Right ventricular injury and pulmonary embolism: The perils of deep intramyocardial left anterior descending artery dissection in off-pump coronary artery bypass grafting.

An inadvertent vent in the right ventricle (RV) resulted during dissection of a deep intramyocardial left anterior descending coronary artery (LAD), during off-pump coronary artery bypass grafting (OPCAB), led to pulmonary artery air embolism and hemodynamic instability, requiring conversion to cardiopulmonary bypass (CPB) prior to repair. This required a special maneuver in positioning the patient to identify the RV injury and prevent the pulmonary air embolism.

Lung Retraction for Exposure of Lateral Wall Vessels in Off-Pump Bypass Grafting.

One of the major challenges in off-pump coronary artery bypass grafting (OPCAB) is ensuring adequate exposure of the lateral wall vessels. In most cases when the left pleura is opened during harvesting of the left internal thoracic artery , the lung frequently obscures the view. Reducing the tidal volume is practised by certain surgeons, which however in the presence of a single lumen tube affects both lungs and is best avoided in OPCAB. We describe a technique that allows adequate exposure of the circumflex artery and its branches without compromising the tidal volume.

Simple Extracorporeal Knot-Tying Technique in Minimal Access Surgery.

Extracorporeal knot tying is one of the challenges in minimally invasive surgery. The current aids are often associated with mechanical failures and application difficulties, a long learning curve, fraying of sutures, user errors, increased cost, and reduced haptic feedback. We describe a technique that is very conventional and uses a polytetrafluoroethylene pledget to lower the knot. Also, there is no contact between the suture and the instrument at any point, and therefore fraying and tearing of sutures is not an issue. The technique is simple and inexpensive and has an extremely short learning curve.