was initiated. The right atriotomy was closed and full
cardiopulmonary bypass was achieved. The head vessel snares were removed. Rewarming to 37oC was begun.
[If right ventricle to pulmonary artery shunt performed: The distal main pulmonary artery was transposed to the rightward
side of the aorta. The right ventricle to pulmonary artery shunt was cut to an appropriate length and beveled to reach the main
pulmonary artery. The distal anastomosis was then performed in an end-to-side fashion between the graft and the anterior
aspect of the main pulmonary artery using running [6-0 OR 7-0] polypropylen suture.]
[If modified Blalock-Taussig shunt or central shunt performed: A Castaneda clamp was used for vascular control of the
[INNOMINATE ARTERY OR NEOAORTA]. A [3.5 MM OR 4.0 MM] heparin bonded Gore-Tex graft was selected, cut t
length and beveled appropriately. An [ARTERIOTOMY OR AORTOTOMY] was made and the proximal anastomosis was
then performed in an end-to-side fashion between the graft and the [INNOMINATE ARTERY OR NEOAORTA] using a
running [6-0 OR 7-0] polypropylene suture. [SNARES OR CLAMPS] on the branch pulmonary arteries were then used fo
vascular control of the main pulmonary artery. An arteriotomy was made and remaining ductal tissue resected. The distal
anastomosis between graft and main pulmonary artery was then performed in a similar fashion. The graft was de-aired in the
usual fashion.]
After rewarming, ventilation was resumed. The patient was weaned from cardiopulmonary bypass on
[INOTROPES/VASOPRESSORS]. Modified ultrafiltration for 10 minutes was then performed. The cannulae were
removed. The right atrial cannulation site was replaced with a transthoracic intracardiac line. Protamine sulfate was
administered at a dose of 1 mg per 100 units of heparin given. Hemostasis was obtained. Atrial and ventricular pacing wires
were placed. A mediastinal chest tube was placed through a separate stab incision and secured in the usual fashion. The
sternum was left open. The skin was closed with a Silastic patch. A sterile dressing was applied. The patient tolerated the
procedure well with no apparent complications and was transferred to the Pediatric Cardiothoracic Intensive Care Unit for
further evaluation and management.
Cardiopulmonary bypass data included a height [CM], weight [KG], body surface area [M2] and blood type [BLANK]. Total
cardiopulmonary bypass time was [MIN], aortic cross clamp time [MIN] and deep hypothermic circulatory arrest time [MIN].
All instruments, sponges and needles counts were correct twice at the conclusion of the procedure.
15. Bidirectional Glenn Procedure
Muhammad Aftab, MD, Ismael Alejandro Salas De Armas, MD, E. Dean McKenzie*, MD

1. Lines and Monitoring (Note: IJ line in SVC for PAP monitoring postop and NTG delivery).
3. Bilateral cerebral near-infrared spectroscopy sensors (NIRS).
4. Transesophageal Echocardiogram (Not useful unless AV valve regurgitation).
5. Redo median sternotomy with oscillatory saw.
6. Lysis of adhesions under direct vision between the heart, the sternum and the diaphragm.
7. Dissect around the SVC, right atrium and Neoaorta (extreme care with phrenic nerve).
8. Dissect the pulmonary artery (PA) from the hilum on the right onto the left PA. (Note: mostly done prior to heparinization).
9. Identify the BT shunt and perform circumferential dissection.
11. Direct aortic cannulation (Neoaorta).
12. Direct distal SVC cannulation.
13. Right atrial (IVC) cannulation (Note: IVC cannulation is necessary only if intracardiac procedure required).
15. Check ACT >350.
17. Immediately after initiation of CBP, ligate the BT Shunt or clip the Sano shunt (Ultimately the shunt needs to be
divided).
18. Normothermic beating heart.
19. Snare the SVC proximal to the cannula, divide azygous vein to prevent retrograde flow.
20. Apply a vascular clamp to the SVC-right atrial junction.
21. Divide the SVC and suture closure the cardiac end.
22. Ligated the azygos vein to further mobilize the SVC.
23. Excise the shunt from the PA and extend the arteriotomy medially and laterally on the superior aspect of the branch pulmonary arteries. with Hegar dilators)
24. Construct the end to side cavopulmonary anastomosis.
25. Resume mechanical ventilation.
26. Wean from CPB.
27. Place common atrial, if no femoral venous catheter.
28. TEE evaluation, hemodynamic and oxygen saturation assessment
29. Protamine and sequential decannulation.
30. Assure hemostasis.
31. Place mediastinal drains.

1. A safe sternal reentry is one of the major steps to the successful outcomes of redo operations.
2. Careful evaluation of preoperative imaging to assess the proximity of vital structures to the sternum, use of an
oscillating saw for the anterior table, lifting the sternal edges and incising the posterior table under direct vision,
removing the sternal wires sequentially after incising the posterior table are some of the considerations for a safe
sternal reentry.
3. Special attention should be paid to avoid any inadvertent injury to the right phrenic nerve during the lysis of adhesions
between the right side of the heart and pericardium and dissecting the SVC. A combination of sharp and blunt
dissection should be carried out and use of electrocautery should be avoided.
4. Sinoatrial (SA) node is located on the lateral aspect of the SVC-right atrial junction. The inferior vascular clamp
should be applied across the SVC just above the atrio-caval junction and SVC should be divided above the clamp and
the stump is oversewn.
5. The azygous vein should be doubly ligated and divided to avoid the post-operative decompression of superior
cavopulmonary shunt (Glenn) flow into the IVC.
6. Entire procedure can be performed on full flow bypass with beating heart and normothermia.
7. To avoid pulmonary over circulation during the procedure, the systemic-pulmonary shunt (BTS) should be ligated and
proximally divided immediately after instituting the cardiopulmonary bypass.
8. The correct orientation of the proximal SVC should be maintained and any twisting should be avoided to create an
optimal cavopulmonary anastomosis. This can be facilitated by placing the marking sutures on the SVC and dividing
the azygous vein.
9. The SVC should be completely mobilized and opening on the right pulmonary artery (RPA) should be made as close
to the SVC as possible to perform a tension free cavopulmonary anastomosis. In case of previous systemic-
pulmonary shunt, all the shunt material should be completely removed and incision should be extended few
millimeters medially before creating the SVC to RPA anastomosis.
10. To avoid purse-stringing of the cavopulmonary anastomosis, two separate sutures can be used for anterior and
posterior rows. Alternatively, the interrupted suture technique may be prudent to construct the anterior aspect of the
anastomosis.
11. If it is decided to eliminate the source of additional pulmonary blood flow at the time of second stage procedure, the
main pulmonary artery should be divided just above the valve and pulmonary valve should be either excised or over-
sewn (Note: this will require myocardial arrest). Proximal and distal pulmonary stumps should be closed with
running polypropylene. Simple suture ligation of main pulmonary artery should be avoided as it creates a space
between the valve and ligature where thrombosis occurs which can result into systemic emboli and stokes.
12. A monitoring catheter should inserted in the common atrium and needle measurements of SVC and PA pressure
should be done at the time of weaning from bypass to evaluate for any anastomotic problems. The common atrial
pressure should be no more than 5-6 mm Hg. The pulmonary artery pressure, which should be equal to SVC pressure,
should be no more than 12-15 mm Hg.
Template Dictation
1. Hypoplastic left heart syndrome
2. Status post Norwood palliation with placement of systemic-to-pulmonary artery shunt.
Repeat median sternotomy for:
1. Creation of bidirectional cavopulmonary shunt (bidirectional Glenn anastomosis).
2. Takedown of previous systemic to pulmonary artery shunt.
3. Pulmonary patch arterioplasty with pulmonary homograft [Variation]
Drainage: Mediastinal chest tube(s).
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: Patient is a [BLANK] -month-old infant with single ventricle congenital heart disease consisting
o f [BLANK] who underwent Norwood palliation with placement of a systemic-to-pulmonary artery shunt as a neonate.
Clinically, he/she has done well and is being put forward now for the next stage of his/her single ventricle palliation.
Operative Findings: The systemic and pulmonary venous drainage were normal. There were significant adhesions between
the heart and the chest wall and pericardium. The neo-aorta was of adequate caliber. The superior vena cava was of low
normal size. [Variation: There was an area of stenosis on the pulmonary artery at the level of the insertion of the ligamentum
arteriosum]. The coronary arteries were normal. There was trace tricuspid regurgitation and good ventricular function at the
end of the case.
Description of Procedure:After informed consent and patient identification the patient was brought to the operating room and
placed on the operating table in a supine position. After induction of general endotracheal anesthesia and placement of
monitoring lines the patient was positioned, prepped and draped in routine sterile manner. A transesophageal echocardiogram
(TEE) was not performed.
A reoperative median sternotomy was performed and preliminary dissection was carried out. There were expected adhesions
in the mediastinum, which were taken down sharply. A sternal retractor was placed. The phrenic nerves were identified
bilaterally, and care was taken to avoid injuring these structures. The innominate vein and superior vena cava (SVC) were
dissected. The SVC was circumferentially dissected on its entirety from the innominate vein down to the right atrium. The
dissection was performed around the inferior vena cava (IVC) and right atrium. The neoaortic reconstruction was mobilized.
The previous systemic-pulmonary shunt /Blalock-Taussig Shunt (BTS) was identified and circumferentially dissected. A
limited dissection was carried out on the right pulmonary artery.
Heparin was administered and aorto-bicaval cannulation was performed. These cannulae were secured, deaired and connected
to the bypass circuit. Having ascertained an adequate anticoagulation, bypass was initiated. The temperature was allowed to
drift to 34°C. The heart was allowed to maintain a normal sinus rhythm throughout the procedure. Immediately after instituting
bypass the shunt was doubly suture-ligated and divided. The proximal end was oversewn using running polypropylene suture.
The azygos vein was divided between silk ligatures. The superior vena cava was snared just proximal to the level of the
venous cannula. An angled vascular clamp was placed across the cardiac end of the SVC. The SVC was transected at the
cavoatrial junction with the cardiac end being over-sewn with running polypropylene. The pulmonary artery was then
circumferentially dissected from the hilum on the right onto the left pulmonary artery. Upon inspection of the pulmonary artery
there was no stenosis and we were able to pass a normal-sized Hegar dilator upto the branch pulmonary arteries [Variation
for pulmonary artery stenosis: There was an area of stenosis of the pulmonary artery to the right/left of the shunt. The
decision was made to do a pulmonary artery patch augmentation. A longitudinal pulmonary arteriotomy was performed and
extended with Pott’s scissors. A patch was tailored as appropriate and sutured to the pulmonary artery with fine 7-0
polypropylene suture in a running fashion].
All of the systemic-pulmonary shunt material was removed from the main pulmonary artery. The resulting arteriotomy was
extended both medially and laterally on the anterior superior surface. An end-to-side cavopulmonary anastomosis was then
created using running 7-0 polypropylene suture. The patient was rewarmed. Temporary atrial epicardial pacing wires were
placed. Patient was weaned from cardiopulmonary bypass without difficulty and with good hemodynamics. Pressures in the
Glenn circuit were 9-11 mmHg. Systemic arterial saturations were 90% on an FIO2 of 1.0 [Optional: A right atrial line was
inserted through the right atrial appendage and secured]. Protamine was administered and the patient was sequentially
decannulated. Hemostasis was assured. The mediastinum was irrigated with copious amounts of warm antibiotic saline
irrigation. A single mediastinal chest tube was placed. The sternal edges were re-approximated using stainless steel wires.
The soft tissues were closed in multiple layers using running absorbable suture. The skin edges were re-approximated using a
running absorbable subcuticular stitch and steristrips. Sterile dressings were placed.
The patient tolerated the procedure without complications. The patient was extubated in the operating room and transported to
the Pediatric Cardiac Intensive Care Unit in a satisfactory condition.
Sponge, needle and instrument counts were correct at the end of the procedure.
Cardiopulmonary bypass time was [BLANK] minutes.
Suggested Readings:
1. Khonsari S, Sintek CF. Cardiac Surgery: Safeguards and Pitfalls in Operative Technique. 4th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2008, p 354-366.
2. Jonas R. (editor) Comprehensive Surgical Management of Congenital Heart Disease, Hodder Arnold
Publication; 2004, p 357-385.
3. Kouchoukos NT, Blackstone EH, Hanley FL, Kirklin JK. Kirklin/Barratt-Boyes Cardiac Surgery: 4th ed.
Elsevier Saunders, Philadelphia, PA; 2013, p 1533-1540.
16. Completion Lateral Tunnel Fontan
Jonathan C. Hong, MD and Andrew I.M. Campbell, MD
Division of Cardiovascular Surgery, BC Children’s Hospital
University of British Columbia, Vancouver, BC

2. General anesthesia
4. Redo median sternotomy
6. Arterial cannulation of ascending aorta
7. Venous cannulation (right angle cannula in the superior vena cava and flexible straight/right angle cannula in the
inferior vena cava encircled with tourniquet)
8. Insert cardioplegia cannula in the ascending aorta
9. Establish cardiopulmonary bypass (CPB)
10. Ensure ACT>480 seconds
11. Systemic hypothermia (24o C).
12. Ensure all systemic-to-pulmonary artery shunts are controlled (if present).
13. Cross clamp the aorta
14. Antegrade cardioplegia
15. Snare IVC and SVC tourniquet
16. Left atrial vent through right superior pulmonary vein
17. Make oblique incision along the free wall of the right atrium parallel to sulcus terminalis
18. Confirm intracardiac anatomy
19. Excise previously constructed patched orifice between the pulmonary artery and right atrium
20. Cut appropriately shaped baffle out of polytetrafluoroethylene (PTFE)/Gore-Tex graft
21. Suture in a baffle in right atrium directing blood flow from the IVC to the right pulmonary artery
22. Create fenestration in baffle
23. Rewarm to normothermia
24. De-air the heart
25. Remove the cross clamps
26. Atrial and ventricular pacing wires
28. Wean from CPB
29. Measure PA pressure, consider leaving catheter if pressures elevated (>15)
31. Administer the Protamine
34. Placement of chest tubes

