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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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