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Pacemakers may be placed through a lateral thoracotomy or a ventral midline celiotomy. In larger, deep‐chested dogs, for a ventral midline approach, sandbags are placed on either side of the thoracic cavity to aide in proper positioning.

In addition to the instrumentation previously mentioned for a standard abdominal approach, including a routine soft tissue instrument set and an appropriately sized Balfour retractor (Figure 2.1) to improve exposure, the use of the balfour retractor blade allows for upward retraction of the xyphoid process following a ventral midline diaphragmatic incision. If a balfour blade is not available, Parker Kerr retractors may aide as a handheld retractor substitute (Figure 2.23). If the pacemaker is placed through a lateral thoracotomy approach, appropriate instrumentation is listed in Box 2.12. Prior to anesthetic induction, the surgeon should consult with a cardiologist to determine the pacemaker best suited for a particular patient.

Figure 2.12 Patient positioning for dorsal perineal urethrostomy approach.