1. Catastrophic hemorrhage during redo sternotomy.
2. Cannulation complications.
3. Inadequate myocardial protection.
4. Obstruction of pulmonary venous return by the lateral tunnel prosthesis.
5. Failure to securely snare the tourniquets may result in venous air lock and flooding of the operative field.
6. The superior extension of the right atrial incision must not injure the sinus nodal artery.
7. Manipulation of the crista terminalis, atriocaval junction and area around the sinoatrial node may increase the risk of
atrial arrhythmias, so a gentle tissue handing is prudent.
8. The fenestration of the baffle must be created in a location amenable to device closure
9. Acute thrombosis of the baffle fenestration.
10. Collateral blood flow to the pulmonary circulation is often significant, so the left atrium and ventricle must be
adequately vented to prevent any distension.
11. Incomplete de-airing.
12. Incomplete hemostasis prior to the sternotomy closure
Template Dictation
1. Hypoplastic Left Heart Syndrome (HLHS)
2. Post hemi-Fontan
Procedure(s) Performed: Lateral Tunnel Fontan
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DIAGNOSIS – e.g. hypoplastic left heart syndrome, pos
hemi-Fontan]. Cardiac catheterization demonstrated [suitability of anatomy and hemodynamics – e.g. pulmonary vascular
resistance, unobstructed flow between systemic veins and pulmonary arteries]. An echocardiogram revealed [e.g. assessment
of chamber size and function, valvular function]. It was felt that the patient was suitable for completion lateral tunnel Fontan.
Description of Procedure: The patient was taken to the operating room on [Date]. The patient’s identity, consent, and planned
procedure were verified. The patient was placed on the operating table in the supine position. The procedure was performed
under general anesthesia with left radial arterial line and right internal jugular central venous line access. A preoperative
transesophageal echocardiogram (TEE) was performed to evaluate anatomy and function. The patient was prepped and draped
in the standard fashion including both groins for emergency access. A redo median sternotmy was performed. Cannulation sites
and the right atrium were exposed. Limited dissection of the superior vena cava was performed taking care not to injure the
phrenic nerve. The pericardium was retracted to create a well using [#2-0] silk sutures. The patient was systemically
heparinized with [IU] of heparin.
A right angle venous cannula was placed in the SVC and an arterial cannula was inserted into the ascending aorta. After
ensuring that the ACT was > 480 seconds, cardiopulmonary bypass was initiated. A right angle venous cannula was placed in
the inferior vena cava (IVC). IVC was encircled with a tourniquet. The patient was cooled to moderate hypothermia [e.g. 28o
C]. The ascending aorta was clamped and antegrade cardioplegia was delivered into the aortic root. A left atrial vent was
placed through the right superior pulmonary vein. There was rapid arrest of the heart. [Blank] mL of cardoiplegia was
administered. The tourniquets around the IVC and left innominate vein were snared. The right atrial free wall was opened with
an oblique incision parallel to the atrioventricular groove with the superior end veering anterior to the sinus node taking care
not to injure the sinus nodal artery. The intra-cardiac anatomy and previous hemi-Fontan shunts were examined including the
previously constructed patched orifice between the right pulmonary area and right right atrium. A 15-blade scapel was used to
excise the right atrial patch and it was removed.
A PTFE baffle was shaped appropriately to divert blood from the IVC to the pulmonary circulation. A 10-mm PTFE tube graft
was cut longitudinally to create a half-cylinder. The two ends were beveled with the medial side longer than the lateral side
running along the free edge of the right atrium. The baffle was sewn in place using a #5-0 polypropylene running technique
starting medial to the IVC orifice then posterior to the IVC then cephalad along the lateral wall of the atrium and then around
the SVC orifice. After three quarters of the SVC circumference was sewn, the other end of the #5-0 polypropylene was used to
complete the anastomosis. The two ends of the suture were tied together to secure the baffle. A 4 mm punch was used to create
a fenestration in the medial aspect of the baffle opposite to the ASD to allow for device closure at a later date. The right atrial
free wall was sutured obliquely over the anterior surface of the PTFE baffle using a running #5-0 polypropylene.
The patient was rewarmed to normothermia. The heart was de-aired in the usual fashion. The cross clamp to the aorta was
removed. Atrial and ventricular pacing wires were placed epicardially. Hemostasis was confirmed. The patient was weaned
from cardiopulmonary bypass. A transesophageal echo was performed to confirm appropriate deairing of the systemic atrium
and ventricle and good systemic ventricular function. The patient was decannulated and protamine was administered. A fine
pressure line was inserted through the previous SVC cannulation site and secured with the pursestring suture. Three [Size]
chest tubes were placed in the left pleural, right pleural and mediastinum. The sternum was closed with stainless steel wires.
The fascia was closed with #2-0 Vicryl in continuous fashion. The deep dermal layer was closed with #2-0 Vicryl. The
subcuticular layer was closed with running #3-0 Monocryl.
All instruments, sponges and needles counts were confirmed to be correct x 2 at the end of the operation. The patient was
subsequently transferred to the postoperative cardiac surgical intensive care unit in stable condition.
17. Extra-Cardiac (Non-Fenestrated) Completion Fontan Procedure
Muhammad Aftab, MD, Ramanan Umakanthan*, Jeffrey S. Heinle*, MD

1. Lines (central venous line, arterial line, volume line) and Monitoring.
4. Redo-median sternotomy.
5. Lysis of adhesions.
6. Dissection of superior cavopulmonary shunt (Glenn)
7. Dissection of branch pulmonary arteries to the hilum.
9. Direct aortic cannulation.
10. Bicaval cannulation, both Cavae encircled with the tourniquets.
11. Establish Cardiopulmonary bypass (CPB) circuit
12. Check ACT >450
14. Systemic hypothermia (cooling to 34oC).
15. Ensure that all the systemic to pulmonary shunts are controlled or ligated.
16. Prepare the GORE-TEX (or PTFE) conduit beveled.
17. Snare the branch Pulmonary Arteries (PAs) and SVC tourniquets.
18. Longitudinal pulmonary arteriotomy – along inferior aspect of the right PA and carried centrally.
19. End-to-side conduit-to-PA anastomosis (running 6-0 GORE-TEX suture).
20. Clamp across the right atrium at the right atrial-IVC junction.
21. Snare the Inferior vena cava (IVC) tourniquet
22. Transect the IVC.
23. Oversew the cardiac end (double running layer of 4-0 Polypropylene).
24. Trim the conduit - transected to an appropriate length.
25. End-to-end conduit-to-IVC anastomosis (using running 5-0 GORE-TEX suture).
27. Atrial epicardial pacing wires.
28. Start ventilation and suction the lungs.
29. Remove the caval snares.
30. Allow the heart to fill and eject.
32. Check pressure in the Glenn circuit and systemic arterial saturations.
34. Administer protamine to reverse heparin.
37. Placement of mediastinal drain and bilateral pleural Blake drains.
39. Attempt extubation in the operating room.

1. A safe sternal reentry is one of the major steps to the successful outcomes of redo operations.
2. Special attention should be paid to avoid any inadvertent injury to the phrenic nerves during the lysis of adhesions
between the right side of the heart and pericardium and dissecting the SVC/superior cavopulmonary shunt.
3. Injury to sinoatrial (SA) node during dissection should be avoided.
4. Purse string for the IVC cannulation should be placed as low a possible on the IVC.
5. Occasionally, a relatively short intrathoracic segment of IVC may require taking down the diaphragmatic reflection
onto the IVC for an optimal exposure. Alternatively, the femoral vein can be cannulated in larger patients.
6. Placing the clamp on the right atrium can result into an inadvertent injury to the coronary sinus or right coronary
artery. This can be avoided by careful inspection prior and after the clamp placement.
7. An adequate rim (1-2 cm) of right atrial tissue should be left beyond the clamp for the suture line on the cardiac
stump. An accidental slipping of right atrial tissue can result into catastrophic air embolism.
8. Any areas of branch pulmonary artery stenosis should be addressed by either the direct patch augmentation (GORE-
TEX/pericardial patch) or the long beveled proximal anastomosis should be fashioned to patch augment the
pulmonary artery narrowing, if possible.
9. To maintain the laminar flow in the main pulmonary artery the anastomosis of the GORE-TEX conduit to Pulmonary
artery should be as central as possible, thus offsetting the flows from IVC and SVC to the pulmonary artery and
avoiding direct collision of two blood streams.
10. There is no growth potential growth for the extra cardiac conduits. Simultaneous placing a larger conduit will result
into IVC-conduit diameter mismatch, with an increased risk of stasis and thrombosis. Typically an 18-22mm GORE-
TEX conduit will be used.
11. Keep the conduit short.
12. Avoid obstruction of right sided pulmonary veins due to compression by the conduit. Confirm an unobstructed ASD
and unobstructed pulmonary venous return after conduit placement.
13. Significant atrioventricular valve regurgitation should be addressed at the time of Fontan.
Template Dictation
1. Hypoplastic left heart syndrome (Variation: Aortic Atresia/Mitral Stenosis)
2. Post Norwood procedure
3. Post bidirectional Glenn (cavopulmonary shunt).
Procedure Performed:
1. Third redo-sternotomy.
2. Completion Fontan: Total cavopulmonary connection with non-fenestrated extra-cardiac conduit (20-mm GORE-TEX
conduit).
Drainage: Mediastinal chest tube and bilateral pleural Blake drains were placed.
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: This is a 4 year old with hypoplastic left heart syndrome (aortic atresia/mitral stenosis) who is
status-post the first 2 stages of his single-ventricle palliation and is now being put forward for completion Fontan.
Preoperative echocardiogram and cardiac catheterization show favorable anatomy and hemodynamics for Fontan operation.
There is a normal right ventricular function with mild tricuspid regurgitation. There is good development of the branch
pulmonary arteries, pulmonary arterial resistance was 2.0 Wood units and pulmonary artery pressure 14 mm Hg with an end
diastolic pressure 9 mmHg.
Operative Findings: The branch pulmonary arteries were of good caliber. Transesophageal echocardiogram showed good
right ventricular function with mild tricuspid regurgitation and an unobstructed intra-atrial communication. Completion Fontan
was performed using total cavopulmonary connection with 20-mm GORE-TEX non-fenestrated extra-cardiac conduit.
Pressures in the Fontan circuit were 12-14 mmHg with systemic arterial saturations in the high 90s. [Variation: There was
small venous collateral in the form of a persistent left vein of Marshall, which was ligated at the level of the innominate vein.]
Description of the Procedure: After informed consent and patient identification the patient was brought to the operating room
tube intubation, arterial and central venous monitoring lines were placed. A transesophageal echocardiogram (TEE) was
performed and the above findings were noted. The patient was positioned, prepped and draped in a surgical sterile fashion.
A repeat median sternotomy was performed. For this purpose, the previous scar was excised and the incision was carried
down to the sternum. The sternal wires were removed and the anterior table of the sternum was divided with the use of an
oscillating sternal saw. The posterior table of the sternum was divided with scissors and electrocautery after dissecting the
structures attached to posterior sternum under direct visualization. Chest wall adhesions were taken down bilaterally. There
were dense adhesions in the mediastinum, which were divided using electrocautery. The phrenic nerves were identified
bilaterally, and care was taken to avoid injuring these structures. The superior vena cava and cavopulmonary anastomosis
were dissected. A limited dissection was carried out on the branch pulmonary arteries. Pursestrings were placed on the
ascending aorta, superior vena cava and the inferior vena cava for cannulation. The patient was then systemically heparinized
and cannulated for cardiopulmonary bypass using direct aorto-bicaval cannulation. After reaching appropriate ACT, bypass
was established and the patient was cooled to 34 oC. The procedure was performed with the beating heart.
The branch pulmonary arteries were further dissected. [Variation: The innominate vein was dissected, and the venous
collateral in the form of left vein of Marshall was identified and ligated.] A [20-mm] GORE-TEX (or PTFE) conduit was then
brought onto the field and beveled on its distal end. The branch Pulmonary arteries were controlled with atraumatic snares and
the SVC tourniquet was snared. A longitudinal arteriotomy was created on the inferior aspect of the right pulmonary artery and
carried centrally. An end-to-side conduit-to-pulmonary-artery anastomosis was performed using running 6-0 GORE-TEX
suture. A large vascular clamp was placed across the right atrium at the right atrial-inferior vena caval junction and the inferior
vena cava (IVC) tourniquet was snared. The IVC was transected and the cardiac end was over-sewn using double running
layer of 4-0 polypropylene suture. The conduit was transected to an appropriate length, and an end-to-end conduit-to-IVC
anastomosis was performed using running 5-0 GORE-TEX suture.
During the final anastomosis, the patient was rewarmed. Temporary atrial and ventricular epicardial pacing wires were
placed. The lungs were suctioned and ventilated. The patient was weaned from cardiopulmonary bypass without difficulty and
with good hemodynamics. Pressure in the Fontan circuit was 12-14 mmHg with systemic arterial saturations in the high 90s.
The TEE showed an unobstructed atrial septal defect and unobstructed right-sided pulmonary veins. Protamine was
administered, and the patient was sequentially decannulated. Hemostasis was assured. The mediastinum was irrigated with
copious amounts of warm antibiotic saline irrigation. A mediastinal chest tube and bilateral pleural Blake drains were placed.
The sternum was re-approximated using stainless steel wires. The soft tissues were closed in multiple layers using running
absorbable suture. Skin edges were re-approximated using a running absorbable subcuticular stitch.
The patient tolerated the procedure without complications. The patient was extubated in the operating room and transported to
the Pediatric Cardiac Intensive Care Unit in a satisfactory condition. Sponge, needle and instrument counts were correct.
Suggested Readings:
2. Jonas R. (editor) Comprehensive Surgical Management of Congenital Heart Disease, Hodder Arnold
Publication; 2004, p 376-382.
4. de Leval MR, Dubini G, Migliavacca F, Jalali H, Camporini G, Redington A, Pietrabissa R. Use of
computational fluid dynamics in the design of surgical procedures: application to the study of competitive
flows in cavo-pulmonary connections. J Thorac Cardiovasc Surg. 1996 Mar; 111(3):502-13.
18. Repair of Supravalvular Aortic Stenosis
Raghav Murthy MD, David Graham MD, Vinod Sebastian MD

3. Intraoperative transesophageal echocardiogram (generally if > 2.5kg).
5. Total/subtotal thymectomy.
6. Open pericardium, create pericardial well.
7. Ligation of patent ductus arteriosus, if present.
8. Dissection of the pulmonary artery from the aorta.
9. Assess location of supravalvular stenosis and size of ascending aorta and arch.
11. Arterial cannulation in the distal ascending aorta or proximal arch.
12. Single venous dual-stage cannula.
13. Placement of antegrade cardioplegia cannula.
14. Initiate cardiopulmonary bypass when ACT in acceptable range.
15. Placement aortic cross clamp.
16. Antegrade cardioplegia (40ml/kg).
17. Reverse Trendelenburg position to better view aortic pathology.
18. Aortotomy (longitudinal for Option A, transverse for Option B).
19. Reconstruction Options:
1. Inverted ‘Y’ Incision, vertical over the ascending aorta and the thickened sinotubular ridge and bifurcate into the
non-coronary sinus and the right coronary sinus, staying to the left of the RCA; assess the valve and the coronary
ostia; pantaloon shaped patch is sutured using 6-0 polypropylene; aortic anastomosis created.
2. 3-patch technique (Brom) with incisions into each coronary sinus; assess the valve and coronary ostia; shield
shaped patch is sutured using 6-0 polypropylene in each sinus; aortic anastomosis created.
20. Patch options include: Dacron/Gore-Tex, pulmonary homograft, bovine pericardium and autologous pericardium.
21. Deep Tredelenburg position, de-airing at the cardioplegia cannula site, removal of aortic cross clamp.
23. Atrial and ventricular wire placement.
26. Assess gradient with TEE.
30. Mediastinal Blake drain and intracardiac line placement.

