Tetralogy of Fallot | Sternotomy, Pericardiotomy and Purse String Sutures. скачать в хорошем качестве

Tetralogy of Fallot | Sternotomy, Pericardiotomy and Purse String Sutures.

This patient has Tetralogy of Fallot requiring surgical repair. The operation starts with a midline sternotomy. The patient's sternum is divided in the midline with a sternal saw from below upwards. The space behind the sternum is gently packed with sterile surgical gauze and the cut surface of the periosteum of the sternum is treated for haemostasis. A sternal retractor is used to distract both halves of the sternum. The portion of the thymus gland overlying the aorta and the pulmonary trunk is removed to facilitate surgical access. Before that, the pleura overlying the front of the pericardium is cleared out to the sides. Then a subtotal thymectomy is performed. Once the bulk of the thymus gland has been removed, the aorta and pulmonary trunk are clearly visible beneath the underlying pericardium. The pericardium is opened for access to the heart and great vessels. It is opened vertically, just slightly to the right of center. The upper corner of the pericardiotomy is extended to the pericardial reflection at the ascending aorta. The pericardiotomy is then taken down to the surface of the diaphragm where it is extended to the left and to the right, producing a T-shape. The edges of the pericardiotomy are then secured to the skin wound with silk stay sutures. The pericardial pledgets used in the repair of the ventricular septal defect are harvested. Double-ended sutures have their needles passed through the pericardial edge, are pulled through and secured. The process is repeated four more times. The pericardium is cut out around the sutures, producing five pledgeted sutures for use during the ventricular septal defect repair. The freshly cut edge of the pericardium is then treated with diathermy for haemostasis. The interarterial plane between the aorta and the pulmonary trunk is opened. The ascending aorta is drawn slightly forwards and off to the left. This is the right atrium and this is the superior vena cava. Where the right pulmonary artery runs behind the superior vena cava, the pericardium is incised. The tip of a right angled forceps is passed behind the superior vena cava through the incision in the pericardium and used to plumb a path for the superior caval snare. A braided, absorbable purse string suture is placed high in the front of the ascending aorta, around the intended sight of cannulation. The cannula for return of oxygenated blood from the cardiopulmonary bypass machine will be placed through this purring suture. The right atrial appendage is drawn downwards to expose the cannulation site on the superior vena cava. A purse string suture is placed around the intended site of cannulation, just below the level of the superior caval snare. The drainage cannula for the superior vena cava will be placed through the purse string. A purse string for the inferior vena cava is placed just above the superior cavoatrial junction. Another drainage cannula will later be placed through this purse string: the second venous drainage cannula for cardiopulmonary bypass.