Cardiothoracic Surgery: Open-Heart, Coronary Artery Bypass, and Thoracic Procedures

Objective. Students will identify cardiopulmonary bypass components, describe the scrub role during coronary artery bypass grafting, and demonstrate correct handling of cardiothoracic instruments and chest retractors.

Cardiothoracic Surgery: Overview and Scope

Cardiothoracic surgery encompasses procedures performed on the heart, great vessels, lungs, esophagus, and mediastinum. As a surgical technologist, you will encounter some of the most complex cases in any operating room setting. Meticulous instrument management, strict sharps accounting, and a clear understanding of your scope of practice are non-negotiable in this specialty.

Cardiopulmonary Bypass: What the Scrub Technologist Must Understand

Cardiopulmonary bypass (CPB) temporarily takes over the function of the heart and lungs, allowing the surgeon to operate on a still, bloodless field. The CPB circuit includes a venous reservoir, oxygenator, heat exchanger, roller or centrifugal pump, arterial filter, and tubing that connects to the patient via cannulae.

The perfusionist primes, operates, and manages the CPB circuit throughout the case. This is entirely outside the scrub technologist's scope of practice. Your role is to assist the surgeon in placing and securing the cannulae and to pass the appropriate instruments and sutures at each step. You do not adjust flow rates, set alarms, or manipulate the pump. Understanding the circuit layout helps you anticipate surgeon needs — for example, knowing that arterial cannulation of the ascending aorta comes before venous cannulation of the right atrium — but operation of the circuit belongs to the perfusionist.

Common cannulation sutures include purse-string sutures, typically heavy braided or pledgeted sutures, placed by the surgeon before cannulae are inserted. Have pledgets and the correct suture loaded and ready before this step begins.

The Sternal Retractor: Setup, Assembly, and Safe Passing

Median sternotomy provides access to the heart. Once the sternum is divided with a sternal saw, a Finochietto retractor (sternal retractor) is placed to spread the chest wall and maintain exposure throughout the procedure.

The Finochietto consists of two blades attached to a frame with a ratcheted spreading mechanism. Before passing the retractor:

1. Confirm that the ratchet is fully closed (blades at minimum separation).

2. Orient the retractor so the handle and ratchet mechanism face away from the operative field when placed — this prevents accidental activation and gives the surgeon unobstructed access.

3. Pass the retractor handle-first with the blades closed, verbally confirming "retractor passing" as you transfer it.

4. Never hand off the retractor with the ratchet in an open or partially spread position — uncontrolled spreading can injure tissue or contaminate the field.

At the end of the procedure, the retractor is released gradually. Sudden release of a fully spread retractor can cause hemodynamic changes. Anticipate this and have it ready to receive back onto the field.

Coronary Artery Bypass Grafting: Scrub Role Step by Step

Coronary artery bypass grafting (CABG) restores blood flow past blocked coronary arteries using conduit vessels — most commonly the saphenous vein from the leg or the internal mammary artery from the chest wall.

Vein harvesting occurs simultaneously with chest opening in many cases, with a second team at the leg. If you are scrubbed at the leg, you will handle vascular clamps (DeBakey, bulldog clamps), vessel loops, and fine vascular suture. Keep all instruments on the field organized, and announce every needle on and off the field.

Anastomosis — the connection between the graft and the coronary artery — requires fine suture, typically polypropylene (Prolene), often sizes 6-0 or 7-0, double-armed (a needle at each end of the suture strand). Handle double-armed suture carefully: load one needle into the needle holder, secure the second needle safely with a clip or in the suture packet edge, and keep it visible at all times. Passing both needles correctly and accounting for both throughout every suture exchange is mandatory.

Needle Accounting in Cardiothoracic Surgery

Needle accounting failures are a leading cause of retained surgical items. In cardiothoracic surgery, where multiple fine double-armed sutures are used sequentially, the risk is significant.

Rules that apply at every suture exchange:

Count both needles of every double-armed suture before, during, and after use.
Use a suture needle counter/mat; each used needle goes directly onto the counter after the surgeon finishes with it.
Never pass a suture to the surgeon without accounting for the previous suture's needles first.
If a needle is missing, immediately inform the surgeon and the circulator; do not proceed until the needle is found. This is a patient safety stop.

Thoracic Procedures: Brief Overview

Thoracic procedures — such as lobectomy (removal of a lung lobe), pneumonectomy, and wedge resection — may be performed open or thoracoscopically (video-assisted thoracoscopic surgery, VATS). In open thoracic cases, a Finochietto or similar rib retractor provides exposure through a lateral thoracotomy incision. Chest tubes are placed at closure; have the correct size ready along with a water-seal drainage system.

Safety Priorities for Cardiothoracic Cases

Maintain strict sterile technique throughout; these cases are long, and vigilance must not lapse.
Confirm all instrument, sponge, and needle counts at each count interval and before chest closure.
Know the location of every sharp on the field at all times.
Communicate clearly and calmly with the surgeon, perfusionist, and circulator.
Never exceed your scope: if the perfusionist asks you to touch the bypass circuit, decline politely and notify the surgeon.

Key terms9

Cardiopulmonary bypass (CPB)A technique that temporarily assumes the function of the heart and lungs during cardiac surgery, using a mechanical circuit managed exclusively by the perfusionist.

Finochietto retractorA self-retaining sternal or rib retractor with ratcheted blades used to maintain chest wall exposure during cardiothoracic procedures; must be passed with the ratchet fully closed.

AnastomosisA surgically created connection between two tubular structures, such as a bypass graft and a coronary artery, typically performed with fine vascular suture.

Double-armed sutureA suture strand with a needle swaged onto each end; both needles must be accounted for individually throughout every exchange.

Polypropylene (Prolene)A nonabsorbable monofilament synthetic suture material commonly used for vascular anastomoses because of its smooth passage through tissue and minimal tissue reactivity.

PerfusionistA certified clinical professional responsible for operating the cardiopulmonary bypass circuit; this role is outside the surgical technologist's scope of practice.

CannulationPlacement of a tube (cannula) into the aorta and right atrium to connect the patient to the CPB circuit; the surgeon places the cannulae with the scrub technologist providing instrument and suture support.

Saphenous vein graftA segment of the great saphenous vein harvested from the leg and used as conduit to bypass a blocked coronary artery in CABG.

Retained surgical item (RSI)Any instrument, sponge, needle, or other item unintentionally left inside a patient after closure; prevented by systematic counting protocols at every required interval.

In class: Instructor demonstrates setup and identification of cardiopulmonary bypass circuit components using a diagram and physical tubing samples, emphasizing the perfusionist's role and where the scrub technologist's responsibilities begin and end. · Students practice assembling and disassembling a sternal retractor (e.g., Finochietto) and demonstrate correct passing technique to a partner acting as surgeon, verifying ratchet orientation before each pass. · Groups simulate a vein-harvesting portion of CABG on a limb model, practicing correct handling of vascular clamps, passing of fine vascular suture (double-armed), and needle accounting at each suture pass.
Materials: Cardiothoracic instrument tray; Finochietto sternal retractor; CPB circuit diagram and tubing samples; vascular clamp set; fine vascular suture samples (e.g., polypropylene); limb model; suture needle counter
Check: Instructor observes each student correctly assembling the sternal retractor and passing it in proper orientation, then passing three vascular sutures with correct needle accounting; errors in needle accounting result in automatic repeat before credit is given.

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.