1. While making the incision into the right coronary sinus it is important to visualize the right coronary ostium so that the
incision has adequate clearance from the ostium to allow subsequent suturing.
2. The pantaloon shaped patch should be rather generous to create bulging sinuses of Valsalva similar to the normal
aorta.
3. Special attention should be focused on cardioplegia protection of the myocardium in view of the severe left
ventricular hypertrophy associated with supravalvular aortic stenosis.
4. If extensive narrowing of the sinotubular junction is seen, a more extensive augmentation of all the three sinuses as
advocated by Brom may be required.
5. Inspection of the aortic valve leaflets and coronary ostia are important. Careful separation of the adhered leaflets
from the ridge may be required.
6. Careful and extensive de-airing must be performed to prevent air embolism and stroke.
7. Injury to the aortic leaflets: the aortic valve leaflets must be protected while making the incision into the sinuses.
8. Incisions into the coronary sinuses should never extend beyond the maximal width of the proximal aortic segment nor
near the aortic commissures. If they do, the patch will distort the base of the valve or alter the commissural geometry
resulting into postoperative aortic incompetence.
Template Dictation
Preoperative diagnosis: (Indication –Supravalvular aortic stenosis, Williams syndrome)
Procedure(s) performed: Inverted ‘Y’ patch aortoplasty
Attending Surgeon: [Blank]
Secondary Surgeon: [Blank]
Assistants: [Blank]
Anesthesia: [BLANK]
Indication(s) for Procedure: (Age) month old (Gender) with history of (Complaint/Diagnosis).
Description of the Procedure: The patient was brought to the operation room on (Date). The patient’s identity and planned
procedure were verified and the patient was placed supine on the operating table. Single lumen general endotracheal tube
anesthesia was administered. Monitoring lines and foley catheter were placed. The chest and abdomen were prepped and
draped in the usual sterile manner. A time out was performed. A median sternotomy was then performed. A total/subtotal
thymectomy was performed. The pericardium was opened in the midline and a pericardial cradle created.
The patent ductus arteriosus was dissected out, ligated and divided (if present). Aortic cannulation sutures were placed as
distal on the ascending aorta as possible. The patient was then systemically heparinized. The aortic cannula was then inserted,
secured and de-aired. A single right atrial venous cannula was placed. An antegrade cardioplegia cannula was then placed in
the ascending aorta. CPB was initiated after appropriate ACT levels were obtained. The aorta was cross-clamped and
antegrade cardiopledia delivered. Rapid arrest of the heart was achieved. Ice was applied to the heart.
A longitudinal aortotomy was made over the narrow segment of the ascending aorta. The coronary ostia and the valve leaflets
were then visualized. The aortotomy was then extended in a bifurcated manner, inverted ‘Y’ configuration, onto the non-
coronary sinus and onto the right coronary sinus staying to the left of the right coronary artery ostium. A generous pantaloon
shaped autologous pericardial/homograft/ Dacron/Gore-Tex patch was then fashioned. This was sutured to the aorta in a
continuous manner using 6-0 polypropylene suture. The patient was then placed in a steep Trendelenburg position and de-
airing was performed through the antegrade cardioplegia site. The aortic cross clamp was removed. Hemostasis was
confirmed at the suture line.
Atrial and ventricular pacing wires were placed. The patient was weaned from cardiopulmonary bypass. Calcium was
administered. The venous cannula was removed from the right atrium. TEE was used to check the repair and any residual
gradient. Protamine was administered. The aortic cannula was removed. Intracardiac lines were placed and secured in place.
All the cannulation sites were checked for hemostasis. A mediastinal Blake drain was placed. The median sternotomy was
closed with stainless steel wires. The fascia was closed using 2-0 Vicryl, the subcutaneous tissue using 3-0 Vicryl and the skin
was approximated using 4-0 Vicryl in a subcuticular manner. Sterile dressing was applied to the incision.
All needles, sponges and instruments counts were found to be correct at the end of the procedure. The patient was transferred
to the intensive care unit in a stable condition.
Cardiopulmonary bypass time was [BLANK] minutes, with a cross-clamp period of [BLANK] minutes.
19. Ross Procedure for the Correction of Congenital Aortic Stenosis
Ala Al-Lawati, MD and Andrew I.M Campbell, MD
Division of Cardiovascular and Thoracic Surgery, BC Children’s Hospital
University of British Columbia Vancouver, BC, Canada

2. General anesthesia
3. Intraoperative Trans-esophageal echocardiography (TEE)
5. Open pericardium
6. Create pericardial well and inspect cardiac and coronary anatomy
8. Aortic and bicaval cannulation
9. Establishing cardiopulmonary bypass (CPB) with ACT > 400 seconds
10. Systemic hypothermia to 28o C
11. Mobilizing aorta and pulmonary artery
12. Insertion of LV vent via right superior pulmonary vein
13. Cross clamp and administration of cardioplegia
14. Aortotomy & inspection of aortic valve, root and left ventricular outflow tract (LVOT)
15. Transect the PA and inspect pulmonary valve for suitability
16. Harvest pulmonary autograft and prepare it for implantation
17. Transect the aorta and excision of aortic valve; root and annular decalcification
18. Prepare the aortic root and harvesting coronary buttons
19. Implant pulmonary autograft in the aortic position [performing proximal anastomosis]
20. Re-implant coronary buttons
21. Perform distal neoaortic anastomosis
22. Start rewarming
23. Right ventricular outflow tract (RVOT) reconstruction with pulmonary homograft
24. De-airing and removal of cross clamp
25. Atrial and ventricular pacing wires
26. Weaning from CPB
27. Hemostasis
28. Postoperative TEE
30. Protamine administration and aortic decannulation
31. Ensure excellent hemostasis
33. Sternotomy and soft tissue closure

1. Correct patient selection – no distal obstruction
2. Inadequate myocardial protection
3. Preoperative AI
4. Preoperative aortic dilatation
5. Aortic root autograft size mismatch
6. Damage to left main coronary during posterior PA root mobilization
7. Bicuspid pulmonary valve or valve leaflet perforation
8. Damage to pulmonary valve during autograft harvest
9. Inadequate muscular rim below the harvested pulmonary valve autograft
10. Damage to first septal perforator during autograft harvest
11. Inadequate aortic valve/annulus decalcification
12. Injure the coronary arteries with button mobilization
13. Improper anatomic alignment of autograft
14. Excessive tension, kinking, or twisting of coronary arteries with button re-implantation
15. Injuring the coronary artery with deep suture placement while performing the posterior suture line of the RVOT
reconstruction
Template Dictation
Preoperative Diagnosis: Congenital, severe aortic stenosis
Procedure(s) Performed: Ross Procedure
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with symptomatic severe aortic stenosis and anatomy suitable for
Ross procedure.
Description of Procedure: After patient identification, surgical site confirmation and informed consent, the patient was taken
to the operating room and placed in a supine position. Single lumen general endotracheal tube anesthesia was induced and all
the necessary monitoring lines including a left radial arterial line and right internal jugular central venous line were placed. A
preoperative transesophegeal echocardiogram was performed to confirm the diagnosis, rule out other associated congenital
anomalies and establish the presence of a structurally normal pulmonary valve and a baseline cardiac function assessment. The
patient was prepped and draped in standard fashion, including both groins for emergency access.
A median sternotomy was performed. The thymus was excised and innominate vein identified. The pericardium was opened
and retracted to create a well using 2-0 silk sutures. Cardiac anatomy was inspected to rule out any obvious anomalies. The
patient was then systemically heparinized with [UNTIS] of heparin.
Aortic and bicaval cannulation sutures were placed in standard fashion. The aorta was cannulated using a [SIZE] cannula. The
cannula was secured, de-aired and connected to the pump circuit. The superior vena cava (SVC) was then cannulated using a
[SIZE] cannula and the inferior vena cava (IVC) was also cannulated using a [SIZE] cannula. Both cannulae were secured and
connected to the pump circuit. SVC and IVC snares were then placed and laid loose. A purse string for the antegrade
cardioplegia cannula was placed in the ascending aorta and the cannula was inserted. Another purse-string suture was placed
in the right atrium for placement of a retrograde catheter. The left ventricle was vented by inserting a catheter through the right
superior pulmonary vein.
The aortic root size and pulmonary valve size were measured externally to ensure size match. These measurements were
correlated with the echocardiographic measures. Extensive aortic and pulmonary trunk dissection was performed including
both pulmonary artery (PA) branches. Once ACT exceeded 480 seconds, cardiopulmonary bypass was established. The ductal
tissue remnants were ligated and transected to provide further mobility. The Patient was cooled to 28o C. An aortic cross-
clamp was applied and [VOLUME] of antegrade cardioplegia solution infused. A dose of cardioplegia was repeated every 20
minutes in a retrograde fashion to ensure an adequate myocardial protection.
An aortotomy was made at a level 1-2 cm above the sinotubular junction to inspect the aortic valve, root and LVOT for
procedure suitability. Both cavae were snared and the main PA was incised below the bifurcation to assess the pulmonary
valve (PV). The Pulmonary valve was assessed for its tri-leaflet structure, intact leaflets and other structural or functional
abnormalities. We judged it appropriate to proceed with the Ross procedure, and the pulmonary trunk was transected below its
bifurcation. We then harvested the pulmonary autograft by inserting a right-angled forceps through the pulmonary valve to
identify our first incision site on the right ventricle’s anterior wall, 1-1.5cm below the valve. The ventriculotomy was extended
circumferentially with sharp dissection in both directions, staying below the valve and leaving a rim of at least 5mm of
myocardial tissue. Extra caution was taken in the leftward posterior dissection, to avoid injuring the first septal coronary
perforator as well as noting any other coronary anomalies. This part was done under direct visualization of the left main
coronary artery and its branches. After harvesting the pulmonary autograft, a dose of cardioplegia was administered to identify
and control bleeding points from the dissection area. The autograft size was measured, scalloped in preparation for its
insertion, and kept in a clearly marked bowl. The pulmonary homograft was then thawed and rinsed.
The aorta was transected above the sinotubular junction. Three commissural stiches were placed above the aortic commissures
as guides for re-implanting the coronary arteries. The aortic valve was excised. The annulus was decalcified and debrided.
The aortic annulus was measured and no further modification of the aortic root annulus was required. The aortic root was
further prepared by excising the aortic sinuses. The right and left coronary buttons were dissected with excess tissue. Both
coronary arteries were mobilized extensively to facilitate reimplantation.
The pulmonary autograft was implanted in the aortic position at a sub-annular level maintaining its anatomic alignment, using
interrupted pledgeted 3-0 ethibond sutures sewn in a horizontal mattress fashion. This suture line was reinforced with a second
running suture line with 4-0 polypropylene.
A #11 blade scalpel was used to create two arteriotomies in the pulmonary autograft at the positions of the left and right
coronary buttons, respectively. The left coronary button was re-implanted using a running 6-0 polypropylene suture. Similarly,
the right coronary button was re-implanted using a running 6-0 polypropylene suture. Care was taken to anastomose the right
coronary button high onto the new right cusp to avoid kinking. Reconstruction was then completed by performing the distal
anastomosis with running 4-0 polypropylene suture.
The cardioplegia cannula was then reinserted into the neo-aorta. Antegrade cardioplegia was administered and the coronary
button suture lines were inspected for hemostasis.
The patient was rewarmed, and we proceeded with reconstruction of an appropriately sized pulmonary homograft. The
homograft was sutured first to the RVOT with running 4-0 polypropylene suture. While completing the posterior suture line,
special care was taken to avoid injury to the coronary arteries. This was followed by completion of the proximal pulmonary
anastomosis.
The left side of the heart was then de-aired and the cross-clamp was removed. The heart started beating in a normal sinus
rhythm. Both atrial and ventricular pacing wires were placed. At normothermia, after 15 minutes of reperfusion, mechanical
ventilation was resumed and patient was weaned from the cardiopulmonary byass uneventfully. The post operative TEE
showed no gradient or regurgitation across the neoaortic valve, and a satisfactory pulmonary homograft with preserved left
ventricular function. Venous cannulae, left sided vent and cardioplegia lines were sequentially removed. Protamine was
administered. The aorta was subsequently decannulated.
Hemostasis was secured, and two [SIZE] chest drains were inserted. The sternum was approximated using [SIZE] wires. The
subcutaneous layer was closed using [SIZE] vicryl in two layers, followed by subcuticular skin closure using [SIZE]
monocryl. The patient tolerated the procedure well. He/she was then transferred to the cardiac surgery intensive care unit in
stable condition.
Needles, sponges and instruments counts were correct at the end of the procedure. Cardiopulmonary bypass time was
[BLANK] minutes, with a cross-clamp period of [BLANK] minutes.
20. Repair of Obstructive Hypertrophic Cardiomyopathy: (Septal
Myomectomy)
Justin R. Van Meeteren, D.O., Joseph A. Dearani, MD

5. Open pericardium
6. Create pericardial wall, survey ascending aorta for plaque burden and cannulation sites
7. Systemic Heparinization (400 u/kg)
8. Arterial Cannulation
9. Venous Cannulation
10. Myocardial protection cannula placement (aortic tack vent in the aortic root)
12. Initiate CPB
13. Systemic hypothermia to 28o C
14. Aortic cross clamp (reduce CPB flow rate, apply cross clamp, increase CPB flow to 2.0-2.5L/min/m2)
15. Antegrade cardioplegia (+/-1000 ml for satisfactory asystolic arrest)
16. Create an oblique aortotomy (Note: Aortotomy is carried down toward the noncoronary sinus)
17. Suspend the aortotomy with pledgeted polypropylene sutures
18. Perform septal myectomy
19. Inspect Mitral valve
20. Inspect Aortic valve
21. Close the aortotomy closed
22. Removal aortic cross clamp
23. Post-Operative transesophageal echocardiogram (TEE)
25. Wean from CPB
29. Asses hemostasis

1. Incomplete (inadequate) septal myectomy towards mid-ventricle resulting in residual obstruction and systolic anterior
motion (SAM) of mitral valve
2. Injury to the mitral valve or aortic valve
3. Complete heart block
4. Ventricular septal defect or free wall perforation
Template Dictation
Preoperative Diagnosis: [Indication: - e.g. hypertrophic obstructive cardiomyopathy, left ventricular outflow tract
obstruction]
Procedure(s) Performed: Extended left ventricular septal myectomy
Attending Surgeon: [Blank]
Secondary Surgeon: [Blank]
Assistants: [Blank]
Anesthesia: [BLANK]
Indication(s) for Procedure: [Age] year old [Gender] with [Duration] history of [Complaint – e.g. shortness of breath,
diastolic heart failure, syncope, chest pain] . Preoperative echocardiogram reveals [Findings – e.g. hypertrophic
cardiomyopathy with obstruction, basal septal thickness, left ventricular outflow gradient].
procedure verified, and the patient was placed on the operating room table in the supine position. Single lumen General
endotracheal tube anesthesia was obtained. A right internal jugular central venous line and pulmonary artery catheter and radial
arterial line were inserted. Preoperative transesophageal echocardiogram was performed to evaluate ventricular outflow tract
anatomy, septal thickness, ventricular function and valve function. We then proceeded to prep and drape the chest, abdomen,
groins, and lower extremities in sterile fashion. A time out was performed. Median sternotomy was then performed. After
identification of the innominate vein, the pericardium was opened and a pericardial well was created. The aortic cannulation
sutures were then placed in the distal ascending aorta below the level of the innominate artery. The right atrial cannulation
sutures were placed within the right atrium. A total of [UNITS] of systemic heparin was administered. The aortic cannula was
inserted, secured and de-aired. The venous cannula was placed and secured in the right atrium. Total cardiopulmonary bypass
was instituted and cooling for moderate hypothermia was begun (28o C). An aortic tack vent was then inserted into the
ascending aorta on aspiration for administration of antegrade cardioplegia and venting of the left heart. The aortic cross-clamp
was placed. Cold blood antegrade cardioplegia was administered obtaining asystolic arrest of the heart. Additional cold
blood cardioplegia was administered via the coronary ostia at 20-minute intervals during the cross clamp period.
After administrating [Blank] ml of cardioplegia, an oblique aortotomy was made and carried down toward the noncoronary
sinus. The aortotomy was suspended with pledgeted polypropylene sutures. The septal myectomy was performed by making
an incision at the nadir of the right coronary cusp and extending this in a counterclockwise manner, around toward the mitral
valve. Further resection was done on the apical third of the resection to the right of the right coronary cusp incision. The base
of the resection was deepened with a rongeur. The mitral and aortic valves were inspected and noted to be intact. The
aortotomy was closed with running polypropylene suture in two layers. Air was evacuated from the suture line before securing
it. The cross-clamp was released with suction on the aortic root vent was turned on. Cardiopulmonary bypass was gradually
discontinued with satisfactory hemodynamics. Postcardiopulmonary bypass transesophageal echocardiogram showed
[Findings]. Decannulation was accomplished and surgical sites were over-sewn. Protamine was administered and hemostasis
was achieved. A total of [Number] of chest tubes were placed in the mediastinum. The sternum was closed with interrupted
wires in the usual manner and the soft tissue was approximated in layers using absorbable sutures.
All instruments, sponges and needles counts were confirmed to be correct x 2 at the end of the operation. The patient was
21. Arterial Switch Procedure
Muhammad Aftab, MD, Charles D. Fraser, Jr.*, MD

