Watching open heart surgery – in the operating room

Luke Blair
By Luke Blair     17/08/2022

Luke Blair, head of communications, writes about his first-hand experience watching a surgeon and his team carry out a triple bypass. 

Most people would readily acknowledge that what happens in an operating theatre is in many ways a miracle. Patients go in, with often very serious threats to their lives due to the condition they are in, and emerge fully treated, having literally had their lives saved.

Of course it is not actually a miracle. Medicine is a science and is built upon centuries of learning, evidence, experience, and clinical practice. Miracles have nothing to do with it.

But having now been lucky enough to stand right next to a surgeon performing a triple bypass operation, I can honestly tell you – what happens is indeed somewhat miraculous.

I’ve spent much of my career in and around the NHS. I find the business of looking after the human body more interesting than a lot of other work, and so when I arrived here a year ago, I immediately harboured the ambition to see what really happens, where the care is most directly and obviously delivered, in the operating theatre. I worked on a short project with one of our consultant heart surgeons, and so we became friendly enough for me to ask him – he was only too pleased to show me what he does in theatre, and the day was set.

I arrived at the somewhat eye-blinking hour of 7am, so I could watch the full process of the teams getting ready, accompanying the patient’s consultant to the ward, watching the theatre being prepared. I also of course needed to change into scrubs, a new experience for me in itself (top tip – don’t think that because they are rubber clogs, and you don’t want to make a fuss, accepting a shoe one size too small is going to be at all comfortable. It really isn’t.)

It was two hours before the patient and theatre were ready, and the iodine was being brushed over their skin to sterilise the key areas for surgery. At this stage, you see the patient, and you know it is a live person with a family and friends who are waiting with acute anxiety to know how well the next few hours will go, but you are also oddly detached from this. The clinical process, conducted in the sanitising glare of the operating theatre – the cleaning of the body with bright yellow liquid, the shrouding with those turquoise-green covers, the mass of tubes and screens and instruments that are then brought in to surround them – all have de-humanising effect. I suppose this makes it easier for the team in one sense. It puts some professional detachment into a situation where they have someone’s life in their hands.

The process in question here was a triple bypass or, as I now know it is professionally called, a ‘cabbage’ (CABG, coronary artery bypass graft). This first requires the ‘harvesting’ of suitable vessels from other parts of the body, which are then basically sewn onto the heart to replace the coronary artery – or arteries – that have become clogged with fat and thus are not doing their job well enough any more.

So even before we got to see the chest cavity, there were other operations to be done. One of the surface veins in the patient’s leg was pulled out, through a hole cut at the top of the leg. A ‘keyhole’ device was used to do this, manipulated with the same level of skill as an artist working on a miniature oil painting. I watched the screen being used by another expert clinician as the camera-guided device was threaded down the inside of the leg, cut and cauterised the vessels branching off from the main vein, and then cut and cauterised the main vein itself in two places to extract it completely. I have no idea how you can do this to a leg, without some major blood loss, or a massively reduced circulation in future, or causing some other problem which cutting a vein out of your leg, logic suggests, would entail. It’s medicine, but it did seem sort of miraculous.

You are then left with what looks basically like a piece of gristle. After all, much of surgery is essentially carried out on a microscopic scale. So the vein that took no time at all to cut out of the leg was really small, flimsy, and about six inches long, if that. How could this possibly be used, I thought. On the heart itself? How? How could that possibly work?

At the same time, another vessel was harvested from another part of the body, this time an artery. One of the few questions I asked later was how it was possible that all these vessels could be cut out, and nothing happened to the person they were cut out of. We have a lot of body parts that are superfluous, my surgeon friend said. Another miracle of sorts.

I didn’t actually see the moment the chest and rib cage were cut open. Luckily I am not squeamish but those who are often find this the worst bit, so maybe I was tactfully kept away. However, to my delight, when the surgeon then started work on the heart itself, he beckoned me over, and I found myself standing right next to him, as close as it’s possible to be to the whole operation, without actually conducting it myself.

And there I saw it. The patient’s beating heart in their own chest cavity. It looked, of course, like any heart you see in a butcher’s shop. More white than red, like a brightly coloured stone of a size that can be perfectly cupped in the hand. I know this because the surgeon then did indeed cup his hand around the organ and examine it, as it was beating. He then – with an apparently brutal swiftness – cut the aorta and forced a tube into it, so that the blood could be diverted away from the heart to a nearby machine, allowing the heart to be stopped completely. Of course it looked brutal, but it was entirely skilled and carried out with such precision and exactitude that the patient, under all the instruments and sheets and with their chest wide open and their heart about to be stopped, continued living as though nothing was happening to them at all.

The surgeon was at this point like an orchestra conductor, his eyes and ears acutely tuned to his team, their performance and their equipment. He was monitoring all the tubes, making sure the flow, position and pressure in each was correct, making sure the right surgical instruments were in his hands at the right moment, and of course locating the correct places to cut out the failing artery and sew on the new vessels.

He was also talking to his team, constantly. It was a masterclass in leadership, management, communication and motivation. There really is no time to lose in an operation. Seconds of delay can cause problems. So knowing what everyone should be doing, when, and how, all contributes to a more successful outcome. The surgeon has to congratulate when things are just right, chase when things seem slow, correct – without causing more fumbling – when the things go even just slightly wrong.

And then comes the sewing, perhaps the most extraordinary part of it all, where that bit of gristle, having been cleaned and prepared (extraneous branches removed, ends cut in a certain way) is sewn onto the heart, using curved needles held with tweezers, and the most incredible precision of the surgeon’s hands, and the assistance of magnifying spectacles. The stitches somehow ensure the thread holds this vessel in exactly the right way to replace the previous arteries carrying blood at pressure around the beating heart. Again, how this happens I have no idea. I simply do not understand how a flimsy piece of tissue can be sewn onto a heart, which is then restarted, and takes over where an artery has previously been for 50 years quietly doing its job. It is extraordinary how resilient the human body can be, and how far human knowledge has come. Extraordinary and miraculous.

Frustratingly (but perhaps just as well given the length of this blog) I then had to leave. I did not therefore see the second and third bypasses being grafted. I left the theatre in a bit of a daze. The whole experience had been so extraordinary, and so moving; to be that close to a heart being stopped, to witness so much skill, and a life being saved, was emotionally draining. Also, my feet were really hurting from those damn shoes.

I bumped into my surgeon friend a few days later. The patient was doing well, he said. I looked at him and struggled to express my thoughts. He could see what I was thinking, and smiled. It’s just decades of experience, he said. No it isn’t, I thought, it’s actually a miracle.