How I Teach Hemi-Arch Replacement.

Even the most basic cardiac surgery operation is a complex cognitive, technical, and psychological experience for many residents. The resident should be taught how to “eat the elephant one bite at a time.” Teaching residents how to replace the ascending aorta lends itself well to a graduated level of responsibility. Components of the operation can be increasingly performed by the residents as they progress. I frequently explain to my residents that there are three key components to technical learning. Firstly, the surgeon needs to know the specific goals and detailed steps of the operation. Secondly, the surgeon should be able to construct a mental picture in the “mind’s eye” of what each step should look like when that step is successfully performed. Finally, the surgeon needs to get his or her hands to perform the technical tasks required to expose, dissect, resect, and reconstruct the goals of the operation [1]. In addition to accomplishing the task at hand (eg, cannulation, aortic resection, and sewing the anastomoses), I believe that paying special attention to the fundamental technical skills needed to accomplish those tasks is in many ways a more important educational goal than performing the tasks themselves [2]. Axillary Artery Cannulation Axillary artery cannulation is a challenging anastomosis on which residents can hone their technical skills without the time pressure associated with myocardial or cerebral ischemia [3]. The right arm should be placed on an arm board abducted at 90 degrees. The incision starts below the midpoint of the clavicle and extends 6 cm laterally in the direction of the pectoralis major fibers. The pectoralis major fibers are bluntly separated, exposing the clavipectoral fascia. The clavipectoral fascia is incised, branches of the axillary vein are divided, and the vein is retracted toward the feet. The resident is encouraged to explore the deep hole digitally to locate the pulsatile axillary artery. This temperamental artery, which is fragile and can easily dissect, should be handled more like the internal mammary artery than the femoral artery. Three to four centimeters of the artery should be mobilized, being mindful of the brachial plexus. To improve exposure, the pectoralis minor muscle can be divided with impunity using diathermy. After systemic heparinization therapy, fine angled vascular clamps are used to obtain proximal and distal control. The middle of the artery is incised longitudinally, and the arteriotomy is extended proximally and distally for a total length of 12 mm. A 5-0 polypropylene traction suture through the inferior portion of the artery can facilitate exposure. An 8-mm Dacron (C. R. Bard, Haverhill, PA) graft is cut, with a slight 30-degree bevel; too acute a bevel will potentially distort the graft. The first bite of the continuous 5-0 polypropylene suture is placed inside out through the 8 o’clock position of the arteriotomy (9 o’clock being the heel). The same needle is then brought outside in through the 7 o’clock position of the graft and continued in kind, traveling in a clockwise direction (Fig 1). Some axillary arterial walls have a tendency to delaminate; therefore, it is important for the resident to take generous bites inside out on the artery. I encourage residents to think of the graft and the arteriotomy as two separate clock faces. Make a mental image in your mind’s eye to visualize corresponding imaginary clock numbers on the arteriotomy and the graft to facilitate spacing of the sutures. The lateral half of the anastomosis is best performed forehand, whereas the medial portion of the anastomosis is performed backhand. Exposure is optimized if the assistant gently holds the graft up and away, providing countertraction to the 5-0 traction stitch. The sutures