3. Intraoperative TEE.
6. Open the Pericardium.
7. Harvested pericardium (for reconstruction of the defects created by excision of coronary buttons from the native
aortic root).
8. Create a pericardial well.
9. Ascending aortic cannulation.
10. Bicaval cannulation.
11. Establish total Cardiopulmonary bypass circuit.
12. Systemic hypothermia - cooling to 28-30oC (deep hypothermic circulatory arrest 18oC with antegrade cerebral
perfusion is employed only if an arch repair is needed).
13. Dissect out, doubly ligate and divide the PDA.
14. Extensive mobilization of pulmonary arterial branches (past their first-order divisions).
15. Cross clamp the Aorta.
16. Administer anetgrade cardioplegia.
17. Vent the left atrium utilizing transseptal approach / ASD after right atriotomy.
18. Repair the VSD, if present, through the right atriotomy with trans- triscupid approach using autologous
pericardium (Variation: in case of TGA/VSD).
19. Interval doses of cardioplegia every 15-20 minutes – antegrade cardioplegia directly into the coronary ostia.
20. Divide both aorta and the main PA above the semilunar valves.
21. Reposition the aortic cross clamp.
22. Excise the coronary ostia from the native aortic root.
23. Reimplant the coronary buttons into the native pulmonary root (neoaortic root).
24. Perform Lecompte maneuver (translocation of the pulmonary artery confluence in front of the aorta).
25. Establish the aortic continuity by anastomosing the native pulmonary root (neoaortic root) to the ascending aorta.
26. Patch the defects of coronary buttons in the native aortic root (neopulmonary root) using the autologous
pericardium.
27. Re-establish the Pulmonary arterial continuity by anastomosing the neopulmonary root to the pulmonary artery
bifurcation.
28. Close the ASD primarily or by patch the closure.
29. Start rewarming and de-airing- trendelenburg position.
30. Remove the aortic cross clamp.
31. Start de-airing; confirm complete de-airing under TEE guidance.
32. Wean from the cardiopulmonary bypass.
37. Place mediastinal drains and peritoneal dialysis catheter.
38. Standard sternotomy closure.

1. Special attention should be paid to avoid any inadvertent injury to the phrenic during partial thymectomy.
2. The preliminary dissection includes mobilization of aorta (Variation: mobilize beyond the origin of innominate artery
if the arch repair is planned). Aorta should be dissected free from the main pulmonary artery to the level of coronary
ostia. Similarly, the branch pulmonary arteries should mobilized well out past their first-order divisions to allow for
anterior translocation.
3. Pulmonary valve should be carefully assessed by the preoperative TTE and intra-operative TEE (Optional). A
competent and non-stenotic pulmonary valve (neo-aortic valve) must be ensured prior to excising the coronary ostia.
4. Injury to the sinoatrial (SA) node during SVC cannulation or placement of the SVC snare should be avoided.
5. To prevent the flooding of lungs from the run off of aortic cannula flow, the ductus arteriosus should be immediately
ligated or occluded after the institution of cardiopulmonary bypass.
6. If a VSD is present, it can be repaired through the right atrium across the tricuspid valve with an adequate exposure.
Alternative approaches include through the anterior great vessel or pulmonary artery.
7. Intracardiac repair (VSD and ASD repair), if needed, should be performed after the application of initial cross-clamp
and administration of cardioplegia. This allows additional doses of cardioplegia to be administered prior to the
aortic reconstruction.
8. Prospective sites of coronary reimplantation onto the proximal main pulmonary artery can be marked with marking
fine polypropylene sutures.
9. While performing the Lecompte maneuver, to bring the ascending aorta behind the pulmonary artery bifurcation,
extreme care should be exercised not to twist the aorta as this will result into the torsion of the suture line.
10. To prepare the coronary arteries, a D-shape cuff of coronary artery ostia with at least 2-3 mm rim of the surrounding
aortic tissue is usually excised. The proximal coronary arteries should also be mobilized using a low-voltage
electrocautery.
11. Any injury to neo-aortic leaflets should be avoided while making medially-based trap-door flap incisions in the
neoaorta.
12. During coronary reimplantation special care should be taken to avoid rotation and distortion of the coronary arteries.
Template Dictation
1. D-transposition of the great arteries with intact ventricular septum.
2. Yacoub type A coronary branching (Variation: Yacoub A, B, C, D).
3. Large secundum atrial septal defect after balloon atrial septostomy.
4. Small patent ductus arteriosus.
5. Small perimembranous ventricular septal defect (Variation: in patient with TGA/VSD).
Via median sternotomy on cardiopulmonary bypass support:
1. Arterial switch operation.
2. Direct suture closure of secundum atrial septal defect.
3. Ligation and division of patent ductus arteriosus.
4. Direct suture closure of small perimembranous ventricular septal defect (Variation: in TGA/VSD).
5. Insertion of left atrial catheter.
6. Insertion of peritoneal dialysis catheter.
Drainage: Left pleural chest tube(s).
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: This is a [BLANK]-day-old, [BLANK] kilogram, full-term neonate with a prenatal diagnosis of
transposition with intact ventricular septum. He was attended to immediately at birth. He had a restrictive atrial level of
communication and was very hypoxic. He underwent urgent balloon atrial septostomy and improved rapidly. He was
subsequently weaned off of prostaglandin and has been in the Cardiac Intensive Care Unit being prepared for surgery. A
lengthy preoperative consultation was carried out with the patient's parents detailing the anatomy, planned surgery and
attendant perioperative risks. All of their questions were answered, and they are in favor of proceeding with the operation.
Operative Findings: The patient had normal thymic tissue. The pericardium was not adhered to the heart. The great vessels
were situated in an anterior-posterior relationship. There was Yacoub type A coronary branching. The semilunar valves both
were tricuspid, but the pulmonary valve (neoaortic valve) had asymmetric sinuses. The leftward anterior sinus was somewhat
rudimentary, although the leaflet tissue appeared adequate. There was a large secundum ASD after balloon atrial septostomy.
There was a small patent ductus arteriosus. (Variation: There was a small perimembranous ventricular septal defect).
Description of Procedure: After informed consent and patient identification, the patient was taken to the operating room and
placed on the operating table in a supine position. After induction of general anesthesia, the patient was intubated. Central
venous and arterial lines were placed. The patient was then positioned, prepped, and draped in standard sterile fashion. A
complete median sternotomy was performed. A partial thymectomy was carried out. The pericardium was opened, and patches
were harvested and kept fresh for later use. After our preliminary dissection, pursestring sutures were placed in the ascending
aorta and superior and inferior venae cavae. Heparin was administered. The heart was then cannulated for cardiopulmonary
bypass utilizing bicaval venous drainage. Bypass was initiated. The patient was cooled to a nasopharyngeal temperature of 30
degrees centigrade (Variation: Lower temaprature 22-25oC if VSD repair is required). The ductus arteriosus was dissected
out, doubly ligated, and divided. The branch pulmonary arteries were mobilized well out past their first-order divisions. The
ascending aorta was cross-clamped, and the heart was arrested with potassium cardioplegic solution instilled in the aortic
root. The heart became flaccid. An oblique right atriotomy was performed, and a pump sucker was placed into the left atrium
to act as a vent. (Variation for TGA/VSD: Working through the tricuspid valve, the VSD was visualized. It was quite small
and very difficult to see underneath the septal leaflet of the tricuspid valve. After careful deliberation, it appeared that the only
safe way to address the VSD would be with a primary mattress suture buttressed with Teflon felt.Therefore, 6-0 polypropylene
pledgeted horizontal mattress sutures were placed across the VSD and then tied and cut.). We then turned our attention to the
arterial switch operation. The ascending aorta was transected just above the sinotubular junction. The coronary ostia were
visualized. They were centrally located in their respective aortic sinuses of Valsalva. There was type A branching. The
coronary ostia were then mobilized as buttons of aortic wall. The main pulmonary artery was then transected. As mentioned,
the leftward anterior sinus was somewhat rudimentary but suitable for translocation of the left main ostium. Appropriate
medially-based trap-door flap incisions were made in the neoaorta. The coronary ostia were translocated to these incisions
and then sewn in with running fine polypropylene sutures. A LeCompte maneuver was performed. Aortic continuity was then
reestablished with the primary anastomosis between the ascending aorta and neoaortic root with a running fine polypropylene.
At this time, the patient was rewarmed. The ASD was closed primarily with a running fine polypropylene. Multiple additional
de-airing maneuvers were then carried out with the heart venting through the anterior ascending aorta. The aortic cross-clamp
was removed. Normal sinus rhythm resumed spontaneously, and the electrocardiogram normalized. The right atriotomy was
closed with a running fine polypropylene. We then reconstructed the neopulmonary sinus of Valsalva with liberal patches of
the previously harvested autologous pericardium, sewn in with running fine polypropylene. Pulmonary arterial continuity was
then reestablished with an anastomosis between the neopulmonary trunk and the pulmonary artery bifurcation, also with a
running fine polypropylene. As we finished warming the patient, a left atrial catheter was placed. Ventilation was commenced.
The heart was then allowed to fill and eject, and the patient separated from cardiopulmonary bypass without difficulty. The
heart was sequentially decannulated. Protamine was administered to counteract the heparin. The suture lines and cannulation
sites were inspected and found to be hemostatic. The wound was irrigated with copious amounts of antibiotic irrigation. Chest
drains were placed. A peritoneal dialysis catheter was placed, and then the wound was closed in layers. All needle, sponges
and instruments counts were correct at the end of the case, as indicated by the circulating nurse. The patient tolerated the
procedure well and returned to the Pediatric Cardiac Surgical Intensive Care Unit in a good hemodynamic state.
Cardiopulmonary bypass time was [BLANK] minutes. Cross-clamp time was [BLANK] minutes.
Suggested Reading:
2. R. B B. Mee Surgery for Congenital Heart Defects by J. Stark and M. de Leval, VT Tsang. John Wiley &
sons, Ltd; 2006, p 471-487.
3. Spray, Thomas L Mastery of Cardiothoracic Surgery by Kaiser, Larry R.; Kron, Irving L.; Spray, Thomas L.,
2nd Edition. Lippincott Williams & Wilkins; 2007. P 856-872.
22. Tetralogy of Fallot: Transventricular Repair
Juan M. Lehoux, MD and E. Dean Mckenzie, MD
Texas Children’s Hospital/Baylor College of Medicine, Houston, TX

3. Intraoperative transesophageal echocardiography (TEE)
5. Partial Thymectomy
6. Open pericardium
7. Harvest pericardial patch (place in glutaraldeyde for 10 min)
8. Set up pericardial well
9. Preliminary dissection of aorta and main pulmonary artery
11. Cannulation, direct aortic and single venous cannula.
12. Confirm ACT (>400)
13. Start cardiopulmonary bypass
15. Place vent in right superior pulmonary vein
16. Cross clamp the aorta
17. Antegrade cardioplegia.
18. Incise RVOT and pass hagar dialator antegrade through the pulmonary valve [Note: if it is too small, carry the
incision thru the pulmonary valve annulus into the main pulmonary artery].
19. Identify location of VSD, tricuspid valve and subvalvar apparatus of the tricuspid valve.
20. Resect hypertrophied septoparietal muscle bundles avoiding the infundibular septum and subvalvar aparatus of the
tricuspid valve.
21. Place interrupted 6-0 pledgeted polypropylene stitches circumferentially around VSD and secure to perforated sheet.
22. Pass circumferential stitches into appropriately sized and trimmed pericardial patch.
23. Parachute patch into position and tie down sutures.
24. De-air the left heart
25. Remove cross clamp
26. Remove vent from left upper pulmonary vein
27. Place pericardial patch over infundiblar incision.
28. Place left atrial line through the left atrial appendage.
29. Resume ventilation
30. Wean cardiopulmonary bypass
31. Remove venous cannula
32. Confirm adequate repair with TEE
33. Place needle into RV through the infundibular patch and measure pressure
34. Administer protamine
35. Decanulate the aorta
36. Obtain hemostasis
37. Mediastinal drain

