In a previous article, we discussed strategies for patients and their families to prepare for cardiac bypass surgery. This included tips and suggestions to reduce stress during the pre-operative consultation.
Details vary, but basics are basics.
While every cardiac surgery program is different and the details may vary, the general procedures are essentially the same. Some hospitals, particularly hospitals with large cardiac surgery programs, have specialty intensive care units designed specifically for cardiac surgery patients. Some surgeons prefer to perform more off-pump procedures, while others have specific protocols in place for rapid extubation, glucose control, fast-tracking for rapid discharge and cardiac rehabilitation.
In this article, we will talk about the one of the most stressful times for families and loved ones, the waiting period. Many surgical programs offer updates during the procedure to help reduce this worry, but it also helps to know more about the actual surgery process.
It also means that family members should feel confident enough to leave the waiting room to use the restroom, get a cup of coffee or take a lunch break without worrying that they will miss anything.
But, how long will surgery take? It depends on who you ask, and when the clock begins.
Many surgeons will cite “two or three hours” when speaking with patients and family. While this may be technically correct for the actual surgical time, it can cause undue stress and concern among family members. So – add two to three hours to this figure. This window covers many of the essential pre-surgical activities that take place before the surgeon makes his first incision.
The clock begins when the patient is wheeled away
For family members and friends, the clock starts ticking the moment their loved one is wheeled away, so that’s where we will start the countdown. Why is this important? If we don’t include the pre-surgical time in our operative estimates, family members are left glancing at their watches and worrying unnecessarily as the clock creeps past three to four hours.
The surgeon might just be getting started, but the family doesn’t know that. So it is helpful for people to know that once the patient leaves the room, there is a lengthy process ahead, before surgery ever begins. This process includes several final checklists – patient confirmations like the WHO safety checklist and final preparations to be completed. The blood bank will be notified of the patient’s arrival, along with the pharmacy. The anesthesiologist, the surgeon and other team members will come to see the patient in pre-operative holding to review much of the information and answer last minute questions.
The patient is then wheeled to the operating room. At this point, the anesthesiologist will start several intravenous lines for medication administration and hemodynamic monitoring. The patient may be given medication for relaxation or induction of anesthesia at this point. The patient will then undergo an extensive surgical scrub, with hair clipping as needed. The scrub is allowed to air dry for additional antibacterial effects, and additional monitors and electrodes are applied. A foley catheter with a temperature sensor will be inserted into the patient’s bladder.
Another checklist will be completed, with the surgeon and the rest of the surgical team. The patient will be draped and positioned for surgery and the surgeon will do a last minute review of cardiac catheterization films before heading out of the room to perform a lengthy hand-washing procedure. Photos of target lesions may be posted for reference during surgery, depending on the surgeon’s preference.
The anesthesiologist may place a transesophageal probe at this point. The surgeon’s assistant or a secondary surgeon may begin harvesting vein from the patient’s leg for use as conduit for bypass grafts.
When the surgeon completes his scrub, he will return to the operating theater where he will be gowned and gloved. The primary surgeon often checks the progress of the vein harvesting procedure as well as the quality of the vein removed before starting.
It is at this point, that he will make his first cut.
After the first incision
After the first chest incision, surgery usually proceeds fairly rapidly. The surgeon will isolate an artery from the chest, called the internal mammary artery to use as one of the grafts, and depending on the specifics of surgery (CPB or off-pump) will prepare the patient for cardiopulmonary bypass (CPB). Then the surgeon will inspect and repair the vein harvested from the leg. Excess tissue is trimmed off, and the vein is measured for an accurate fit (not too much tension, not too much slack). This can take anywhere from 20 to 45 minutes.
This is when the actual revascularization or ‘bypass’ portion of the operation begins. Sewing the bypass grafts, weaning from cardiopulmonary bypass, and completing the remainder of the surgery may take another one to two hours.
Surgery is over, now what?
Once surgery is completed, the surgeon will come and speak to waiting family and friends. The patient will then be transferred to an intensive care unit to recover from anesthesia and begin the post-operative healing process. Here the patient will be closely monitored by a team of people for those first critical hours after surgery.