Atlas Of Surgery

[Doris Joo]

Current patients will feel more at ease knowing what they can expect before and after surgery with our helpful Patients section. This page provides additional information about our neurosurgical expertise, and provides easy access to patient resources.

We always strive to offer our patients the best level of care, and are excited to further enhance our level of patient support with our comprehensive new website. Learn more about Atlas Surgery Center at atlassurgery.com.

Dr. Jackler and Ms. Gralapp retain copyright for all of their original illustrations which appear in this online atlas. We encourage use of our illustrations for educational purposes, but copyright permission should be sought before publication or commercial use. To request permission for publication or commercial use please contact Christine Gralapp (eye...@chrisgralapp.com, ).

Ambulatory surgery centers are a key piece of the outpatient strategy for some legacy hospital operators, especially Tenet Healthcare, which expects earnings from its ASC business to account for nearly half of the company's overall earnings by 2023, according to its latest earnings presentation. Tenet has used acquisitions to increase its size and scale.

Based on that growth, Atlas' Chief Strategy and Growth Officer Scott Nordlund said "it was a logical next step for Banner to invest in Atlas to help the company scale and grow into a larger national partner for other health systems as well."

Banner Health operates more than 30 hospitals and has a significant footprint in Arizona. It also operates a health insurance unit, employed-physician group, home care and hospice services, among an array of other offerings. Banner has locations in California, Colorado, Nebraska, Nevada and Wyoming.

From our very beginnings, the Department of Surgery has contributed meaningfully to the provision of quality health care services. Our firsts range from authoring the first textbook in this country on aseptic and antiseptic surgery to performing the initial liver transplantation in the State of New York. Today, we have a cohort of world class surgeons that possess more surgical experience than any hospital in the Northeast and an unmatched capacity of 138 operating rooms.

Sydney Yankauer performed the first successful removal of a foreign object via bronchoscopy in New York. He also developed the Yankauer suction, clamps, an endoscope and bronchoscope, ether anesthesia mask, and many otolaryngeal operative instruments.

First in New York State to perform a single-incision laparoscopic splenectomy and cholecystectomy, removing the spleen and gallbladder of a patient completely through a one-inch incision hidden in the belly button.

Boasts a resident training program with more than 70 residents. Our department includes 10 divisions and more than 200 full-time faculty members across the Mount Sinai Health System, all dedicated to patient care, teaching, and research.

Minimally-invasive mitral valve surgery was introduced into the surgical routine by Alain Carpentier, one of the pioneers of mitral valve surgery, in 1996 (1). It was at this time that minimally-invasive access was also performed at the Leipzig Heart Center for the first time. Since then, this technique has become routine at our institution with an annual number of up to 400 cases (2). It has been shown to be a safe technique not only in patients with impaired left ventricular function (3) and in patients of advanced aged (4), but also in selected patients who have had a previous sternotomy (5). In the majority of cases, the mitral valve is operated under direct vision. However, some cases are performed using pure videoscopic vision, as it has been promoted by Hugo Vanerman and others (6).

The goal of minimally-invasive mitral valve surgery is to perform the operation with the same high repair rate compared to conventional mitral valve surgery through a median sternotomy and without putting the patient at a higher surgical risk. Avoiding sternotomy has major advantages for the patient, such as decreased surgical trauma and therefore improved recovery, less postoperative pain and improved cosmesis. These issues are of major importance for patients. There are, however, specific contraindications to this access, which have to be taken into account. In particular, a heavily calcified mitral valve annulus or severe annular abscess formation with the need to perform extensive annular reconstruction techniques should necessitate a conventional approach. Previous right chest surgery with severe adhesions of the right lung to the chest wall is an additional contraindication to minimally-invasive access. In addition, aortic valve regurgitation >I is in our experience also a reason to perform a conventional sternotomy, in order to avoid insufficient administration of cardioplegia.

The first additional incision should be positioned anteriorly in a safe distance to the right internal thoracic artery. This incision will be used for the holder of the left atrial retractor blade and may also be used for getting the cardioplegia line/root vent out. The incision for the cross-clamp should be directed towards the ascending aorta, without putting any force onto the aorta after the left atrium has been retracted. Care must be taken to avoid interference with the camera, which should be inserted anterior and superior to the cross-clamp, achieving a direct view of the mitral valve. One or two of these additional incisions can be used later for getting the chest drains out.