1. Avoid phrenic nerve injury during partial thymectomy
2. Identify coronary anatomy prior to infundibular incision. The anterior descending may come from the right,
crossing the site of planned incision.
3. Avoid injury to subvalvar aparatus of the tricuspid valve when resecting septo-parietal muscle bands
4. Do not resect muscle over the infundibular septum, as it forms part of the margin of the VSD.
5. Sutures will not hold through cut endocardium.
6. In order to preserve the long term right ventricular function, the ventriculotomy incision should be just larger
enough to adequately visualize and relieve the infundibular obstruction.
7. Identify aortic valve and its annulus.
8. The patch should be secured to aortic valve annulus to avoid a residual VSD.
9. The aortic valve leaflets are situated immediately below the superior margin of the ventricular septal defect. The
injury to the aortic valve leaflets should be avoided when placing sutures.
Template Dictation
Preoperative diagnosis: Tetralogy of Fallot
Procedure(s) performed: Trans-ventricular Tetralogy of Fallot repair
Attending surgeon: [Blank]
Secondary surgeon: [Blank]
Assistants: [Blank]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] month old [GENDER] with prenatal diagnosis of tetralogy of fallot.
Description of procedure: The patient was taken to the operating room and placed in the supine position. General
endotracheal anesthesia was induced. Arterial and central venous access was obtained by the anesthesia team.
Transesophageal echo probe was placed.
The patient was prepped and draped in the usual sterile fashion. A median sternotomy was performed. The thymus was
excised. The pericardium was incised and a pericardial patch was harvested and placed in glutaraldehyde solution for 10
minutes. A pericardial well was set up. The aorta and pulmonary artery were dissected. After heparin administration, the
patient was cannulated with single venous and arterial cannula. A vent was placed thru the right superior pulmonary vein. The
patient was cooled to 28oC. The aorta was cross clamped and antegrade cardioplegia was administered with prompt cardiac
arrest in diastole. Cardioplegia was given every 20 minutes while cross clamped.
The right ventricular outflow tract was incised. Hegar dialators were passed to size the pulmonary valve, which was found to
be inadequate. The incision was thus carried through the pulmonary valve annulus into the main pulmonary artery.
The VSD margins, the aortic valve and the subvalvar apparatus of the tricuspid valve were identified. The aortic and tricuspid
valves were in fibrous continuity. We then divided and resected hypertrophied septo-parietal muscle bands with special care
taken not to injure the tricuspid valve subvalvar apparatus. The VSD was patched with pericardium of sufficient size to baffle
the LVOT to the aortic valve using interrupted pledgeted polypropylene sutures.
After the VSD was closed, the left heart was de-aired and cross clamp was removed.
The heart restarted to contract spontaneously with a sinus rhythm. The infundibular incision was closed with a pericardial
patch using running polypropylene suture.
A left atrial line was placed thru the left atrial appendage for post-operative monitoring of filling pressures.
Ventilation was resumed and the patient was weaned from cardiopulmonary bypass. The venous cannula was removed. The
repair was confirmed by TEE. A needle was passed into the RV through the trans-annular patch to measure RV pressure. This
was found to be less than 2/3 systemic. Protamine was administered and the arterial cannula was removed. After adequate
hemostasis, a peritoneal dialysis catheter and mediastinal drains were placed. The sternum was approximated with the
stainless steel sternal wires. The soft tissue and skin were closed in layers. A sterile dressing was applied. The child was
transported to the cardiac intensive care unit stable having tolerated the procedure.
Sponges, needles and instruments counts were correct twice at the end of the procedure.
23. Tetralogy of Fallot Repair - Infundibular Sparing (Transatrial
Repair)
Muhammad Aftab, MD, Ismael Alejandro Salas De Armas, MD, E. Dean McKenzie*, MD

3. Intra-operative Transesophageal Echocardiogram (TEE).
6. Open pericardium, Pericardial patch harvest (two segments)
7. Create pericardial well.
8. Dissection of SVC, aorta and main pulmonary artery.
10. Direct aorto-bicaval cannulation.
12. Both Cavae encircled with the tourniquets.
13. Check ACT > 350.
16. Cross clamp the aorta.
17. Antegrade cardioplegia-diastolic arrest.
18. Snare the SVC and IVC tourniquets.
19. Oblique right atriotomy.
20. Vent left heart chambers though the interatrial septum/PFO.
21. Evaluate right ventricular outflow tract and ventricular septal defect through the tricuspid valve.
22. Resection of obstructing muscle bundles (hypertrophied septoparietal trabeculations) at the right ventricular outflow
tract (RVOT) obstruction. Preserve moderator band.
23. Baffle/closure of the ventricular septal defect (Avoiding conduction system). [Note: May require incision in anterior
and septal leaflets of tricuspid valve parallel to the annulus].
24. Longitudinal Pulmonary arteriotomy.
25. Pulmonary valve assessment.
26. Incise the commissure to the level of annulus. May carry incision onto infundibulum for 2-5mm.
27. Reassessment of RVOT through the pulmonary valve.
28. Perform additional subvalvular infundibular resection.
29. Ensure adequate size of RVOT and branch PA’s.
31. PFO/ASD closure and deairing.
32. Remove the aortic cross clamp.
33. Closure of right atriotomy.
34. Pulmonary artery/annulus pericardial patch plasty.
35. Left atrial catheter placement in LA appendage.
36. Temporary pacing wires.
38. Remove the caval snares.
40. Wean from cardiopulmonary bypass (Variation: on Esmolol +/- Milrinone)
41. Confirm satisfactory post-operative TEE findings [Note: Anticipate mild residual dynamic RVOT obstruction].
42. Administer protamine.
45. Placement of mediastinal drains and peritoneal catheter (if indicated).
46. Standard Sternotomy closure.

1. To perform an optimal repair it is of paramount importance that surgeon should be thoroughly familiar with the
patient’s anatomy including the size and distribution of pulmonary arteries, extent of RVOT obstruction, size and
nature of pulmonary annulus, coronary distribution, anatomy of VSD and any other anomalies.
2. Care should be exercised to perform as little manipulation of the heart as possible during the preliminary dissection,
to avoid any precipitating severe hypoxemia from a “spell”.
3. The patient should be outside the neonatal period and weigh >4 kg for considerations for the right ventricular
infundibular sparing (RVIS) repair of Tetralogy of Fallot. The ideal weight for the RVIS repair of Tetralogy of Fallot
is 5kg or greater. We wouldn’t advocate for infundibular sparing repair in a child of weight less than 5 kg and would
probably perform a BT shunt.
4. Avoid the injury of the phrenic nerve during partial thymectomy.
5. Injury to sinoatrial (SA) node during SVC cannulation or placement of the SVC snare should be avoided.
6. A high right atrial incision should be made close to the AV groove for a transatrial repair.
7. To achieve optimal exposure for evaluation intra-cardiac anatomy and repair, purse string for the IVC cannulation
should be placed as low a possible. Occasionally, a relatively short intrathoracic segment of IVC may require taking
down the diaphragmatic reflection onto the IVC for an optimal exposure.
8. Special care should be taken to avoid excessive resection of muscle from RVOT to avoid perforation of free anterior
wall. Avoid unnecessary retraction to avoid junctional ectopic tachycardia (JET).
9. In younger children incision, rather than the excision, of the obstructing septal and parietal bands is all that is usually
necessary [Note: Neonates are not considered good candidates for RVIS repair]. In older children fibrous and
hypertrophied rim of septal and parietal bands must be resected.
10. Pulmonary valvotomy should be performed such that valve leaflets are mobilized and fused commissures are divided
all the way to the pulmonary artery wall; up to but not through the annulus.
11. The pulmonary annulus and main pulmonary artery are evaluated with a Hegar dilator. Following completion of the
infundibular resection and pulmonary valvotomy if the RVOT does not accept a Hegar dilator 1-2mm larger than the
predicted Pulmonary Valve annulus based on BSA then a very limited transannular incision is created.
12. Conduction system is located close to inferior margin of the VSD. Aortic valve leaflets are situated immediately
below the superior margins of the defect. Special care should be taken by avoiding deeper bites in above locations
to prevent puncturing/tethering the aortic valve leaflets and damaging the conduction system.
13. Preserve the visible RV coronary artery branches. Also preserve the conal coronary branch during the limited
infundibular incision.
Template Dictation
Preoperative Diagnosis: Tetralogy of Fallot
Procedure(s) performed:
Infundibular sparing repair of tetralogy of Fallot including
1. Transatrial creation of intracardiac baffle from LV to the anteriorly displace aorta through the VSD (glutaraldehyde-
prepared autologous pericardium).
2. Pulmonary valvotomy and Infundibular-sparing transannular patch augmentation of main pulmonary artery (autologous
pericardium).
3. Transatrial/transpulmonary right ventricular outflow tract resection/Excision of right ventricular outflow tract muscle
bundles.
4. Primary closure of patent foramen ovale
5. Insertion of peritoneal dialysis catheter [Optional].
6. Insertion of left atrial catheter [Optional].
Drainage: [BLANK] Fr. mediastinal chest tube.
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: This is a 6 month old child with the prenatal diagnosis of tetralogy of Fallot with a large
conoventricular malalignment ventricular septal defect, significant pulmonary valvar/subvalvar and supravalvar stenosis.
He/she has been growing and developing well, with adequate oxygen saturations and has been followed with the diagnosis of
tetralogy of Fallot. This child was recently referred to us for surgery and was felt to be a candidate for promotion to a
complete repair. Lengthy consultation was carried out with the patient's family prior to surgery emphasizing the planned
surgery, attendant perioperative risks, and the need for life-long medical follow-up and possible reintervention. All of their
questions were answered and they were in favor of proceeding with the operation.
Operative Findings: A thymus was present. The pericardium was not adherent to the heart. The systemic and pulmonary
venous drainage were normal. There was atrial solitus with atrioventricular concordance and ventriculoarterial concordance.
The aorta was anterior, consistent with the lesion. There was a left aortic arch with normal branching. The coronary arteries
were normal with just a small conal branch crossing the right ventricular outflow tract. There was a large conoventricular
malalignment ventricular septal defect. There were a significant amount of muscle bundles in the right ventricular outflow tract.
The pulmonary valve annulus was small, requiring creation of a transannular incision. There was a vertically oriented
fishmouth-shaped bicuspid pulmonary valve with a functional orifice of 4mm. [Variation: The Pulmonary Valve was
unicuspid/trilaflet]. There was a mild to moderate supravalvar main pulmonary artery stenosis [Variation: There was a
mod/severe valvar/subvalvar and supravalvar main pulmonary artery stenosis]. The main pulmonary artery was small but both
branch pulmonary arteries were of normal caliber. There was a small ligamentum arteriosum with no flow and a patent
foramen ovale.
Description of Procedure: After obtaining appropriate consent, the patient was brought to the operating room and placed in
supine position. General anesthesia was induced with the use of a single-lumen endotracheal tube. All monitoring lines were
placed by the Anesthesia Service. A TEE probe was placed in the esophagus confirming the mitral/aortic continuity and
preoperative diagnosis. The patient was prepped and draped in usual sterile fashion. A time out was performed confirming the
patient's identity and procedure to be performed.
A primary median sternotomy was performed, sternal retractor was placed. A thymus was present and partial thymectomy was
carried out. The phrenic nerves were identified and protected; the upper horns of the thymus were preserved. The pericardium
was opened and two separate patches were harvested for later use and cardiac repair. One pericardial segment was treated
with glutaraldehyde while the second one was left fresh in saline solution.
Pericardial stitches were placed in order to create a pericardial well. The superior vena cava and the aorta were
circumferentially dissected. The pulmonary artery was dissected up to the level of the ligamentum arteriosum. Purse string
sutures were placed in the ascending aorta, and superior and inferior venae cavae. Heparin (3-4 mg/kg) was administered and
direct aorto-bicaval cannulation was achieved. These cannulae were secured, de-aired and connected to the bypass circuit.
After confirmation of adequate ACT, cardiopulmonary bypass was initiated. There was excellent venous drainage. The patient
was cooled down to 28oC. An antegrade cardioplegia catheter was placed on the proximal ascending aorta. An aortic cross-
clamp was placed and antegrade cardioplegia was administered into the aortic root achieving a rapid diastolic cardiac arrest.
Cardioplegia was administered every 20 minutes throughout the case. The superior and inferior vena caval tapes were snared.
The patent foramen ovale was enlarged and a vent was placed into the left atrium, through which, the left side heart chambers
were vented. Flow on CPB was decreased significantly until the left heart could be vented. We encountered significant
collateral return to the left atrium.
The right ventricle was examined through the tricuspid valve. There was an anterior malalignment of the infundibular septum,
with a ventricular septal defect and a significant hypertrophy of multiple septopareital trabeculations obstructing the right
ventricular outflow tract. A trans-tricuspid right ventricular resection of hyperthrophied septoparietal trabeculations was
performed. The muscle bundles were excised on the anterior, lateral, and posterior walls of the right ventricular outflow tract,
just lateral to the infundibular septum.
Attention was then turned to the ventricular septal defect. The previously prepared glutaraldehyde-treated autologous
pericardial patch was used to baffle the ventricular septal defect to the anteriorly displaced aortic valve. A series of
interrupted pledgeted 6-0 polypropylene sutures were placed through the annulus of the tricuspid valve and into the medial
edge of the ventricular septal defect. The previously harvested glutaraldehyde-prepared patch of autologous pericardium was
brought to the field and was trimmed to the appropriated size and configuration. It was used to close the ventricular septal
defect with a running 6-0 polypropylene and the previously placed tricuspid valve stitches. Care was taken to not damage the
conduction system around the posterior inferior aspect of the defect. The patch was then inspected and found be seated nicely.
The tricuspid valve was tested by inflating the right ventricle with cold saline and was found to be competent.
The main pulmonary artery was opened longitudinally and the incision carried to the bifurcation distally. The branch
pulmonary arteries were assessed and both were of normal caliber. This incision on the main pulmonary artery was then
carried proximally to the pulmonary annulus. The pulmonary annulus was small/normal and there was a very stenotic fishmouth
shaped bicuspid pulmonary valve. The anterior commissure was incised down to the level but not through the pulmonary valve
annulus and then working through the enlarged pulmonary valve an additional subvalvar infundibular resection was carried out.
Having done this we could pass a Hegar dilator through the right ventricular outflow tract which is almost 2 mm larger than the
mean expected pulmonary valve size for this child [Variation, If Unicuspid valve: The unicuspid pulmonary valve had a
posterior commissure. Anteriorly the valve leaflet was incised up to the level of the annulus. With a posterior commissurotomy
and by extending the incision through the annulus for a distance of approximately 1 mm, a dilator 2 mm larger than the mean
expected pulmonary valve size for this child could be passed into the relaxed right ventricle. Working through the enlarged
pulmonary valve the infundibular resection was completed].
We began to rewarm systemically and the atrial septal defect was closed primarily as the left heart was de-aired. Additional
de-airing was accomplished via the ascending aorta and confirmed with TEE. The aortic cross-clamp was removed and a
normal sinus rhythm returned rapidly. The right atriotomy was approximated with running polypropylene and the caval
tourniquets were removed. A previously prepared pericardial patch was tailored and this was used to augment the main
pulmonary artery incision. This was sewn and secured in place with running 7-0 polypropylene. A left atrial catheter was
placed through the left atrial appendage. Temporary atrial/ventricular pacing wires were placed.
At this point the child was warmed systemically, the lungs were ventilated, and the heart was in sinus rhythm with good
contractility. Having ascertained adequate de-airing utilizing the TEE the child was weaned from cardiopulmonary bypass and
separated on a beta blocker infusion [Variation: on Esmolol +/- Milrinone]. The TEE demonstrated no residual ventricular
septal defect, normal functioning tricuspid valve and acceptable velocity across the right ventricular outflow tract. Protamine
was administered and the heart was sequentially decannulated. A peritoneal dialysis catheter and mediastinal chest drains
were placed. [Optional, If patient younger than a year: A non tunneled peritoneal dialysis catheter was placed by making an
incision in the peritoneum under the diaphragm and placing the catheter through the abdominal wall and into the peritoneal
cavity under direct visualization].
The mediastinum was irrigated with antibiotic solution and aspirated. The sternum, fascia and skin were all approximated in a
standard manner. The child was transported to the cardiac intensive care unit stable having tolerated the procedure.
Sponge, needle and instrument counts were correct.
Suggested Readings:
2. Philadelphia, PA: Lippincott Williams & Wilkins; 2008, p 276-287.
3. E. L. Bove and J. C. Hirsch.Surgery for Congenital Heart Defects by J. Stark and M. de Leval, VT Tsang.
John Wiley & sons, Ltd; 2006, p 399-409.
24. Pulmonary Valve Replacement and Reconstruction of Right
Ventricle Outflow Tract
Muhammad Aftab, MD, Ramanan Umakanthan*, Jeffrey S. Heinle*, MD

1. Lines (central venous line, arterial line, volume line) and monitoring.
3. Intra-operative Transesophageal Echocardiogram (TEE) to rule out residual intracardiac lesions (especially residual
ventricular or atrial septal defects)
4. Redo-median sternotomy.
8. Bicaval cannulation, both cavae encircled with the tourniquets.
10. Check ACT >450.
13. Dissect right ventricle outflow tract (RVOT) – dissection is facilitated once heart is decompressed on CPB.
14. Longitudinally open RVOT, main pulmonary artery (MPA) extending to the level of bifurcation. [Variation: RVOT
was opened transversely at the level of the pulmonary valve annulus].
15. Excise the remnants of native pulmonary valve and inspect right ventricular outflow tract.
16. Measure the annulus and select the prosthesis (Bioprosthesis). NOTE: We do not use mechanical valves in the
RVOT
17. Trim the redundant aneurysmal RVOT/main PA [Variation: completely excise the calcified outflow patch or
previous RV-to-PA conduit].
18. Secure the prosthetic valve into orthotropic position using multiple horizontal mattress pledgeted sutures [Variation:
Running 2-0 polypropylene].
19. Anteriorly, non-pledgeted sutures are placed through the valve sewing ring and tied exterior to the PA.
20. Re-approximate the edges of trimmed aneurysmal PA/RVOT [Variation: Augment the Pulmonary artery/RVOT using
autologous pericardial/CorMatrix/Dacron patch etc.with an oval or diamond shape patch]. NOTE: we do not like nor
do we use CorMatrix although others do.
25. Administer protamine to reverse the heparin.
28. Placement of mediastinal drains and pleural chest tubes.

