Where is the left internal mammary artery located
How to harvest the left internal mammary artery (LIMA) : Part 1
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welcome to another video from the heart
factory today we'll be discussing about
the technique to harvest the left
internal mammary artery especially for
the students and Venus now there are two
ways of harvesting the left internal
mammary artery the first one is called
the pedicle technique the second one is
called the silk nice technique
now the pinnacled in other words means
that you will be harvesting the left
internal mammary artery along its wing
fascia muscle and fat and if need be
after harvesting the artery you you can
or you may certain eyes it after
harvesting whereas the skeletonized
technique means that the only the artery
is harvested in situ leaving the veins
fascia and muscle intact now the first
part is to open the pericardium this I
guess is quite important though some
surgeons may not agree with me and some
do not open the pericardium to just
Holliston average erect and then open
the Ricardian I think if you open the
belly column you'll be able to assess be
enacted well now the shoe respect is
quite important always preserve the fat
pad on yota help you closure assess the
distance especially the LED and the
diagonal that's the category way the
lima would be going to feel for the
already low finally calcification of
glass etc Alfred the pulmonary artery
which is a measure of every function
I'll bet the i sinning iota look for any
big glass though everybody diode is this
time that you do
and once you went to Russia with Anatomy
you'd get to need to harvest is a
peninsula memory actually so what I'm
doing here is putting a mop on the right
side of the divider stone idea what the
dish was the surgeon side now what it
does is the little building that may be
occurring from that mousse sternal table
is taken care of by the small and the
second advantage ease in case of women
with well tell oppress the mob if pulled
and fixed to the drapes will push the
breasts back to the thoracic cage they
by giving a good you know remember ERT
large press usually interview op2 member
ahartry now open the inter mammary
artery retractor the catch-all relief
the left side of the stomach develop
while depressing the right side of this
tunnel table now I am pulling the the
more but fixing it to the drapes day by
if there's a breast that will be fragile
at that point in time now adjust the
catch for and you should not be
attracting too much you can always
adjust the table by by getting the table
up and away from you to view the
definitely mammary artery now this is a
bit of philosophy that is coming between
the cat's paw this will take care of any
little bleeding that may be arising from
the left sternal table mind you despite
good use of wax is always some water
dribbling there a boss back at the top
end would also take care of any bleeding
that may be occurring from the mandible
Olivia
especially after her polarization now
this is another view of the same cause
that I'm trying to put across the bone
marrow of the divider sternum close the
left side and this will go towards
diamond obliques so the first part of
the dissection stars but let me section
just below the sternothyroid muscle
mind you there's a lot of loose yellow
tissue here and blood lead is acting
with rapidly create a space
now once that's done gently run the day
attorney and what you see is that is the
timing branch of the internal mammary
artery as you can see here the timing
branches very nicely seen no we have to
divide that artery now finding this
artery means two things first is we'll
be dividing it and second this artery
after division will define the plane
between the internal mammary artery and
the Bluebird
so once the artery is divided we tend to
dissect along that line live there for
bringing the pleura down from the
thoracic cage of the inverted Isaac
ratio the Lima is or runs between the
costal cartilage and the endo thoracic
fascia up to the third intercostal space
and then is covered by the transverse
esterases muscle from there down to the
sixth or seventh intercostal space now
as we are trying to run the fluid down
from the thoracic cage you will find
some named branches like this one which
has to be clipped you can cut that will
be a pretty decent way of doing it as it
preserves the collateral circulation
now once the pleura is detected away
from the thoracic cage certain branches
are really seen at the top and
especially within the fat so you may
have to find them and divide them
between that
so once that's done you will see the
left internal mammary artery nearly
seems so this is the left internal
mammary artery behind the inter classic
fascia and the transversus Telesis
muscle mind you are jesting the table a
bit higher at a higher level and then
moving them away from you will
definitely bring the view of the mammary
artery in a good way
now this technique is called the hydro
dissection now what does this hydro
direction dissection do is I'm injecting
saline or sometimes - I say light within
the infographic fascia and the
transversus Colossus muscle basically
this a line is infused under pressure
between the costal cartilage and the
face yeah so the logic here is to bring
or create a plane between the mammary
artery and the path of accolades so this
is a age-old technique when described in
annals of thoracic surgery the link of
which you find in my youtube channel
mind you you should not be entering the
mammary artery all the way unless that's
small bleeding will be some headache
while harvesting so after we're after
doing this inflating the area between
the costal cartilage and in the thoracic
pressure you find that varies or the
swollen area along the internal mammary
