title: Subxiphoid multi-arterial OPCAB: surgical technique and initial case report.
abstract: BACKGROUND
  The surgical technique of transsternal coronary artery bypass grafting (CABG) has remained relatively stagnant for the past three decades. Unlike general and orthopedic surgery, cardiac surgery has made very little progress in converting our most common procedure into a minimally invasive alternative. Minithoracotomy techniques introduced in 1995 enjoyed a brief period of popularity but were inherently single vessel (LIMA-LAD) procedures and thus not an answer to the need for a less invasive multivessel operation. Totally endoscopic CABG has been performed in a small number of cases but the learning curve is very steep and the rate of conversion to open surgery remains high with only a few successful multivessel cases. There remains a great need for a less invasive approach that has the potential to graft all coronary targets without disturbing the chest wall and which can be performed by all current and future surgeons with acceptable hospital costs. A small subxiphoid incision has been used for single vessel grafting to anterior or inferior targets, but until now lateral wall grafting has not been considered possible. Development of a successful multivessel subxiphoid technique on the beating heart, including lateral wall grafting, is now reported in this article.
  
  
  METHODS
  Subxiphoid multi-arterial bypass grafting was performed on a 79-year-old male using commercially available equipment but modified surgical techniques. Instead of midline sternotomy, full exposure to the heart was obtained by four essential steps: (1) removal of the xiphoid process, (2) vertical lifting of the lower sternum, (3) caudal retraction of the diaphragm, and (4) spreading of the wound using a specific retractor to create an adequate working portal. Both internal mammary arteries were harvested for their full length as skeletonized conduits using only direct vision (headlight and loupes). Off-pump distal anastomoses to the left anterior descending (LAD) and first obtuse marginal branch of the circumflex (OMB-1) were performed using available stabilizer systems. The obtuse marginal was exposed using the Medtronic Starfish suction-positioner without any hemodynamic compromise. The wound was closed with a simple running fascial suture and the patient discharged on postoperative day 4 with no complications and no angina.
  
  
  CONCLUSIONS
  Most practicing surgeons are reluctant to perform multiple distal grafts through small incisions because of the difficulty in simultaneously mastering a host of new skills at the same time (robotics, endoscopics, beating heart techniques). The subxiphoid approach offers the potential to perform distal anastomoses to all regions of the beating heart with excellent exposure while utilizing the same skill sets that surgeons now possess. There is potential that further evolution of this technique will permit outpatient CABG while providing long-term clinical outcomes superior to coronary stenting.
authors.affiliation: Cardiothoracic Surgery, Hutchinson Hospital, Hutchinson, KS 67502, USA. mmlevinson@hsforum.com
authors.forename: Mark M
authors.initials: MM
authors.lastname: Levinson
mesh_terms: D000368:Aged; D047549:Coronary Artery Bypass, Off-Pump / Q000379:methods* / Q000639:trends; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods* / Q000639:trends