1. A safe sternal reentry is one of the major steps to the successful outcome of redo operations. Typically the RV and
RA will be dilated and immediately adjacent/adherent to the posterior aspect of the sternum. A previous RV-to_PA
conduit may be densely adhered to the sternum.
2. Careful evaluation of preoperative imaging to assess the proximity of vital structures to the sternum, use of an
oscillating saw for the anterior table, initially leaving the untwisted sternal wires in place, lifting the sternal edges
and incising the posterior table under direct vision, removing the sternal wires after incising the posterior table and
use of peripheral cannulation in high risk situations are some of the considerations for a safe sternal reentry.
3. Special attention should be paid to avoid any inadvertent injury to the phrenic nerves during the lysis of adhesions
between the right side of the heart and pericardium and dissecting the SVC. The left phrenic nerve will be in close
proximity to the lateral aspect of the dilated MPA and left PA.
4. Entire procedure can be performed on warm and beating heart, if no intracardiac defect (residual VSD or ASD) needs
to be repaired. Residual intracardaic shunts allow for potential air entrainment into the left heart once the right heart
is opened.
5. The incision along the anterior aspect of the main PA/RVOT can often be difficult due to severe calcification of the
previous trans-annular patch.
6. A calcified transannular patch should be completely excised followed by anterior RVOT augmentation using
autologous pericardial/Dacron/CorMatrix/bovine pericardial patch/Gore-Tex patch. If the RVOT patch is not
clacified, it may be trimmed and closed primarily. NOTE: we do not use CorMatrix but others do.
7. The prosthetic valve is usually positioned in the annulus/RVOT at the orthotopic position with a slight posterior tilt.
8. The prosthesis is positioned such to avoid obstruction of the branch PA’s.
9. The valve can be secured by either multiple horizontal mattress pledgeted sutures or running polypropylene suture.
10. For the reconstruction of RVOT, the oval or diamond shape patch should be secured starting from the apex of
pulmonary arteriotomy with sutures lines running on both sides of the pulmonary atreriotomy upto to annulus. The
patch is then folded on itself and running polypropylene suture will incorporate the anterior annulus of prosthesis and
the patch into the suture line. Alternatively, non-pledgeted sutures can be taken through the anterior aspect of valve
sewing ring and then brought through the patch and tied exterior to the neo-pulmonary artery. The remaining portion
of the patch is used to augment the RVOT.
Template Dictation
1. Tetralogy of Fallot, status post repair with placement of a transannular right ventricular outflow tract patch
2. Severe pulmonary valve insufficiency.
3. Severe right ventricle dilatation.
1. Repeat median sternotomy.
2. Total cardiopulmonary bypass
3. Pulmonary valve replacement with [BLANK] mm bioprosthetic valve
4. Right ventricular outflow tract reduction [Variation: Reconstruction of main pulmonary artery and right ventricular
outflow tract with autologous pericardial/Dacron/CorMatrix/bovine pericardial patch/Gore-Tex patch].
Drainage: Mediastinal chest tube and right/left pleural drains were placed.
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: This is a [AGE] -year-old [GENDER] who had undergone previous repair of the Tetralogy of
Fallot with placement of a transannular RVOT patch when he was 9 months old. He has done well but has developed severe
pulmonary insufficiency with severe right ventricular dilatation. He was, therefore, put forward for pulmonary valve
replacement to preserve right ventricular function. A lengthy preoperative consultation was carried out with the patient and his
family detailing the anatomy, planned surgery and attendant perioperative risks. All of his questions were answered.
Operative Findings: Intraoperative TEE confirmed no residual intracardiac lesions. The previously created sternotomy was
well-healed. The patient had the expected pericardial adhesions consistent with his previous surgery. The right ventricle and
right atrium were severely dilated. The main pulmonary artery and right ventricular outflow tract (RVOT) were severely
dilated. The RVOT patch was densely adhered to the sternum. The ascending aorta was mildly dilated. The systemic venous
drainage was normal. The branch pulmonary arteries were of excellent caliber bilaterally. No pulmonary valve tissue could be
identified. A [BLANK]mm bioprosthesis was placed in an orthotopic position to restore pulmonary valve competency.
[Variation: The RVOT reduction was performed by excising the redundant portion of the main pulmonary artery and the
outflow tract patch].
Description of Procedure: After informed consent was obtained and the patient’s identity and the surgical site were
confirmed, the patient was brought to the operating room and positioned supine on the operating table. Adequate general
anesthesia was induced and patient was intubated. Central venous and arterial lines were placed and a transesophageal echo
(TEE) probe was passed. A preoperative TEE was carried out and contrast study was performed which demonstrated no
residual intracardiac shunting. The patient was positioned supine and all the pressure sites were padded appropriately. The
chest, abdomen and groins were prepped and draped in standard sterile fashion. A repeat median sternotomy incision was
made over the sternum and carried down to the presternal fascia with electrocautery. The chest was entered through the
previous median sternotomy with an oscillating sternal saw initially leaving the sternal wires in place, lifting the sternal edges
and incising the posterior table under direct vision and removing the sternal wires after incising the posterior table.
Hemostasis was achieved with electrocautery. Adhesions in the mediastinum were taken down with careful sharp dissection
and electrocautery. The heart was dissected out from the surrounding mediastinal structures and ascending aorta was
mobilized. The phrenic nerves were identified bilaterally, and care was taken to avoid injuring these structures.
Pursestrings were placed on the ascending aorta, superior vena cava and the inferior vena cava for cannulation. The patient
was then systemically heparinized and cannulated for cardiopulmonary bypass using direct aorto-bicaval cannulation. After
reaching appropriate ACT, bypass was established and the patient was cooled to 34 oC. The entire operation was carried out
with the beating and empty heart. With the heart decompressed, the RVOT tract was dissected out and noted to be severely
dilated and aneurysmal [Variation: The Transventricular patch was noted to be severely calcified]. There was also significant
dilation of the right ventricle.
A longitudinal incision was made on the anterior aspect of the main pulmonary artery patch and carried proximally onto the
right ventricular outflow tract and distally to the level of the bifurcation. [Variation: RVOT was opened transversely at the
level of the pulmonary valve annulus]. TEE confirmed no air in the left heart. There were no remnants of native pulmonary
valve. The branch pulmonary arteries easily accepted a Hegar dilator several millimeters larger than normal based on body
surface area. Given the massive size of the right ventricular outflow tract, a [BLANK] mm bioprosthesis/mechanical valve
could easily be placed in an orthotopic position. Prior to placing the valve, the size of the right ventricular outflow tract and
main pulmonary artery was reduced by excising a portion of the redundant anterior wall [Variation: The aneurysmal calcified
outflow patch was completely excised]. The posterior aspect of the valve was then secured in place using multiple horizontal
mattress pledgeted 2-0 Ticron/Ethibond sutures (multifilament braided suture) which were placed at the level of the annulus
and then passed through the sewing ring of the prosthetic valve. Valve was positioned into the annulus and sutures were tied
and divided. Anteriorly, non-pledgeted sutures were taken through the valve sewing ring and then brought through the
pulmonary artery and tied exterior to the pulmonary artery [Variation: Posteriorly the sewing ring of the valve was secured to
the muscular right ventricular outflow tract at the level of the pulmonary annulus with running 2-0 polyproplyene. Anteriorly,
the sewing ring was incorporated into the closure of the arteriotomy]. The edges of the main pulmonary artery and right
ventricular outflow tract were then closed using running 4-0 polyproplyene suture. [Variation: A bovine
pericardial/CorMatrix/GORE-TEX/Dacron patch was used to augment the MPA/RVOT being sewn in place with running
polypropylene suture. Anteriorly, non-pledgeted sutures were taken through the valve sewing ring and then brought through the
patch and tied exterior to the neo-pulmonary artery].
The patient was fully rewarmed and weaned from cardiopulmonary bypass without difficulty and with good hemodynamics.
Protamine was administered to reverse the heparin and the patient was sequentially decannulated. The suture lines and
cannulation sites were inspected and found to be hemostatic. A mediastinal chest tube and right/left pleural drains were placed.
The mediastinum was irrigated with copious amounts of warm antibiotic saline irrigation. The sternal edges were re-
approximated using stainless steel wires. The soft tissues were closed in multiple layers using running absorbable suture. The
skin edges were re-approximated using a running absorbable subcuticular stitch.
The patient tolerated the procedure well. The patient was extubated in the operating room and transported to the Pediatric
Cardiac Intensive Care Unit in a satisfactory condition. Sponge, needle and instrument counts were correct.
Suggested Readings:
2. B.E. Kogon, K.A. Rodby, P.M. Kirshbomet al. Adult congenital pulmonary valve replacement: a simple,
effective, and reproducible technique, Congenit Heart Dis, 2 (2007), pp. 314–318.
25. Repair of Truncus Arteriousus (TA)
Joshua L. Hermsen, MD and D. Michael McMullan, MD
Seattle Children’s Hospital, Seattle, WA

2. Standard lines and monitors
3. Review of transesophageal echocardiogram (TEE)
4. “Time-out” pre-surgical check
6. Thymectomy
7. Harvest pericardium and treat with gluteraldehyde
8. Pericardial well
9. Dissect, control and snare right pulmonary artery between aorta and SVC
10. Dissect truncus/ascending aorta/aortic arch to allow high cannulation
11. Complete circumferential dissection of RPA to hilum
12. Circumferentially dissect LPA to hilum and control with tape
13. Identify coronary origins and coronaries crossing RVOT
14. Systemic Heparinization (3mg/kg)
15. Bicaval - high ascending aortic cannulation
16. Initiate CPB when ACT > 400s
18. Snare LPA
19. Place antegrade cardioplegia cannula
20. Cross clamp ascending aorta
21. Administer antegrade cardioplegia with topical cooling
22. Consider ostial cardioplegia depending upon truncal valve regurgitation.
23. Administer maintenance cardioplegia per institutional protocol
24. Place vent to capture return to left heart
25. Transect ascending aorta just superior to PA’s
26. Excise PA’s as a “Carrel patch” using the posterior truncal wall. This is done even for type 1 truncus to aid
reconstruction of the aorta
27. Perform right ventriculotomy guided by a right angle clamp passed through the truncal valve and VSD.
28. Patch close the VSD through the ventriculotomy and/or atrium
29. An appropriately sized RV-PA conduit is selected and the distal conduit is anastomosed to the PA confluence
30. Truncal valve repair is performed as needed
31. Truncus (proximal) is anastomosed end-to-end to the ascending aorta (distal)
32. Begin rewarming to 36oC
33. The proximal conduit is anastomosed to the ventricle.
34. De-air and remove aortic cross-clamp. Continue deairing through cardioplegia site
35. Inspect for hemostasis
36. Remove LA vent and ensure LV contracting well
37. Evaluate deairing, ventricular function, VSD closure, conduit/PA flow and truncal valve function with TEE
38. Address residual shunts, anastomotic or valve problems as needed
39. Wean from CPB
40. Assess RV pressures with direct measure by needle.
42. Modified Ultrafiltration
43. Heparin reversal with protamine
45. Place atrial and ventricular epicardial pacing wires
46. Place drains as needed
47. Assure hemostasis
48. Pericardial reconstruction with 0.1 mm goretex membrane [Optional]
49. Sternal Closure