artery that's nothing but the internal
memory actually along with we're under
pressure now you can start by selecting
the actualization of the internal
mammary artery
fee for the g5 process and divide the
transversus versus muscle now the
transversus muscle has to be divided to
see the left
are true now as you can see the machine
isn't a bit of tension so as I run my
data me you'll see the internal mammary
artery on the costal cartilage behind
and the muscle is being separated from
the internal mammary artery there is no
need to remove the muscle and throw it
away after harvesting the mammary artery
the same thing applies to the fish and
the fascia is supposed to be there
so our technique is to separate the
transverse esterases muscle and be in
the thoracic fish from the internal
mammary artery to begin before
harvesting they will not watch it what I
mean is you can see here I'm separating
the plant source of classes fascia away
from the internal exactly there is
definitely a plain day so the if you
strike the fish and the mussel away from
the internal mammary artery and then try
to separate it from the internal mammary
artery you will definitely get a plane
which is quite safe without injuring the
internal Yahtzee so as you can see here
the whole length of internal mammary
artery is exposed the face here or the
internal mammary artery proximally and
the muscle or the internal memory or
traditionally has been separated from
the artery which is unlisted or lying as
it is on a spit so we're just moving the
artery away from the fascia and allowing
the fascia to sit there now what happens
is this piece here I'm the muscle will
protect because the ROI of the harvest
in the internal mammary artery which you
will see at the end of this vini
now the internal mammary artery is is
loosely added into because we fertilize
approximately or I would rather say at
the monopoly area them are there is lot
of lousier tissue and you can definitely
find the space between the mammary
artery and the manubrium other costal
cartilage so if you start by sitting
there you'll definitely find branches
which can be clipped you can then cut
if you clip clip and cut they are the
mammary artery branches the collateral
circuit is well preserved this is
scientifically established make sure
clipping is smooth and if the tripping
is rough you made them to disagree on
Navaratri so as you clip a pen cut them
the branches whilst working towards the
distal end of the internal mammary
artery the way the mammary artery keeps
on flowing so my new the artery is still
flowing and you're dissecting it inch by
inch towards its distal end which would
be the superficial a previously and the
muscarinic artery so anatomy say is that
the lower third of the sternum and the
xiphoid process has less vascularity so
it has been already suggested that
leaving the bifurcation intact we
preserve the lower end of the sternum
all will provide good supply to the
lower end of the salon by means of an
estimate it flexes but every surgeon has
his or her view we usually tend to
divide the superior the mammary artery
after its bifurcation into these two
branches now once major part of the
artery is exposed whilst you are trying
to free them away from the face here
you'll find certain branches coming into
view these are the lateral interpersonal
branches so mind of every intercostal
space will have interpersonal branches
and once they are divided you'll see
there are three easy freely separating
itself from the fascia so this fresh air
has to be left in place I guess that is
a good technique that tissue traumas
very less and the fascia will remain in
situ what it does is as you can see the
bread of the internal mammary artery is
quite clean it's just the preoperative
low molecular weight heparin that's
causing a bit of redness there but apart
from that v the field looks clean
so once the mammary art is harvested by
this technique you have enough length on
the left internal mammary artery and and
the literature also suggests that the
flow of this type of mammal
is better than the predicate one so we
usually tend to get the mammary arteries
distally some surgeons tie it you can do
whatever you like and then do I be
mammary artery so topical administration
of this other letters especially paper
were in seems to dilute the internal
mammary artery I guess by stimulating
the period rotation sympathetics so once
you are done with this one or you can
divide it distally and your arteries
ready for use now always be
approximately for the latter cost
largely it's a rare occurrence I don't
fight a 15-person but if we present has
to be divided without fail now coming
through the basics of this technique is
you can see the fascia and the muscle
there this fascia and the muscle whilst
closing the chest will cover the raw
area of the internal mammary artery it
is very clearly seen this is what is
basis of surgery is I guess this will
give rise to less post-operative
drainage along with just you and less
paresthesia patient will not complain
more of paresthesia in the
post-operative period say six months to
eight months in time so ladies and
gentlemen I guess you should give a try
to this way of harvesting a little
manually actually leaving the fascia and
muscle in situ this technique of
harvesting the left internal mammary
artery is less traumatic this less
tissue trauma you live in the frisian
muscle behind which covers the raw area
this less post-operative Danish you get
good memory with the excellent flow
initially the memory maybe inspires him
and we may not get the flow that may be
as good but in a period of time say 10
to 15 minutes the mammary
dilates by itself I am the flow will be
excellent for use on the left hand to
addition exactly so ladies and gentlemen
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