The aortic adventitia is dissected with McIndoe’s scissors away from the proposed site of anastomosis.
A side-clamp is applied to the ascending aorta, and its position fine-tuned with a Duvall clamp.
A stab incision is made with a 15-blade scalpel and an aortotomy punch passed inside to make a circular hole. Any pieces of the aortic wall are cut off and removed.
The vessel is grasped with the hand and an oblique cut is made. With the top held by the with ring-tip forceps and stretched, the bottom of the cut face of the vessel is split in the midline using back-hand Pott’s or with McIndoe’s. The length of the incision makes the cut face of the vessel a rhombus.
The top of the rhombus is called the toe or 12 o’clock position and the bottom is the heel or 6 o’clock position.
The assistant holds the vessel at the adventitia on the toe using ring-tip forceps, and the operator at the heel using the non-dominant hand.
A 5-0 prolene double-ended suture with curved 3/8-circumference needle is held at two-thirds from the sharp tip with the needle-holder blades biting the inside and outside of the needle evenly, so as to prevent slipping. The needle point is pointing in a forehand manner away from the needle-holder tip at approximately 30 degrees from the perpendicular.
The needle is passed at the toe 1-2mm from the edge from inside the vein to outside. A curved line of motion by supination is used to pass the needle to minimise trauma, as opposed to a straight line motion. The needle is regrasped by its body and not the tip to prevent blunting. When pulling through, use a curved line of motion following the needle curvature again rather than a straight line of pulling. This end is put down and the other needle grasped.
The needle on the opposite end of the suture is passed from inside the aorta to outside with a slightly larger bite of 3-4mm.
Both suture ends brought together and knotted at least 3 times to produce two equal lengths of suture with needles on either end. The knots (especially the first) are placed securely at the toe One end is brought out under the vessel to the other side.
The anti-clockwise direction suture is completed by forehand with the third bite at 9 o’clock and the fifth/sixth bite at 6 o’clock. The needle is passed from outside the vein to inside and from inside the aorta to outside with bite sizes as mentioned above. This suture end is then placed away and protected with a rubber-shod bulldog clamp.
The clockwise direction suture is completed by backhand grip with the same number of bites. The needle is again passed from outside to inside on the vein, and inside to outside on the aorta.
With each bite, the assistant follows the suture to keep up the tension.
At the 6 o’clock position where both ends meet, tension is applied and the needles cut off. The ends are knotted with at least 6-9 surgical knots and a long tail left when cutting the suture.
The aorta is then unclamped and the anastomosis checked for any leakage, which is resolved with additional sutures as necessary.
After all the proximal anastomoses are performed and the aorta unclamped, the venous conduits are de-aired by using an orange (25-gauge) needle to puncture them at a single site.