Discovering Coronary Artery Bypass Surgery – Step 5

Step 5: Decannulation and Thoracic Wall Closure

Introduction

To conclude this series on coronary artery bypass grafting (CABG), we address the final phase: decannulation and closure of the thoracic wall. This critical step involves closing the various layers to secure the surgical site, prevent infections, and ensure thoracic stability.

Cardiac surgery requires various sutures for the different layers involved in thoracic wall closure:

CLOSURE OF THE PERICARDIUM
CLOSURE OF THE STERNUM
CLOSURE OF THE FASCIA/MUSCLE
CLOSURE OF THE SUBCUTANEOUS LAYER
CLOSURE OF THE SKIN

Braided sutures provide high resistance but reduced glide properties, while monofilament sutures exhibit less inflammatory response and superior glide characteristics.

I. Removal of Cannulas and Closure of Openings

After weaning off extracorporeal circulation (ECC), the cannulas previously placed in the ascending aorta and right atrium are removed, and the openings are closed with purse-string sutures.

The sliding capacity and resistance of the Polytresse® 0 braided multifilament sutures (coated polyester braid) used in this step are of utmost importance.

II. Hemostasis Verification and Thoracic Drain Fixation

Following hemostasis verification, thoracic drains are positioned to quickly identify any intrathoracic bleeding and prevent cardiac tamponade, a potentially serious complication.
The drains must be securely fixed to the skin using sutures. Both monofilament (Filapeau® 2/0) and multifilament (Polytresse® 0) sutures are suitable, offering sufficient strength to withstand manipulation or traction during resuscitation. These sutures do not need to be absorbable. Hemostasis is then re-verified.

III. Pericardium Closure

The pericardium may be closed at the surgeon’s discretion using resorbable multifilament sutures (Optime® 2/0) or non-resorbable.

The lower portion of the pericardium is left open to allow drainage access to the pericardial cavity, should it become necessary during the procedure.

IV. Thoracic Wall Closure

1. A Crucial Step

The closure of the thoracic wall, particularly the bony layer, is a critical phase. As such, it must be performed meticulously to minimize the risk of complications such as sternal instability, dehiscence, or surgical site infection.

2. Sternal Closure

Stainless steel monofilament wires (Acier sutures) are used for their strength. The needle must ensure optimal penetration through the sternum, and the wires should have some elasticity to facilitate their tightening and securing. This elasticity reduces the risk of delayed wire breakage or bone tearing, as significant mechanical forces will be applied to the sternum during the postoperative period.

The number of wires depends on the sternum’s morphology and the surgeon’s preferences.

Alternative materials for sternal closure include titanium clips, resorbable sutures in PDS Advantime® 3/0 (monofilament polyglycolide-co-caprolactone), or sternal staples to avoid using steel.

V. Layer-by-Layer Closure of Superficial Planes

The layer-by-layer closure of the superficial planes (muscular, subcutaneous, and skin layers) is typically performed with resorbable multifilament sutures (Optime® 2/0 or 3/0) that provide optimal knot strength and tensile resistance. Their coating ensures tissue compatibility and optimal absorption time.

For the skin layer, the choice of suture material (resorbable or non-resorbable) and technique depends on the surgeon’s preference and the patient’s skin quality. Inappropriate suture or technique may result in wound dehiscence later on.

Conclusion

In conclusion, coronary artery bypass grafting, performed in several complex steps, represents a major advancement in the treatment of coronary artery disease.

From initiating extracorporeal circulation to the meticulous closure of the thoracic wall, every phase—heart opening, graft harvesting, clamping, anastomosis, weaning off ECC, and decannulation—is vital to ensure long-lasting and safe revascularization.

This rigorous process not only guarantees the restoration of optimal blood flow to the heart but also ensures the stability and protection of the thorax post-surgery. CABG thus offers patients a reliable and sustainable solution to improve their quality of life and reduce the risk of long-term cardiac complications, while underscoring the importance of maintaining a healthy lifestyle to prevent recurrence. ¹

FILAPEAU®

INDICATIONS:

FILAPEAU® sutures are intended for use to suture superficial cutaneous skin and in plastic surgery.

Class IIb Medical Device- CE 0459 – Manufacturer: Peters Surgical.