1. Hemodynamic instability pre-bypass. Due to systemic and coronary hypoperfusion from pulmonary overcirculation
and diastolic runoff. Hypoventilation (to increase PVR), vasopressors (to increase BP) and snaring of the RPA (to
shunt blood to the systemic circulation) are simple, common methods to address the mismatch between systemic and
pulmonary circulations.
2. An absent or hypoplastic thymus likely indicates 22q11 deletion. Resulting hypocalcemia may impair ventricular
function, especially post-bypass and in response to blood product transfusions. This finding should be shared with
the anesthesia and perfusion providers so they can adjust calcium replacement strategies.
3. Inadequate myocardial protection. Most truncal valves are insufficient to some degree, which may compromise
delivery of truncal root antegrade cardioplegia. Manual compression of the ventricle may suffice for mildly
insufficient valves. More severely regurgitant valves necessitate handheld ostial cardioplegia to ensure good
delivery and avoid ventricular distension.
4. Post-Bypass RV hypertension. RV pressures greater than 75% systemic require treatment. RV outflow obstruction
related to reconstruction must be revised to provide unobstructed pulmonary flow. Residual VSD’s causing RV
hypertension must be closed (the influence of an echocardiographically evident residual defect can be assessed by the
Qp:Qs using simultaneous SVC and PA blood samples and Qp:Qs > 1.5 indicates need for closure).
5. Pulmonary hypertension should be treated with inhaled nitric oxide. Elevated PVR not responsive to medical
treatment may require fenestration of the VSD patch. RV diastolic dysfunction that increases CVP will resolve with
time but may require creation of a small ASD to: minimize morbidity associated with early post-operative systemic
venous congestion and maintain cardiac output at the expense of mild cyanosis.
Template Dictation
Preoperative Diagnosis: Truncus arteriosus (type 2), DiGeorge Syndrome
Post-operative diagnoses: Same
Procedure(s) Performed: Repair of truncus arteriosus
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [Age] year old [Weight] neonate with pre-natal diagnosis of truncus arteriosus. The aortic arch
is intact and the baby is well saturated with very mild failure symptoms while feeding. Informed consent for neonatal repair
was obtained from the parents to limit progression of pulmonary vascular disease and enable long-term survival.
Description of Procedure: A time-out was performed per institutional protocol. General endotracheal anesthesia was
induced and appropriate therapeutic and monitoring lines were placed. A transesophageal echocardiographic exam was
performed. The chest was prepped and draped in a sterile fashion.
A median sternotomy was performed. There was no thymus gland present. A patch of pericardium was excised and treated
with glutaraldehyde. A pericardial well was fashioned.
The right pulmonary artery was circumferentially dissected between the aorta and superior vena cava, encircled with a
silicone tape and occlusively snared which increased the systemic blood pressure. Saturations dipped slightly but remained
above 90%.
The truncus, ascending aorta and aortic arch were completely mobilized. The pulmonary arteries were mobilized to the hila
and the anatomy was consistent with a type II truncus. A silicone tape was placed around the left pulmonary artery. The
coronary origins were normal and no major coronary branches crossed the right ventricular outflow tract.
The patient was anticoagulated with 3mg/kg unfractionated heparin and connected to the heart-lung machine with bicaval to
distal ascending aortic cannulation. ACT was confirmed to be > 480 s, bypass was initiated with adequate drainage and flows
and the tape around the LPA was snared. The patient was cooled to 32oC. A vent was placed through the tip of the right atrial
appendage and the cavae were snared. An antegrade cardioplegia needle was placed.
The distal ascending aorta was cross-clamped under low-flow conditions and antegrade cardioplegia delivered with prompt
arrest and no appreciable ventricular distension. A small incision was made in the right atrium and the vent redirected through
a patent foramen ovale.
The ascending aorta was divided just distal to the origin of the pulmonary arteries. The pulmonary arteries were then
separated from the truncus as a single unit with a cuff of truncal/aortic wall.
A right ventriculotomy was made guided by a right angle clamp passed through the truncal valve and ventricular septal defect.
Care was taken to not injure any coronary branches. The ventricular edges were slightly undermined. The VSD was closed
with a dacron patch sewn with a running 5-0 polypropylene suture.
A 12 mm bovine jugular valved conduit was opened, appropriately rinsed and trimmed. The distal conduit was anastomosed
to the pulmonary artery cuff with running 6-0 polypropylene suture. The ascending aorta was anastomosed to the divided
truncus with running 6-0 polypropylene suture. Rewarming to 36oC was begun and the proximal conduit was trimmed and
anastomosed to the right ventriculotomy with 5-0 polypropylene suture. The vent was removed and replaced via the left atrial
appendage. The PFO was not closed. The right atriotomy was closed with double layer running 6-0 polypropylene sutures.
The heart was thoroughly deaired through the cardioplegia needle site and the cross clamp removed under low-flow
conditions. Deairing was continued allowing the cardioplegia needle site to bleed into the field. The heart appeared well
perfused and sinus rhythm resumed spontaneously within several minutes. TEE confirmed adequate deairing and the needle
site snared. Ventricular function was vigorous and the LA vent was removed. Hemostasis appeared adequate at all suture
lines. Cardiopulmonary bypass was weaned uneventfully.
Post-bypass TEE revealed normal ventricular function, truncal valve function was unchanged and there was no residual VSD.
RV outflow appeared to be unobstructed with low velocity flow in the conduit and PA’s. RV pressures were directly
measured with a needle and found to be 40% systemic. Venous cannulae were removed and modified ultrafiltration was
performed. Protamine sulfate was given and well tolerated. The aortic cannula was removed without incident. Blood and
blood products were administered as needed per anesthesia. Hemostasis was achieved throughout the operative field. Atrial
and ventricular epicardial pacing wires were placed. A single mediastinal drain was placed. The anterior pericardium was
reconstructed with a 0.1 mm goretex membrane [Optional]. Sternal wires were placed to approximate the sternum and the soft
tissues were closed in 3 layers with absorbable suture. Dermabond was used to dress the skin and occlusive dressings were
placed at tube and wire sites.
Sponge, needle and instrument counts were correct. The patient was transferred intubated, in expected condition, to the
cardiac intensive care unit.
26. Cone Repair for Ebstein Malformation
Sameh M. Said, MD, and Joseph A. Dearani, MD

5. Open pericardium, pericardial well
7. CO2 in the operative field
9. Bicaval venous cannulation with caval snares
10. Aortic root vent/cardioplegia needle
13. Maintain normothermia or mild hypothermia
14. Aortic cross clamp (reduce pump flow rate, apply cross clamp, increase pump flow rate to 2.0-2.5 L/min/m2);
include pulmonary artery in cross clamp
15. Antegrade cold blood cardioplegia induction and every 20 minutes
16. Iced slush saline applied to right ventricle
17. Caval tapes are snared
18. Oblique right atriotomy
19. Closure of patent foramen ovale
20. Assess the tricuspid valve (evaluate each component of the anterior, inferior and septal leaflets) and right ventricle
(area of atrialization)
21. Start the surgical delamination process - anterior, inferior (when present) and septal leaflets
22. Augmentation of the shallow anterior leaflet, if needed
23. Delamination (360o) with subsequent rotation of the delaminated anterior leaflet towards the septal leaflet to form the
cone
24. Plication of the atrialized portion of the right ventricle
25. Annular plication
26. Inspection of epicardial surface of heart to confirm no coronary artery compromise
27. Anchoring the delaminated leaflets to the true annular level
28. Check valve competence with saline installation
29. Close residual leaflet fenestrations
30. Annuloplasty band from the anteroseptal to the inferoseptal commissure anchored in coronary sinus
31. Release the aortic cross clamp
32. Right reduction atrioplasty
33. Closure of the right atriotomy
36. Placement of epicardial atrial and ventricular pacing wires
39. Evaluate tricuspid valve with transesophageal echocardiogram
43. Aortic decannulation (systolic blood pressure 90 mmHg)
1. Injury to sinoatrial node during SVC cannulation or during placement of the SVC snare
hepatic veins)
4. Buttonhole the right ventricular wall or the tricuspid valve leaflets during the surgical delamination process
5. Injury to the right coronary artery during plication of the atrialized right ventricle or the annulus
6. Injury to the atrioventricular node during reattachment of the septal leaflet of the tricuspid valve
7. Failure to recognize shallow leaflets which require patch augmentation
8. Missed residual fenestrations which contribute to residual valve regurgitation
9. Improper placement of the annuloplasty sutures with risk of injury to the right coronary artery
Template Dictation
1. Ebstein malformation
2. Severe tricuspid valve regurgitation
3. Patent foramen ovale
1. Complete repair of Ebstein's malformation
2. Suture closure patent foramen ovale
3. Tricuspid valve repair, with placement of flexible annuloplasty ring
4. Plication of atrialized right ventricle
5. Right reduction atrioplasty
6. Establishment of temporary extracorporeal circulation
7. Cardioplegic arrest (blood) 4:1
Drainage: 2 No. 28 Argyle chest tubes
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER]with [DURATION]history of [COMPLAINT–e.g. increasingly
shortness of breath]. Preoperative transthoracic echocardiography reveals [FINDINGS -e.g. severe tricuspid valve
regurgitation in the setting of Ebstein malformation].
Description of the Procedure: After informed consent, patient identification and surgical site confirmation, the patient was
brought to the operating room and placed on the operating table in a supine position. Single lumen general endotracheal tube
anesthesia was induced and all the necessary monitoring lines were placed. Precardiopulmonary bypass transesophageal
echocardiography demonstrated severe tricuspid regurgitation with anatomy consistent with Ebstein's malformation. There was
marked displacement of the diminutive septal leaflet. The height of anterior leaflet was [Blank]. There were multiple
muscular attachments between the body of the anterior leaflet and the free wall of the right ventricle. There was inferior leaflet
that was also displaced apically. The right ventricle was enlarged (Grade xx/6). The patient was prepped and draped in a
surgical sterile fashion and a primary median sternotomy was performed. The pericardium was opened in the midline.
Heparin was administered. The ascending aorta was cannulated with a 20-French DLP cannula, and the superior and inferior
venae cavae were cannulated separately with right-angle venous cannulae. Cardiopulmonary bypass was commenced at 2.4
L/min/m2 for [Blank] minutes, and the perfusate was maintained at normothermia. An aortic tack vent was placed on
aspiration, and a CO2 line was maintained in the operative field. The aorta was cross-clamped and [Blank] cc of cold blood
cardioplegia was infused in the aortic root obtaining satisfactory asystolic arrest. Additional cold blood cardioplegia was
administered antegrade via the aortic root at 20-minute intervals during the cross-clamp period. Iced slush saline was applied
topically to the right ventricle. Caval tapes were snared. An oblique right atriotomy was performed. The patent foramen ovale
was closed with a mattress suture of polypropylene backed with felt pledgets. The anterior annulus was suspended at 10
o'clock and 2 o'clock with fine polypropylene sutures. The anterior leaflet was incised above the annulus. A surgical
delamination process was performed of muscular and chordal attachments to the anterior leaflet. The inferior leaflet was
surgically delaminated. The septal leaflet was surgically delaminated. The inferior leaflet was rotated to meet the proximal
edge of the septal leaflet and was approximated in two layers with fine polypropylene suture. The atrialized right ventricle
was then plicated in a triangular fashion from apex to base with continuos 4/0 polypropylene suture taking care not to injure or
distort the right coronary artery. The tricuspid valve annulus was severely dilated and was plicated in multiple spots around
the annulus, avoiding an exaggerated plication in one location, that would potentially distort the right coronary artery. We then
reanchored the newly reconstructed septal leaflet to the ventricular septum with continuous polypropylene suture in two
layers. This was done to the ventricular side of the conduction tissue. The anterior leaflet was reanchored to the true annulus
with two layers of 5-0 polypropylene. The anterior leaflet reattachment to the Cor Matrix membrane was done using continuous
6-0 polypropylene in two layers. Instillation of saline into the right ventricle demonstrated mild residual central regurgitation.
Next, a [Blank] mm annuloplasty ring was placed and secured in position with multiple interrupted 4/0 Prolene sutures from
the anteroseptal clockwise to the inferoseptal commissure and anchored in the coronary sinus. The cross-clamp was released
after [Blank] minutes with suction on the aortic root vent. Normal sinus rhythm resumed. The redundant right atrium was
excised and the atriotomy was oversewn in two layers of running polypropylene suture. Air was evacuated through the suture
line prior to securing it. Cardiopulmonary bypass was gradually discontinued with satisfactory hemodynamics on low-dose
epinephrine and milrinone infusions. Postcardiopulmonary bypass transesophageal echo demonstrated [Blank]. There was no
gradient across the tricuspid valve, and the atrial septum was intact. Decannulation was accomplished and surgical sites
oversewn with polypropylene suture. Protamine was administered. Hemostasis was achieved, and chest tubes were left in the
mediastinum and the right hemithorax. The sternum was closed with interrupted wire in the usual manner and the wound closed
in layers with absorbable sutures. The patient was transferred to the Cardiac Surgical Intensive Care Unit in a stable
hemodynamic condition.
All the instruments, sponges and needles counts were correct twice at the conclusion of the procedure.
27. Pediatric Lung Transplantation: Bilateral Sequential Lung
Transplantation
Muhammad Aftab, MD, Magdy M. El-Sayed Ahmed€ MD, Ramanan Umakanthan* MD,
Jeffrey S. Heinle*, MD
Baylor College of Medicine/Texas Heart Institute, Houston, TX,
€
Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA

4. Inspection of donor lungs by the procurement team.
5. Confirm the good quality of donor lungs.
6. Administer induction immunosuppressives and steroids
7. Start the recipient operation.
8. Bilateral transverse (clamshell) thoracosternotomy [Variation: Median Sternotomy].
12. Dual stage venous cannulation. (unless need to close PFO)
14. Check ACT >450.
17. Vent the main Pulmonary artery (PA).
18. Deflate both lungs, aspirate bronchial secretions.
19. Tobramycin irrigation of airways [Optional for colonized airways]
20. Start hilar dissection for recipient pneumonectomy.
21. Control the branch pulmonary arteries with atraumatic snares
22. Dissect pulmonary arteries in the pleural space and ligate distally beyond the first order bifurcation.
23. Transect the pulmonary arteries.
24. Ligate large bronchial collaterals.
25. Divide the pulmonary veins with vascular staples.
26. Aspirate instilled tobramycin irrigation and divide the bronchus.
27. Avoid any bronchial contents spillage in the pleural space.
28. Irrigate the pleural space with copious antibiotic irrigation.
29. Perform contralateral pneumonectomy in a similar fashion.
30. Confirm the donor-recipient ABO compatibility and size matching.
31. Prepare the donor lung.
32. Divide the main PA and transect the branch PA’s to the appropriate length. Divide left atrium and prepare the left
atrial cuff.
33. Staple and divide the left bronchus and place the right lung in the ice preservative solution.
34. Trim the donor bronchus up to one tracheal ring (within several mm) proximal to the bifurcation.
35. Lung in pleural space and keep cold with iced saline sponges.
36. Perform an end-to-end bronchial anastomosis using running absorbable fine monofilament suture on membranous
portion and interrupted on cartilaginous portion.
37. Clamp the base of donor pulmonary veins and the left atrial cuff, excise staple lines and create common orifice.
38. Construct an end-to-end left atrium to recipient pulmonary veins anastomosis using running fine monofilament
polypropylene suture.
39. De-air the pulmonary vein by instilling the cold preservative solution into the pulmonary artery.
40. Remove the clamp and snare the pulmonary veins.
41. Create an end to end pulmonary artery anastomosis using running fine monofilament polypropylene suture.
42. Keep the implanted lung cold and reprefuse both lungs at the same time [Variation: Re-perfuse the implanted lung.
We don’t use this technique].
43. Perform contralateral lung implantation in a similar fashion.
44. Start rewarming during the final anastomosis.
45. Remove snares and discontinue the PA vent
46. Aortic root vent to deair
47. Ventilate the donor lungs and perform bronchoscopy to clear the airway.
48. To avoid the reperfusion injury, slowly wean from cardiopulmonary bypass
49. [Note: Also avoid high FiO2, high PEEP and high airway pressures to avoid reperfusion/lung injury].
50. Use Inotropes, vasopressors, prostaglandins infusion and inhaled nitric oxide as needed [Optional].
51. Confirm the graft function, check the ABG and wean supplemental oxygen as tolerated.
52. Administer protamine and sequentially decannulate.
54. Place bilateral anterior and posterior chest tubes.
55. Re-approximate the ribs and sternal edges.
56. Standard wound closure.

