[HSF] shent introducer ?

Tea Acuff tacuff at swbell.net
Sun Mar 7 12:14:03 EST 2010 

We shouldn't?
tea




________________________________
From: Prasanna Simha M <prasannasimha at gmail.com>
To: OpenHeart-L <OpenHeart-L at lists.hsforum.com>
Sent: Sun, March 7, 2010 11:21:30 AM
Subject: Re: [HSF] shent introducer ?

Of course.
I was asking since you mentioned the right lesion but then there is no point
grafting a vessel so small that it would occlude by the time you send him
home !!
Prsanna

On Sun, Mar 7, 2010 at 10:49 PM, <hgrmd at aol.com> wrote:

> Prasanna,
>  Didn't want to belabor the post by mentioning he had a chronic
> thrombocytopenia (50k).  The proximal was to the descending using a side
> biter.  A preop CT with contrast provided assurance that the aorta wasn't
> too heavily diseased. I did it through a standard thoracotomy, so I was
> loathe to add more incisions.  Besides, the right wasn't much of a target.
>  As they say, "sometimes less is more".
>
> Hal
> Sent from my Verizon Wireless BlackBerry
>
> -----Original Message-----
> From: Prasanna Simha M <prasannasimha at gmail.com>
> Date: Sun, 7 Mar 2010 22:27:32
> To: OpenHeart-L<OpenHeart-L at lists.hsforum.com>
> Subject: Re: [HSF] shent introducer ?
>
> Hal what did you do for the right ? Probably taking V.Subramaniam's cue a
> gastroepiploic to the right would have been an enticing thought if the
> artery was worth grafting along with your OM graft through a thoracotomy. I
> have seen him doing  grafts through 2 seperate incisions when the redo risk
> was considered very high usually a left thoracotomy approach for the
> OM's/LAD and a right or transabdominal approach for the RCA/PDA and PLV's.
> Minimal dissection towards the target artery (the adhesions themselves act
> as a good stabilizer) seems to allow for such operations to be done more
> easily than traditional redos.
> How did you do your proximal to the descending thoracic aorta  ? side clamp
> or did you use the subclavian artery as inflow ?
> Prasanna
>
> On Sun, Mar 7, 2010 at 10:09 PM, <hgrmd at aol.com> wrote:
>
> >
> > Michael,
> >  I tend to agree with Prasanna.  I've read your posts for a few years
> now,
> > and you generally are down on anything other than traditional approaches.
> >  It's more of a stance that I would expect from someone my age, not
> yours.
> >  I think we can all agree that our specialty is in deep trouble.
>  Innovation
> > is crucial if we are to remain relevant.  Granted, there will probably
> > remain a few cases that require median sternotomy, arrested heart, etc.,
> but
> > do you really think the bulk of the cases will be done this way in 20
> years?
> >  Maybe they will, but don't be surprised if they aren't.
> >  As for me, I'm trying to safely innovate as best I can.  Last Friday, my
> > first case was a 62 yo dialysis patient with medically unmanageable
> angina
> > who had a widely patient LIMA to the LAD whose pedicle was redundant and
> > perilously close to the sternum.  He had a chronically occluded right,
> and a
> > tight left main supplying a huge OM.  Through a left thoracotomy, I did
> an
> > off pump vein from the descending aorta to the OM.  Though I know this is
> a
> > well known technique, I guarantee you lots of surgeons would have either
> > turned the case down or done a  full sternotomy redo.  I'm not patting
> > myself on the back, but I can guarantee you that this procedure didn't
> even
> > exist when I was training.
> >
> > Hal
> >
> >
> >
> >
> >
> >
> >
> >
> >
> >
> > -----Original Message-----
> > From: Michael Firstenberg <msfirst at gmail.com>
> > To: OpenHeart-L at lists.hsforum.com
> > Sent: Sat, Mar 6, 2010 10:50 pm
> > Subject: Re: [HSF] shent introducer ?
> >
> >
> > I am not anti-everything.
> >  just like to argue (debate?) - in part because sometimes some of the
> stuff
> > hat comes across here is written in a way that suggests than anyone that
> > does
> > x" is a great surgeon and anyone who does "negative x" or less than "x"
> > should
> > e put out to pasture.
> > I just like discussing some of the cons to the approaches that people
> > ake........
> >
> > -michael
> >
> > n Mar 6, 2010, at 10:41 PM, Prasanna Simha M wrote:
> > > Michael, it is not a my incision is bigger than yours or whatever.
> People
> >  like it or not like to have smaller incisions. Reduce incision size ,
> > reduce
> >  stretch and secondary injury etc etc are realities which we need to
> attend
> >  to or strive to do  However this should not be at the cost of safety and
> >  outcomes. I heard these same arguments when Lap procedures were
> advocated
> >  but they have found a definitive place.There are anatomical constraints
> > with
> >  the chest compared to the  abdomen but if I could avoid getting the
> > sternum
> >  cracked open why not ? Also there will be people pushing the boundaries
> of
> >  science and investigation and we need to have them or else we will not
> >  improve. You say men with chest hair - it is unnoticable etc but check
> out
> >  your patients with these scars and see where they button up their shirts
> > and
> >  dresses to. Ask the lady whether she likes having a scar cutting up
> across
> >  her blouse line -she will subtely wear a closed neck dress and so on and
> > so
> >  forth. I bet they (at least most of them) don't parade that scar like a
> >  masochistic trophy.
> >  Also if you are taking down bilateral IMA's why not spare the sternum if
> > you
> >  can if it is a reproducible technique ?
> >  You seem to be anti anything but full incision surgery. I am not so sure
> > why
> >  but I can tell you that  if you do hemisternotomies without lateral
> cuts,
> >  they actually interlock rigidly and have less pain and get out home
> > earlier
> >  (and home for many of us in other parts of the world is usually 200 -500
> > kms
> >  away and sometimes even 3000 kms away and not to an SNF/nursing home or
> >  whatever). If we can significantly reduce morbidity why not ?
> >  Having said all that  I still am curious how the "shent" introducer was
> >  made. It looked elegant.
> >  Prasanna
> >
> >  On Sun, Mar 7, 2010 at 8:25 AM, Michael Firstenberg <msfirst at gmail.com
> > >wrote:
> >
> > > oh here we going again - my incision is smaller than yours.
> > > Granted children are different (or are they????? since they will heal
> > > anything)
> > >
> > > Many patients within a month or so, particularly men with chest hair,
> the
> > > incision (if closed properly) is barely noticeable.  However, the
> > scapular
> > > pain and the pain from broken ribs and torn ligaments/cartilage lasts
> > > longer........
> > >
> > > -michael
> > >
> > >
> > >
> > >
> > > On Mar 6, 2010, at 9:17 PM, Prasanna Simha M wrote:
> > >
> > >> People do get 1 foot long incisions !! I have seen people doing it
> > >> regularly.
> > >> I have done transxiphoid pericardiectomies for children with
> > > pyopericardium
> > >> and was surprised at the amount of exposure  that it affords.
> > >> The sternal sparing is a definite advantage but I am not so sure if an
> > > upper
> > >> abdominal incision is less painful. The upper abdominal  incision is
> > >> considered more painful than a sternotomy or a lower abdominal
> incision
> > >> though various blocks and pain control measures can obviate that.
> > >> Prasanna
> > >>
> > >> On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu <anianyanwu at hotmail.com>
> > > wrote:
> > >>
> > >>>
> > >>> Amazing the exposure one can get from the subxiphoid approach - Mark
> > >>> Levinson has really pushed the frontier on minimally invasive CABG
> here
> > > as
> > >>> sparing sternotomy AND thoracotomy can potentially be a real benefit,
> > as
> > >>> then in terms of trauma not much difference from an upper GI
> operation
> > > and
> > >>> very little limitation on post operative physical activity once pain
> > > settles
> > >>> (assuming the sternal retraction is not disruptive or destructive in
> > any
> > >>> way).
> > >>>
> > >>>
> > >>>
> > >>> One comment though is that not very factual as stated on the website
> > > that
> > >>> conventional CABG incision is 12 inches long. Surely incisions have
> not
> > > been
> > >>> that long in decades?
> > >>>
> > >>>
> > >>>
> > >>> Ani
> > >>>
> > >>>
> > >>>
> > >>>
> > >>>> Date: Sat, 6 Mar 2010 21:30:44 +0530
> > >>>> From: prasannasimha at gmail.com
> > >>>> To: OpenHeart-L at lists.hsforum.com
> > >>>> CC: mmlevinson at mac.com
> > >>>> Subject: [HSF] shent introducer ?
> > >>>>
> > >>>> http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html
> > >>>> What is that device that you used to push in Don's "Shent" Is it
> made
> > > of
> > >>>> ordinary steel wire ?
> > >>>> Prasanna
> > >>>>
> > >>>> --
> > >>>> Prasanna Simha M
> > >>>> _______________________________________________
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> > >>
> > >>
> > >> --
> > >> Prasanna Simha M
> > >> _______________________________________________
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> > >>
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> >  --
> >  Prasanna Simha M
> >  _______________________________________________
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> --
> Prasanna Simha M
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-- 
Prasanna Simha M
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