Experience with the innovative Condor GoldLine surgical retractor system

Open coronary artery bypass grafting (CABG) is the gold standard for the treatment of significant main stem stenosis of the lesser coronary artery (LCA), symptomatic three-vessel disease with complex stenoses and symptomatic branch vessel disease with so-called main stem equivalent. The classic technique of coronary bypass surgery is via median sternotomy with the heart-lung machine (HLM).

This technique, which dates back to the 1970s, has been continuously refined, the first major change being the abandonment of the HLM (off pump CABG). With this technique, the heart is not temporarily replaced, but continues to beat and is only stabilised in the bypass connection area. The invasive and large approach of the median sternotomy is avoided in minimally invasive cardiac surgery (MICS). The intercostal approach, established in minimally invasive mitral valve surgery, is also suitable for coronary revascularisation. The MIDCAB (Minimally Invasive Direct Coronary Artery Bypass) procedure is a recognised surgical option in patients with isolated anterior interventricular artery disease (RIVA and its branches) [1]. It has been shown to reduce mortality and morbidity, particularly in multimorbid and elderly patients [2]. The original surgical technique has had limited success due to its limitation to isolated revascularisation of the RIVA and postoperative pain when using the first thoracic blockers for this procedure.

A new generation of surgical retractor systems achieves better visualisation of both the mammary for dissection of the main bypass vessel and larger areas of the heart for revascularisation. In addition, postoperative pain can be reduced by prioritising elevation of the ribs without excessive spreading of the intercostal space. The minimally invasive bypass surgery (MICS CABG) becomes possible in a larger number of patients due to the now possible multivessel MIDCAB surgery [3].

If the right coronary artery cannot be reached, the revascularisation can be completed by an intervention in the sense of a hybrid concept. Last year, we performed the MIDCAB/Multivessel operation in our clinic using the surgical retractor system. Condor® GoldLine retractor system. The Condor system is already established in other specialties such as abdominal surgery and orthopaedic surgery and is characterised by its variability. The system was specified for use in cardiac surgery. With adapted retractors and a partially self-centring, cranio-ventral traction direction, the exposure of the LIMA bed succeeds without relevant spreading of the intercostal space. With the Condor® GoldLine-retractor has a clear advantage over other systems: Thus, the combination of traction device and spreading of the intercostal space can be separated here - which is associated with less postoperative pain.

A double lumen tube is used for the operation to enable one-lung ventilation on the right. Good thermal management allows for immediate postoperative extubation. W Figure 1 presents the complete set of instruments for a MICS CABG operation - different blades are shown on the right depending on the patient anatomy. Patients are slightly hyperextended, positioned in a 30-degree right lateral position. The central holder is attached to the operating table to the left of the patient and as far cranially as possible. The single adapter with the already integrated traction device is connected to the central holder. The traction device is equipped with a mechanical locking handle and can bear heavy loads. This can be used to set the coarse traction direction for retraction of the upper rib. A wide variability of different retractors is available depending on the anatomy and patient size.

The special feature here is that the thorax can be opened with only one direction of traction. Due to the mobility of the ball joint, the traction device of the Condor retractor can be adapted to the given anatomy. (W Fig. 3a). There is no need to change different frame systems and all surgical steps can be carried out with the wound spreader system from Condor .

The adjustment of the mammary bed is made possible in most cases without spreading the intercostal space (W Fig. 3b). Only the thorax is raised. In some cases, for example in difficult anatomical conditions, an additional claw to caudalise the lower rib is possible (W Fig. 4). With this caudal claw, the LIMA can additionally be visualised up to the bifurcation (W Fig. 5). The operation is continued with the claws used so that no other retractor system is necessary in addition to the Condor system. We thus save time through unnecessary retooling and increase the degree of standardisation.

Minimal and finely adjustable spreading of the intercostal space is achieved by simply adjusting the direction of pull of the Condor® GoldLine-system. After opening the pericardium and inserting pericardial sutures, the anterior wall of the heart is visualised. The ramus interventricularis anterior (RIVA) is located and stabilised in the target segment. A tissue stabiliser is often used. The anastomoses are performed in the usual technique under shunt protection. After successful revascularisation of the anterior wall of the heart, the next target coronaries are exposed. After the exposure is removed, the flow is measured to check the bypass and the position of the conduit graft is checked (W Fig. 7). After insertion of a drain in the left hemithorax, intercostal infiltration with bupivacaine is performed for pain control. The intercostal space is adapted with two sutures, followed by fascial sutures, a subcutaneous suture and intracutaneous skin closure. Patients are regularly extubated in the operating theatre.

Figure 1_a) MICS CABG instruments, b) Condor GoldLine surgical retractor system for cardiac surgery.

Figure 2_Access and LIMA preparation. The approximately eight centimetre long incision is made in the fourth or fifth intercostal space on the left.

Figure 3_a) GoldLine-system for LIMA preparation. b) LIMAPreparationin skeletonised technique.

Figure 4_Thetensile force on both ribs is not dependent on each other.

Figure 5_If several connections are planned, an already harvested graft (vein or radial artery) is first anastomosed to the LIMA as a T or Y after systemic heparinisation.

Figure 6_Thestabiliser is mounted on an outrigger of the Condor- retractor. An extremely high degree of freedom of positioning is possible. Other, classic OPCAB stabilisers are also used.

Figure 7_By holding the pericardial hte and by rotating the heart or straightening or traction at the apex of the heart, the anterior wall (D1/RIM), the lateral wall (posterolateral branches of the RCX) and the periphery of the right coronary artery can be adjusted.

Surgical procedures include the following techniques: