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Page 4 of 15 Ashenhurst et al. Vessel Plus 2024;8:3 https://dx.doi.org/10.20517/2574-1209.2023.90

Table 1. Differentiation of minimally invasive coronary artery bypass grafting techniques
Incision
Median sternotomy Small left anterior thoracotomy
Use of On-pump Conventional CABG (all territories Pump assistance may be used in the learning phase and complicated cases of
CPB accessible) MIDCAB and MICS CABG
Off-pump OPCAB (all territories accessible) MIDCAB (Single vessel; LITA-LAD)
MICS CABG (Single or multivessel; not restricted)

Figure 1. CABG sternotomy incision during operation, demonstrating the invasiveness of the procedure (Internal photos of the incisions
and procedures). The patient gave explicit consent to have their photo included in this review.

T2-T3 level . Using a double-lumen endotracheal tube or a regular endotracheal tube and a left bronchial
[17]
blocker, the patient is intubated, and the left lung is deflated. The patient is then placed in a 15-30° right
lateral decubitus position and a roller is placed under the supine patient between the spine and left scapula
with the left arm tucked at a 45-degree angle to facilitate rib separation. The patient is draped in a way that
facilitates access to the groin for femoral venous and arterial cannulas should CBP be required. The legs are
also available for saphenous vein harvest if indicated in the procedure. The main incision or the “window
incision” aims to access the thoracic cavity through the fourth or fifth intercostal spaces at the midclavicular
line and starts medially right beneath the left nipple in males and is then extended 5 to 8 cm laterally
[Figure 2]. For female patients, an inframammary incision is used instead. In MICS CABG, in addition to
the main incision, there are two additional access portals, namely at the subxiphoid region and the sixth or
seventh intercostal space down the anterior axillary line. Through these portals, a Starfish Non-Sternotomy
Heart Positioner (Medtronic, Minneapolis, MN, USA) and the Octopus Non-Sternotomy Tissue Stabilizer
(Medtronic) are inserted through the subxiphoid and the sixth intercostal ports, respectively, enabling
visualization of all coronary arteries as illustrated in Figure 3.