1. Special attention should be paid to identify and preserve bilateral phrenic and vagal nerves.
2. The hilar dissection is extended into the pericardium by creating a pericardial slit posterior to phrenic nerves and
anterior to pulmonary veins. This exposure necessary in order to secure clamps and snares on the left atrium and
pulmonary arteries for creating the anastomosis.
3. Hilar vessels should be dissected to the branch pulmonary arteries into the lung parenchyma and securely ligated
beyond the first order bifurcation.
4. Any skeletonization of recipient bronchus by dissecting the area of bronchial bifurcation is avoided. The peri-
bronchial fat is preserved to maintain the blood supply of main-stem bronchus for new bronchial anastomosis.
5. Bilateral recipient pneumonectomy should be performed first before starting the donor lung implantation to avoid any
spillover of secretions into the implanted lung.
6. Avoid contaminaton of pleural space with bronchial secretions
7. During preparation of donor lung for the anastomosis, a careful attention should be paid to the anastomotic size,
identifying and orienting the hilar structures.
8. The appropriate donor to recipient size matching is crucial to early and long term successful outcomes of pediatric
lung transplantation. While the oversizing of the donor lung can cause compression atelectasis and pneumonia, under
sizing of the donor lung may result in chronic space problems.
9. During the entire process of implantation the lung should be kept cold within the thoracic cavity, wrapped in ice cold
saline sponges/laparotomy pads.
10. Both donor bronchi should be cultured, and all the secretions should be aspirated prior to performing the bronchial
anastomosis.
11. An end-to-end bronchial anastomosis is performed using running absorbable monofilament PDS (polydioxanone)
suture for the membranous portion and interrupted PDS sutures on the anterior cartilaginous portion. (Note: In case of
significant size discrepancy, consider telescoping Optional). I will sometimes telescope if there is a significant size
discrepancy
12. To create the left atrium to recipient pulmonary veins anastomoses, the pulmonary veins are cut open and intervening
tissue between two orifices is incised. Both vascular anastomoses are performed using fine monofilament, non-
absorbable sutures.
13. At the completion of suture lines both pulmonary artery and veins should be deaired and forward flushed and/or cold
saline should be instilled.
14. Special attention should be paid to presence of any pulmonary artery emboli which should be removed and
completely flushed out prior to completing the anastomoses.
Template Dictation
1. Cystic fibrosis
2. End-stage lung disease
1. Bilateral sequential lung transplantation with cardiopulmonary bypass support.
Drainage: Bilateral anterior and posterior chest tubes
Procuring Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: This is a [AGE]-year-old Caucasian boy with [DURATION] history of [COMPLAINT – e
cystic fibrosis with progressive and now end-stage lung disease.] He was listed for bilateral lung transplantation. Suitable
donor lungs have become available and he is felt to be an acceptable candidate for transplantation at this time.
The donor suffered a head injury following an ATV accident. There is good gas exchange in the donor lungs.
Operative Findings: There were minimal adhesions in the pleural spaces. The donor lungs were hyperexpanded. There was
mediastinal lymphadenopathy. The donor lungs were of good quality and good size match. The hilar structures were only
slightly larger than the recipient.
There was excellent early graft function, with PaO2 of greater than 200 on an FIO2 of 0.40 Both lungs inflated well and
appeared to be a good size match.
Description of the Procedure: After informed consent and patient identification, the patient was brought to the operating room
tube intubation, arterial and central venous monitoring lines were placed. The patient was positioned supine with the arms at
the side and the chest and abdomen were prepped and draped. After the donor lungs were visualized and confirmed to be of
good quality, we began the recipient operation.
A bilateral transverse thoracosternotomy incision was performed in the 4th intercostals space [Variation: 5t h Intercostal
space], dividing the mammary pedicles bilaterally. The thymus was divided and a pericardial well was created. The ascending
aorta was mobilized. The patient was then systemically heparinized and cannulated for the cardiopulmonary bypass using an
arterial cannula in the distal ascending aorta and a dual-stage venous cannula inserted through the right atrial appendage. Total
cardiopulmonary bypass was established and there was good venous return. The patient was cooled to a nasopharyngeal
temperature of 32 degrees centigrade. An active vent was placed in the main pulmonary artery. After instituting bypass both
lungs were deflated, the bronchial secretions were aspirated and tobramycin irrigation was instilled into the airways.
Bilateral recipient pneumonectomies were then carried out. The hilar dissections were performed, with care being taken to
identify and avoid injuring the phrenic nerves. The right pneumonectomy was performed first. The branch pulmonary arteries
were controlled with atraumatic snares. Within the pleural space, the pulmonary arteries were further dissected and ligated
distally beyond the first order bifurcation. The pulmonary artery was transected. The pulmonary veins were then divided
between vascular staples. The tobramycin irrigation was aspirated and the bronchus divided using electrocautery. Bronchial
vessels were controlled with hemoclips. Care was taken to avoid spilling bronchial contents into the pleural space. The lung
was removed from the field. Hemostasis was assured in the hilum. The pleural space was irrigated with copious amounts of
warm antibiotic saline irrigation. The left pneumonectomy was carried out in a similar fashion. Again, hemostasis was assured,
and the pleural space was irrigated with warm antibiotic saline irrigation.
By this point in time, the donor lungs were in the operating suite. ABO compatibility was verified. The donor lungs were
brought onto the field and prepared. Atrial cuffs were created. The main pulmonary artery was divided and the branch
pulmonary arteries were transected at an appropriate length. The left bronchus was stapled proximally and divided distally.
The right lung was placed back in the iced preservative solution. The left donor bronchus was trimmed to one tracheal ring
proximal to the bifurcation. The lung was placed in the left pleural space and kept cold with iced saline sponges. An end-to-
end bronchial anastomosis was performed using running 4-0 PDS suture for the membranous portion and interrupted 4-0 PDS
sutures on the anterior cartilaginous portion. Prior to completing the suture line, a suction catheter was advanced into the left
bronchus and placed on low continuous suction. A large vascular clamp was placed across the base of the donor pulmonary
veins, the staple lines were excised and the recipient pulmonary veins were opened creating a common orifice. An end-to-end
left atrium to recipient pulmonary vein anastomosis was then performed using running 4-0 polypropylene suture. Prior to
completing the suture line, cold preservative solution was instilled into the pulmonary artery to de-air the pulmonary veins.
The suture line was then completed. An atraumatic snare was passed around the pulmonary veins and the vascular clamp was
removed. An end-to-end pulmonary artery anastomosis was then performed using running 5-0 polypropylene suture. The suture
line was completed. The lung was packed in ice and attention was then turned to the right side. In a similar fashion, the right
lung was implanted. During the final anastomosis, the patient was rewarmed. A bronchoscopy was carried out by the
anesthesia team to clear the airway of secretions and confirm patency of the airways. The lungs were then ventilated. After
complete rewarming and institution of prostaglandin infusion and inotropic agents, the patient was slowly weaned from
cardiopulmonary bypass over approximately 15 minutes to avoid re-perfusion injury [Variation: Inhaled nitric oxide was
administered]. Both lungs inflated well and appeared to be a good size match. There was excellent early graft function, with
PaO2 of greater than 200 on an FIO2 of 0.40 [Variation: Initial saturations were in the high 80s to low 90s, but with time,
these improved, and prior to leaving the operating room, the PaO2 was greater than 120 mmHg on an FiO2 of 0.50]. Protamine
was administered and the patient was sequentially decannulated. Hemostasis was assured. The pleural spaces and
mediastinum were irrigated with copious amounts of warm antibiotic saline irrigation. The pericardial edges were loosely
reapproximated. Bilateral anterior and posterior chest tubes were placed. The sternal edges were reapproximated using
stainless steel wires. The rib edges were reapproximated using interrupted absorbable pericostal sutures. The muscle and soft
tissues were closed in multiple layers using running absorbable suture. The skin edges were reapproximated using a running
absorbable subcuticular stitch. Sterile dressings were applied.
Cardiopulmonary bypass time was [BLANK] minutes. Donor ischemic time was [BLANK] hours and [BLANK] minutes.
Suggested Readings:
1. Michler RE, Pediatric Lung Transplantation. In Kapoor AS, Laks H (eds). Atlas of Heart-Lung Transplantation;
McGraw-Hill, New York, NY; 1994, p 141-157.
2. Spray TL, Mallory G, Canter CE, et al. Pediatric lung transplantation: indications, techniques and early results. J
Thorac Cardiovasc Surg 1994; 107: 990.
28. Pediatric Heart Transplantation
Brody Wehman, MD, MSc and Sunjay Kaushal, MD, PhD
University of Maryland Medical Center, Baltimore, MD

1. Confirm suitability of donor organ
6. Open pericardium, create pericardial well
7. Systemic heparinization (400U/kg)
10. Myocardial protection cannula placement in aortic root
11. Confirm ACT > 400 sec
12. Initiate CPB (goal 2.0-2.5L/min/m2)
13. Moderate hypothermia (28o C)
14. Cross-clamp aorta
15. Recipient cardiectomy
16. Divide SVC
17. Divide IVC
18. Divide great vessels
19. Create left atrial cuff
20. Donor heart brought to the field
21. Inspection for injury
22. Atrial cuff and great vessels appropriately trimmed
23. Left atrial anastomosis
24. IVC anastomosis
25. Aortic anastomosis
26. LV vent placed via left atrial appendage to de-air left heart
27. Aortic cross-clamp removed
28. Pulmonary artery anastomosis
29. SVC anastomosis
30. Rewarm
32. Wean from CPB
36. Placement of atrial and ventricular temporary pacer wires
37. Blake drainage tube placement
38. Sternal closure

1. Cardiac injury during the sternal re-entry can result into massive hemorrhage (if re-do sternotomy).
2. PA should be appropriately trimmed and kinking of PA from excess donor PA
3. SVC stenosis from purse-string of anastomoses
4. Bleeding from posterior anastomoses
5. Injury to SA nodal tissue from excessive manipulation or short donor SVC
6. Inability to wean from CPB (consider ischemia-reperfusion injury, elevated recipient PA pressures, hyperacute
rejection/graft failure)
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. End-stage dilated cardiomyopathy]
Procedure(s) Performed: Bicaval, orthotopic heart transplantation
Procuring Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: The patient is a [AGE] year old [GENDER] with [DURATION]history of [COMPLAINT or
DIAGNOSISe.g. worsening shortness of breath, history of dilated cardiomyopathy]. The patient was initially treated
medically yet has developed progressively worse left ventricular dysfunction as evidenced by echocardiogram (ejection
fraction 20%) and cardiac magnetic resonance imaging which has been refractory to inotropic therapy. A suitable donor heart
is now available for heart transplantation.
procedure were verified, and the patient was placed on the operating room table in the supine position. General anesthesia
was obtained. Monitoring lines were secured. The patient was prepped and draped in the usual sterile fashion. Median
sternotomy was performed and the mediastinum was entered without any complications. Systemic heparin was administered.
Cannulation sutures were placed in the distal ascending aorta, the SVC and the IVC. The aortic cannula was then inserted,
secured and de-aired. The venous cannulae were then inserted and secured. Cardiopulmonary bypass was then initiated and
we cooled the patient to 28o Celsius. An aortic cross-clamp was applied and snares were secured around the SVC and IVC
cannulae. The recipient heart was next excised starting with division of the SVC, IVC, left atrium and finally the great vessels.
The donor heart was then brought to the field, inspected and appropriately trimmed. An ice pack was placed around the heart.
The left atrial anastomosis was performed with a running #5-0 polypropylene suture. Next, the IVC anastomosis was
performed with a running #5-0 polypropylene suture. The aorta was then anastomosed with a running #5-0 polypropylene
suture. Once completed, an LV vent was then placed in the left atrial appendage. The left side of the heart was subsequently
de-aired and the aortic cross-clamp was removed. The pulmonary artery anastomosis was next performed with a running #5-0
polypropylene suture followed by the SVC anastomosis, which was performed with a #6-0 polypropylene suture.
Upon completion of anastomoses the patient was completely rewarmed. Normal sinus rhythm was regained. Hemostasis was
ensured at each anastomosis prior to weaning from cardiopulmonary bypass. We separated from cardiopulmonary bypass with
low inotropic support. A test dose of protamine was administered and patient was monitored for adverse reaction before the
full protamine dose was resumed. Decannulation was performed and the cannulation sutures tied down. Hemostasis was
achieved. Temporary atrial and ventricular wires were placed and tested for appropriate capture. A total of [NUMBER]
Blake tubes were placed in the mediastinum and the [LEFT/RIGHT] pleural space. The sternum was re-approximated with a
total number of [BLANK] stainless steel sternal wires. The wound was irrigated with Betadine and antibiotic saline solution.
The fascia was closed with a running #1 Vicryl suture and the deep dermal layer with a running #2-0 Vicryl suture. The skin
and subcuticular layer was closed with a running #3-0 Monocryl. The skin was cleansed with sterile saline and dressed with a
Primapore dressing.
All instrument, sponge and needle counts were confirmed to be correct x2 at the end of the operation. The patient was
subsequently transferred to the post-operative cardiac surgical intensive care unit in critical condition.
Ischemic donor time was [BLANK] minutes and and cardiopulmonary bypass time was [BLANK] minutes.
*Size considerations: #5-0 polypropylene suture is used for left atrial, IVC and great vessel anastomoses and 6-0
polypropylene is used for the SVC anastomosis in infants and small children. However, the larger children and adolescents
generally required #4-0 and #5-0 polypropylene for the above-mentioned anastomoses, respectively.
This operative dictations guide was edited by the Thoracic Surgery Residents
Association (TSRA) and authored by more than 50 thoracic surgery residents from
programs around the country. The text was subject to 4 levels of peer review by
both residents and established faculty to ensure the accuracy of the published
material.
The book contains detailed descriptions, in a dictation template format, of
operations in the fields of General Thoracic Surgery, Adult Cardiac Surgery, and
Congenital Cardiac Surgery.
The TSRA is a resident-led organization which represents all thoracic surgery

residents in the United States.
TSRA
THORACIC SURGERY RESIDENTS ASSOCIATION
www.tsranet.org

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TSRA Operative Dictations in Cardiothoracic Surgery

David D. Odell, MD MMSc

Michael P. Robich, MD MPH

Thoracic Surgery Residents Association

DDO and DJL

Magdy M. El-Sayed Ahmed, MD

Anelechi Anyanwu, MD, MSc, FRCS

Andrew I.M. Campbell

Stephen D. Cassivi, MD, MSc

Frederick Y. Chen, MD, PhD

Jonathan D'Cunha, MD, PhD

Amy Fiedler, M.D

Charles D. Fraser Jr, MD

Michael E. Halkos, MD, MSc

John S. Ikonomidis, MD, PhD

Mathéau A. Julien, MD, PhD

Sunjay Kaushal, MD, PhD

Kemp Kernstine, MD, PhD

Damien J. Lapar, MD, MSc

Chaim Leker Locker, MD

Robroy MacIver, MD, MPH

Hari Mallidi, MD, FRCSC

Justin R. Van Meeteren, DO

Carlos M. Mery, MD, MPH

Francis C. Nichols III, MD

David D. Odell, MD, MMSc

Amit Pawale, MD, FRCS

Duc Thinh Pham, MD

Eitan Podgaetz, MD, MPH

Wissam Raad, MD, MRCS

Ramachandra Reddy, MD, MBA

John R. Spratt, MA, MD

Tom P. Theruvath, MD, PhD

Michael Tong, MD, MBA

Brody Wehman, MD, MSc

Samuel Weinstein, MD, MBA

Dennis Wigle, MD, PhD

Kenan W. Yount, MD, MBA

Essential Operative Steps

Potential Complications and Pitfalls

Essential Operative Steps

Potential Complications and Pitfalls

Essential Operative Steps

Potential Complications and Pitfalls

Essential Operative Steps:

Potential Complications and Pitfalls:

Essential Operative Steps

Potential Complications and Pitfalls

Essential Operative Steps

Potential Complications and Pitfalls

Essential Operative Steps

Potential Complications and Pitfalls

Essential Operative Steps

Potential Complications and Pitfalls

Essential Operative Steps

Potential Complications and Pitfalls

Essential Operative Steps

Potential Complications and Pitfalls

Essential Operative Steps

Potential Complications and Pitfalls