Following incision of the pericardium about 3 cm above the phrenic nerve, pericardial retraction sutures may be applied and brought out laterally. Using a purse string suture, a needle vent is brought into the aortic root for application of cardioplegia and later venting of the aortic root.

After aortic cross clamping, the left atrium is entered through the interatrial groove. It is advisable to apply the cross-clamp during a short duration of complete circulatory arrest to avoid the potential risk of aortic dissection. The left atrium is lifted up using a retractor blade, which is available in different sizes and lengths. In some cases, the blade used for pushing the diaphragm away can also be used to improve visualization of the mitral valve by pushing the inferior part of the left atrial incision downwards.

After assessing mitral valve pathology, adequate lengths of premanufactured Gore Tex loops are placed onto the specific papillary muscle (PM). The lengths of the loops are calculated using a special measuring caliper. The measuring device is placed onto the tip of the relevant PM and at the free edge of the leaflet to measure the adequate length of the neo-chords. On average, the mean length for the posterior leaflet is between 12-14 mm and for the anterior leaflet between 22-24 mm. Each set of neo-chords is composed of four loops, which are anchored to the specific PM by getting two sutures through the muscle, which are then knotted over two teflon pledgets. The free edges of the loops are then positioned at the corresponding free edges of the leaflets using an additional 4-0 Gore suture for each loop. It is important to anchor the loops in the body of the PM to prevent tearing of the loops and to grasp enough leaflet tissue. If less than four neo-chords are necessary, two loops may be sutured to the leaflet at once. The maximum number of loops is therefore 16, with eight loops to each leaflet and eight loops coming from each PM. For a simple posterior leaflet prolapse P2, loops in the majority of cases coming from the postero-medial PM are enough to accomplish an adequate reconstructive result.

It is important not to cross the midline of the anterior and posterior mitral leaflet with the loops and therefore, loops from the antero-lateral papillary muscle should support the areas A1, P1 and A2 and P2 up to the midline and the loops from the postero-medial papillary muscle should support the leaflet areas P2/A2 from the midline and P3/A3. Each repair is secured and followed by stabilizing the annulus in a standard fashion.

The left atrium is closed in a standard fashion, using 30 monofilament sutures. Following left atrial and left ventricular de-airing maneuvers, the cross-clamp is released again during a short period of circulatory arrest and a pacing wire is attached to the right ventricle while the heart is still empty.

Finally, the patient is weaned from cardio-pulmonary bypass and the mitral valve repair is assessed by transesophageal echo. If the repair is adequate and adequate de-airing has been performed, cardiopulmonary bypass in reinstituted and the root vent is removed. The patient is then again weaned from bypass. Following decannulation and insertion of one or two chest tubes, the thorax is closed in a routine fashion.

"It is vital that Banner Health continues to meet patients and physicians where they are in their need for care, which continues to expand to outpatient settings for surgeries and procedures," said Banner Health Vice President of Ambulatory Services James Cote. "The network of ASCs that we continue to build with Atlas is key to delivering high-quality, convenient care in a lower-cost setting. This is a must for our physicians and patients seeking care with Banner."

"Over the last nearly four years we have created an integrated partnership with Banner focused on creating a great experience for physicians and patients," said Atlas Healthcare Partners CEO Aric Burke. "These additional ASCs to the network are a critical part of the Banner/Atlas growth strategy. By continuing to expand service lines such as pain and spine, and cardiovascular we are providing outstanding customer service to physicians in a place where they can better care for patients."

About Atlas Healthcare PartnersAtlas Healthcare Partners (Atlas) specializes in the development and management of ambulatory surgery centers (ASCs) in partnership with health systems and physicians. Atlas was formed in 2018 to develop and manage Banner Health's ASC network in Arizona, Colorado and Wyoming. Over a four-year period, Atlas has helped Banner more than triple its ASC network from 8 to 27 ASCs, which has significantly increased its market share and expanded its ASC service line offerings. Atlas now partners with additional health systems, including the newly formed BHSH, to develop and manage ASC networks in their markets, and MedAxiom to create a first-of-its-kind cardiovascular-focused ASC company. Atlas has a unique value proposition through its commitment to health system integration and physician partnerships. For more information, visit

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