CardioSurgeon.co.uk
Who is in the operating room during surgery?
During your heart operation, a highly skilled and experienced team works closely together to keep you safe and ensure the procedure goes smoothly. The cardiac surgeon leads the operation and performs the most important parts of the surgery, supported by assisting surgeons who help with precision and efficiency. A specialist cardiovascular anaesthesiologist and specialist anaesthesiology practitioners carefully manages your anaesthetic, making sure you are fully asleep, pain-free, and stable throughout the procedure, continuously monitoring your heart, blood pressure, oxygen levels, and breathing, adjusting medications as needed, and oversee the ventilator, which supports your breathing during surgery.
If your operation requires it, a perfusion specialist operates the heart-lung machine, which temporarily takes over the work of your heart and lungs so the surgeon can operate safely on a still heart. Throughout the procedure, specially trained theatre nurses play a vital role, preparing instruments, maintaining a sterile environment, and anticipating the needs of the surgical team. All members of the team work in close coordination, communicating constantly and focusing entirely on your safety and the best possible outcome.
In a large teaching hospital such as Oxford University Hospitals NHS Foundation Trust, when your operation takes place under NHS, some parts of your care may also involve the training and education of junior doctors and other healthcare professionals. This is an important part of maintaining high standards of care for the future. You can be reassured that all aspects of your operation are carefully supervised at all times by fully accredited and experienced senior staff, who remain responsible for your care throughout. For private patients, training is not part of the procedure, and all steps of the operation are performed directly by accredited senior healthcare professionals.
Your care is always centred around safety, expertise, and trust. From the moment you enter the operating theatre to your recovery afterwards, you are supported by professionals who are committed to your wellbeing, dedicated and able to deliver the highest standard of care, ensuring that you and your loved ones can feel reassured and confident every step of the way.
Having a General Anaesthetic
Anaesthesia for cardiac surgery in the modern era is very safe, thanks to major advances in monitoring, medications, and specialist training. Before your operation, you are carefully assessed to ensure the anaesthetic plan is tailored specifically to you. Highly sophisticated equipment and protocols are used to manage even complex cases safely. While no procedure is completely without risk, serious complications related to anaesthesia are now rare, and for most patients, it is a well-controlled and carefully managed part of their overall care.
The exact type of anaesthetic you are given depends on the procedure you are having and you can find more information regarding the anaesthesia here. For most operations, anaesthesia is started by injecting a drug into your vein. Within seconds you will fall asleep and won’t wake up again until after your operation is completed. This is known as the ‘induction’ of anaesthesia. It is also possible to bring about anaesthesia with anaesthetic gases, breathed through a face mask. Your anaesthetist will decide what is best for you and will stay with you during the operation.
To keep you asleep, you will be given a mixture of oxygen and anaesthetic gases through a flexible tube put into your windpipe. This part of anaesthesia is known as ‘maintenance’. During the operation, you will be connected to machines that monitor the activity of your heart and other bodily organs. Your anaesthetist will keep a close check on your heart rate, blood pressure, and the amount of oxygen in your bloodstream.
The heart-lung machine is also called a cardiopulmonary bypass machine. It takes control of blood flow around the body during the operation by replacing the heart’s pumping action and by adding oxygen to the blood. This helps the heart to remain stationary for the operation, which is necessary when the heart has to be opened (open heart surgery). Because the heart-lung machine takes over the work of the heart, a surgeon can more easily operate as the heart is not moving or full of blood.
The heart-lung machine carries blood from the right side of the heart (the right atrium) to a reservoir within the machine called an oxygenator. Inside the oxygenator, oxygen is bubbled through the blood allowing it to enter into red blood cells. This causes the blood to turn from dark (oxygen-poor) to bright red (oxygen-rich). A filter then removes the air bubbles from the oxygen-rich blood, and the blood travels back to the body’s main blood vessel, called the aorta. The aorta supplies the newly oxygenated blood to rest of the body in a continuous process of blood circulation. Specially trained technicians called perfusion technologists (blood flow specialists) make sure that the heart-lung machine does its job properly during the surgery. In addition, modern techniques such as mini cardiopulmonary bypass systems (essentially a smaller, more refined version of the heart-lung machine) can be used in selected cases and can be particularly beneficial for patients of smaller body size and weight.
During many heart operations, particularly complex procedures such as aortic surgery where extra protection of the brain and spinal cord is required, the body is gently cooled while on the heart-lung (bypass) machine. Lowering the temperature reduces the body’s metabolic demands, meaning organs (especially the brain and heart) require less oxygen and are better protected during periods of reduced blood flow. In most cases, the heart is temporarily stopped once the patient is safely connected to the bypass machine (specialised potassium-rich solution called cardioplegia) allowing the surgeon to operate with precision on a still, motionless heart. Cooling also helps protect the heart muscle itself by reducing its activity and enhancing the protection of your heart muscle throughout the procedure.
The heart-lung bypass machine provides a very safe and effective service which can take over the work of the heart and lungs for hours. However, your surgeon will try to limit the time that you spend on the machine to ensure that your body returns to is normal physiological function as soon as possible.
