Left anterior small thoracotomy for minimally invasive coronary artery bypass grafting.

Since the 1990 s, minimally invasive cardiac surgery has gained wide acceptance due to patient and economic demand. The advantages are less trauma, bleeding, wound infections, pain and faster recovery. Many studies showed that the outcomes are comparable with those of conventional sternotomy. Left anterior small thoracotomy (LAST) evolved into a routine and safe access in specialized centres for minimally invasive direct coronary artery bypass grafting. The 6-cm incision is localized above the fourth intercostal space, 3-4 cm lateral to the left sternal border and below the left mammilla. With a double-lumen tube, the left lung is deflated before entering the pleural space. The left internal mammary artery is harvested under direct vision with the use of special retractors. The anastomosis of the left anterior descending artery is performed on the beating heart as known from off-pump surgery. One chest tube is inserted. The intercostal space is closed with braided sutures to prevent lung herniation. Ropivacaine is used for local infiltration. The pectoral muscle, subcutaneous tissue and skin are closed with running sutures. Complications of the LAST approach are rare (conversion to sternotomy, re-thoracotomy, phrenic nerve palsy, wound infection and thoracic wall hernia) and well manageable.