Day of Surgery
For patients who are admitted to the hospital the night before surgery, an intravenous (IV) catheter may be used. This allows intravenous fluids to be given once the patient is designated as nothing by mouth (NPO).
All patients — whether they are admitted to the hospital or not — will be placed on NPO (nothing by mouth) status after midnight the night before surgery and should not have anything to eat or drink after that time (this includes gum and hard candy). Clear liquids may be allowed with the specific instructions of the anesthesiologist.
On the morning of surgery, the family will check in at the 3rd floor of the West Tower in the Day Surgery waiting area and then go to the 17th floor waiting area where they will stay until called up to the 18th floor Holding Area.
Approximately one hour prior to surgery, the patient and only 2 visitors will be is taken to the holding area. The patient is dressed in a hospital gown, wiped with a special medicated wipe that decreases the risk of infection and placed in a crib or bed. The anesthesiologist will order medication either by mouth or IV that reduces anxiety and will make the patient relax.
The type of surgery your child will have depends on your child’s heart defect.
Prior to surgery, the surgeon will have a detailed consultation with the family to explain the specific surgical procedure, discuss risks and benefits, and answer any questions.
Throughout the child’s operation, a surgical nurse clinician will update the family approximately every hour and a half. These updates will be given in the private waiting room assigned by the receptionist.
The following steps commonly are followed in all types of congenital heart surgery.
The anesthesiologist and operating room nurses take the patient into the operating room. A heart monitor is connected to the patient that shows the OR team a continuous read-out of the heart rate and rhythm throughout the surgery. The patient is given a mask that disperses a gas that brings on a deep sleep.
Once the patient is asleep, the anesthesiologist puts a breathing tube (endo-tracheal tube or ET tube) into the patient’s windpipe. This tube is attached to a breathing machine (ventilator) that does the breathing for the patient during surgery. Next, the anesthesiologist places several intravenous (IV) catheters in the patient’s veins (usually in the large vein in the neck or the groin). Intravenous fluids and medication are given through them throughout the operation.
Another special catheter — an arterial line — is placed in an artery to monitor blood pressure during and after surgery. This special catheter is used to draw samples of blood to obtain various laboratory values and usually is placed in the wrist or the groin. A nasogastric (NG) tube is placed in the nose and gently guided down to the stomach after the arterial line is in place. An empty stomach will continue to produce juices, which can lead to nausea and vomiting. The NG tube empties the stomach and prevents vomiting. Finally, a Foley catheter is placed in the patient’s urinary opening and guided gently to the bladder. This catheter is attached to a device that drains and measures the urine produced during surgery. This preparation time may take from 60 to 90 minutes.
Once all the lines and tubes are in place, a transesophageal echocardiogram (TEE) is performed. A cardiologist places an ultrasound probe into the patient’s mouth and gently guides the probe down the esophagus. The TEE probe rests behind the heart and provides the surgeon with a continuous picture of the structures of the heart during the operation. When the TEE is completed, it is time for the surgeon to begin the operation.
Incision and operation
The type of surgical incision is based on the specific surgical repair.
Median sternotomy incision: This type of incision is used for open-heart surgery (surgery that occurs inside the heart). This incision usually begins at or below the top of the breastbone (sternal notch) and goes straight down the sternum (breastbone). The breastbone is divided into two to allow the surgeon to look right down on the heart.
The patient may need to be is placed on a heart-lung bypass machine which allows the surgeon to open the heart and operate on the structures inside. The heart-lung bypass machine provides oxygenated blood continuously to the other organ systems (kidneys, brain, liver) during the open-heart surgery. A certified perfusionist is dedicated to maintaining heart-lung bypass throughout the surgery.
Once the patient is on bypass, the surgical repair begins.
When surgery is complete, the patient is weaned off the heart-lung bypass machine until the newly repaired heart is managing all the blood flow. Between one to three chest tubes are positioned at the base of the incision to drain any blood or fluid that may collect in the chest after surgery. Temporary pacing wires may be positioned on one or both sides of the incision that may be used to pace the heart in the post-operative period.
Intracardiac monitoring lines may be placed depending on the type of surgical repair. These special catheters are placed in the chambers and vessels of the heart to provide the surgeon and the postoperative team with valuable information about the pressures within the heart and lungs.
A postoperative TEE is performed that provides the surgeon with valuable information after the surgical repair. Once the TEE is completed, the surgeon closes the sternum. The sternal bone is brought together, and stainless steel wire secures the sternum.
The type of skin closure the surgeon uses is dependent on age and weight:
- Clear, absorbable skin suture (stitches) runs the length of the incision and are placed from the inside. A clear knot is seen at the top and the bottom of the incision. To secure the outside of the incision, adhesive strips (steri-strips) are applied to the surface of the skin along the length of the incision
- Dermabond is surgical glue that is sometimes used to close the skin. Surgical staples are occasionally used in larger patients.
Thoracotomy incision: This is used for closed-heart surgery (surgery that occurs outside the heart). An incision is made on the side of the chest under the arm, extending up toward the shoulder blade. The ribs are separated to expose the heart or blood vessels. Since the procedure is performed on structures outside the heart, the heart-lung bypass machine is not used.
Once the incision is made, the ribs spread and the heart exposed, the surgeon performs a surgical procedure.
When the surgical procedure is complete, the ribs are brought back together, and a chest tube is placed to drain the surgical area. Temporary pacing wires and intracardiac lines are not used with thoracotomy procedures.
Generally, the type of surgical closure is an absorbable skin suture with the clear knot seen at both ends of the incision. To secure the outside of the incision, adhesive strips (steri-strips) are then applied to the surface of the skin along the full length of the incision.
Completion and transfer to recovery room
If steristrips or staples are used, a dressing will cover the incision for 24 hours. The anesthesiologist and operating room nurses then secure all the patient’s tubes and lines, and transport the patient from the operating room to the cardiovascular intensive care unit (CVICU).