Sternotomy.

Leave pericardium closed.

Mammary retractor. Long hook superiorly, short hook inferiorly. Place operator-side blade first, long hook next and short hook last (or short hook on the left to be latched first, open a bit, then the long hook.) Keep the hooks as far apart as possible. The skin incision edge is protected from the ratcheting mechanism.

Lungs off and Keep diathermy high while opening the left pleura completely. Raise the table to standing height. 1-2 large wet swabs in the pleura. Lungs back on.

Visualise the mammary, score the proximal pleura/fascia in the full length of the sternum.

Drop the diathermy energy by half. Expose the mammary at the inferior edge by retracting the fascia with the Dietrichs forceps and using blunt dissection. Identify branches upto the proximal quarter.

The exposure on the distal side usually requires division of tranversus thoracic and rectus abdominis muscle fibres as the vessels traverse lateral and superifical to the fibres.

Apply yellow clips on the mammary side to ligate, and then divide using diathermy on the chest wall side.

Create a pedicle in the mid-section, by incising lateral to the vessels, and being able to see the swabs beyond. There may be more branches but slow and deliberate diathermy is enough to cauterise them.

Free up the proximal section by pressing down on the pedicle, and dividing the connective tissue.

Heparin.

Apply Roberts to clamp inferiorly. Cut the pedicle. Apply ligaclips to stop the flow. Place the pedicle on a papaverine-soaked swab. Spray papaverine. Roll the swab to preserve the orientation and place inside pleura on the medial surface of the left lung.

Ligate the clamped pedicle. Apply ligaclip. Diathermy up. Haemostasis. Suck out any effusion.

Table down.