In some patients, heart surgery can be performed without the use of the heart-lung machine—this is known as off-pump or “beating heart” surgery. Instead of stopping the heart, the surgeon uses specialised stabilising devices to gently steady a small area of the heart while it continues to beat and pump blood to the body. This approach is most commonly used for coronary artery bypass surgery (CABG). In our practice, off-pump CABG is often the preferred technique, as avoiding the heart-lung machine may reduce certain risks such as inflammation, bleeding, and complications in higher-risk patients. However, it is only used when it is safe and appropriate to do so, and when the heart can tolerate the procedure in this way. This decision is sometimes made during the operation itself, once the surgical team can directly assess how the heart responds. As always, the priority is to choose the approach that provides the safest and most effective outcome for you.
Many heart operations can now be performed using minimally invasive techniques that avoid a full breastbone (sternotomy). These approaches include small incisions on the upper or lower breastbone (mini sternotomies), on side of the chest (mini-thoracotomy), keyhole (port-access) surgery using specialised instruments and cameras, and in some centres, robotic-assisted procedures that allow very precise movements through tiny openings. These techniques aim to reduce surgical trauma, leading to smaller scars, less pain, faster recovery, and a quicker return to normal activities. Not all patients or conditions are suitable for minimally invasive surgery, as safety and the quality of the repair remain the top priority, but when appropriate, these approaches can offer excellent outcomes with the added benefit of a less invasive experience.
Our preferred approach in performing heart operations is through mini-lower sternotomy, which is a specialised technique that uses a small vertical incision along the skin in the centre of the chest in order to open the sternum (breastbone). The advantage of this technique is that it produces better cosmetic results without causing risk to the way the surgery is performed. Unlike the conventional sternotomies which extend for a length of 25-30cm and cause an extensive length of tissue damage, mini sternotomy has a length of only 10-15cm and preserves the skin and underlying tissues.
Mini-lower sternotomy leaves the patient with a smaller scar that is located lower than a conventional scar. It can enable the patient to wear a lower neck line garment without fear of the scar showing, and it is often well hidden on men with chest hair or within women’s cleavage. The full cosmetic outcome can be assessed after a period of 3 months when the incision is almost fully healed and incorporated into the patients’ body.
Minimaly invasive conduit harvesting is a technique used to remove the radial artery from your forearm or the long saphenous vein from your leg using less invasive techniques, so that it can be used as a graft for bypassing the diseased coronary artery of your heart. Conventional techniques involve a long vertical cut which must be made deep into the leg tissues to expose the artery or the vein.
The conventional procedures of harvesting arteries and veins (long incisions) have high rate of complications which can include cellulitis, blood clots, neuralgia and ischemic sequelae, delayed in wound healing, necrosis and infections. These post operative complications are frequently associated with peripheral vascular artery disease, obesity, diabetes, female sex, preoperative steroid treatment, and anaemia. In addition to complications, the patient may experience discomfort from the leg wound that may restrict their mobilisation during the first 6 weeks following the operation.
Minimally invasive – endoscopic conduit harvesting is an advanced method of artery or vein removal, which has a low complication rate and excellent cosmetic results. The artery or vein is removed with the help of special surgical instruments and specialist surgical techniques which ensure that the quality of the removed vein is maintained. This method also ensures that trauma to the patients’ forearms or legs is minimised and blood loss is restricted to an absolute minimum. Patients can put weight on their leg and use their hands on the first day following their operation and mobilise free from the discomfort of long painful leg scars. Healing of the small wounds is complete after 3 months and the cosmetic outcome is very pleasing .
Fully endoscopic arterial and vein harvesting reduces the number of small incisions required to remove the vein, leaving only 2-3 small scars. However, it requires the use of special “single use” equipment at an additional cost to enable the surgical team to harvest the arteries and veins with direct vision. The cosmetic and functional result of this method is the most superior of all techniques used for peripheral arteries and veins harvesting.
For many patients, one of the most worrying aspects of heart surgery is the idea of the breastbone (sternum) being divided to access the heart. This approach, known as a median sternotomy (either full or smaller “mini” version), is actually a well-established and very safe technique that has been used successfully for many decades. It provides the surgeon with excellent, direct access to the heart, allowing complex procedures to be performed with precision and safety. Although the thought of the bone being divided can sound alarming, the sternum is carefully closed and secured at the end of the operation, and in most patients it heals reliably over time. The majority of patients tolerate this approach very well, and it remains the gold standard for many types of heart surgery because it offers the best exposure and the highest level of safety.
Most cardiac surgeons continue to use stainless steel wires to close median sternotomies at the end of the surgical procedure. Sternal wires are effective at sternal approximation and have been widely used across the world for decades, with excellent results. Sternal wires however, do not provide rigid fixation and are inadequate at preventing sternal movement following surgery.
The alternative way of closing median sternotomies is by using rigid plate fixation (similar technique to what the orthpaedic surgeons have been using for decades in treating bone fractures and thoracic surgeons using in treating rib fractures). In a prospective, randomized, multicenter trial, closing median sternotomies with rigid fixation (using plates and screws, like SternaLock Blu) resulted in improved sternal healing, fewer sternal complications, less postoperative pain and use of painkillers/opioids, along with faster postoperative mental and physical recovery.
