The anterior fourth interspace minithoracotomy is our current choice f
or exposure of the anterior myocardial wall for minimally invasive cor
onary bypass grafting procedures. This approach provides direct access
to the left anterior descending coronary artery for anastomosis, and
good exposure of the midsegment of the internal thoracic artery. We de
scribe the use of instrumentation that facilitates the harvest of the
left internal thoracic artery under direct vision. The use of this ret
ractor system, which elevates the third and fourth and depresses the s
econd and first ribs, permits better visualization of the internal tho
racic artery and allows for proximal internal thoracic artery harvest
without rib resection. (C) 1997 by The Society of Thoracic Surgeons.