Asian Cardiovasc Thorac Ann 2007;15:468-471
© 2007 Asia Publishing EXchange Ltd
Minimally Invasive Right Posterior Minithoracotomy for Open-Heart Procedures
Khaled Samir Mohamed, FETCS
Cardiovascular Services Department, Saad Specialist Hospital, Alkhobar, Saudi Arabia
For reprint information contact: Khaled S Mohamed, FETCS, Tel: 966 5 5137 8225, Fax: 966 3801 1978, Email: ksam68{at}yahoo.com, #817, 101 Bd Sacre-Coeur, Gatineau, J8X 1C7, QC, Canada.
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ABSTRACT
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A right posterior minithoracotomy was evaluated in 123 selected patients between November 2002 and August 2006. Their ages ranged from 1.5 to 32 years (mean, 7.8 years) and weights ranged from 12.3 to 61.6 kg (mean, 23.3 kg). Pathology included atrial septal defect in 81 (66%), ventricular septal defect in 16 (13%), and 24 other (mainly valve) defects. All patients had a strictly posterior right minithoracotomy through the 4th or 5th right intercostal space, with a 7–9-cm skin incision. There was no mortality or procedure-related morbidity. The mean cardiopulmonary bypass time was 68 min, ischemic time was 47 min, and 47 (38%) patients were extubated on the operating table. The mean hospital stay was 4.3 days and it was < 5 days in 108 (88%) patients. A cosmetically fine scar was achieved in all patients. The right posterior minithoracotomy is a safe, cosmetically superior, and cost-effective approach for selected open-heart procedures.
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INTRODUCTION
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Although a thoracotomy was the original approach used by all the pioneer cardiac surgeons, a median sternotomy has become routine for open-heart procedures. Patients’ feedback tells us that the midline scar is considered unsightly and displeasing, and may evoke psychological distress, especially in young female patients. As the safety of cardiac surgery has increased, more emphasis has been placed on the cosmetic results.1,2 The right anterolateral thoracotomy has been used in selected cases, and the esthetic result was accepted and preferred by many patients. However, the indications are limited due to the anterior scar and the possibility of breast asymmetry in females.3–5 Recently, atrial septal defect (ASD) closure by a right posterolateral thoracotomy has been reported.6 The aim of this study was to evaluate procedures for various simple intracardiac pathologies performed via a strictly posterior minithoracotomy (7–8-cm posterior to the posterior axillary line) without any additional drain scars.
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PATIENTS AND METHODS
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This was a retrospective nonrandomized study on 123 patients needing relatively simple intracardiac procedures between November 2002 and August 2006. The inclusion criteria were age < 16 years, simple intracardiac pathology (initially used for ASD closure in girls and extended to other simple intracardiac procedures regardless of sex), family approval after explaining the difference between this method and the conventional approach. The exclusion criteria included complex anomalies, simple lesions with cardiac malposition, expected right pleural adhesions, and family choice to have a conventional sternotomy. The patients’ characteristics are listed in Table 1
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Chest radiographs in anteroposterior and lateral views were studied carefully to choose between the 4th and 5th intercostal spaces for the thoracotomy, to give maximum ease in manipulation of the heart. The position and slope of the ribs in relation to the atrial shadow were used as guidelines. The patient was fixed in the left lateral decubitus with semi-flexion of the left knee, extension of the right knee, and lateral rotation of the right hip to make the femoral vessels accessible in case of difficult aortic cannulation. The right arm was not fixed and should be left in anterior flexion of the shoulder to avoid imperfect repair of the chest wall muscles, which can cause some long-term deformity. The chosen intercostal space was marked. A 6–7-cm incision was made, starting anteriorly 1-cm posterior to the midaxillary line, and extending parallel to the rib curvature 2-cm inferior to the inferior angle of the scapula. Using diathermy, the subcutaneous tissue and latissimus dorsimuscle were incised. The serratus anterior muscle was preserved. The periosteum of the rib inferior to the chosen space was elevated, and the intercostal space was opened by blunt dissection to avoid lung injury. Two perpendicular chest retractors were used to gain better exposure, and the lung was retracted with a malleable retractor. The lower part of the thymus was mobilized by blunt dissection to facilitate exposure of the aorta. The pericardium was incised vertically 1-cm anterior to the phrenic nerve. The posterior border was suspended to the exterior, and the anterior was suspended interiorly to the rib periosteum. Once the pericardium was suspended, exposure was very satisfactory. The right atrium was momentarily suspended to expose the aorta which was controlled with cotton tape. Heparin was given, and the aortic and atrial pursestring sutures were prepared. In many cases, a femoral arterial cannula was used for aortic cannulation, otherwise a flexible aortic cannula was employed. In all cases, a side-biting clamp was made ready in case of difficult cannulation. A right-angled venous cannula was inserted in a juxtacaval position to maximize exposure. Direct superior vena caval cannulation was easily obtained if needed. The superior vena cava can be controlled with cotton tape. It must be noted that taping of the inferior vena cava (IVC) should always be carried out on bypass. The aorta was clamped using a malleable aortic clamp, and intracardiac procedures were performed as usual.
In the case of a left superior vena cava, it can be snared, temporarily compressed, or cannulated transatrially, according to size. When de-airing, as well as the usual method, it is important to apply steady suction to the aortic root after clamping, in addition to the crucial syringe aspiration of the right superior pulmonary vein. The ventricular pacemaker electrodes should be inserted on bypass before filling the heart, as this would be difficult afterwards. When hemostasis was assured after terminating bypass, an intrapericardial drain was inserted and its free end was passed 3 spaces below the incised intercostal space and through the latissimus dorsimuscle 1–2 cm from the level of the incision, with a valve to prevent pneumothorax on removal. The pericardium was closed with interrupted sutures or a thin synthetic patch if part of it had been removed, another basal pleural drain was inserted in the same way, intercostal nerve block was performed, the intercostal space was closed as usual, and the muscles were sutured. Subcutaneous tissue was sutured with attention to the areas around the drains where small bites should be taken. The skin was closed with intradermal absorbable suture, also with small bites around the drains, and adhesive strips were used to decrease wound tension. Many patients could be extubated on the operating table, and the drains were removed a few hours later if there was no significant bleeding and satisfactory radiographs (adhesive strips were used to close the exits). Patients were given physiotherapy if needed, before discharge. They were followed up by echocardiography before discharge, 10 days after discharge, and at 3 and 6 months.
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RESULTS
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The operative data are given in Table 2. There was no mortality. Most patients (109; 89%) did not require a blood transfusion and were extubated early; 47 (38%) on the operating table and 19 (15%) in the recovery room. The majority (118; 96%) were discharged from the intensive care unit on the 1st postoperative day. One patient needed immediate reoperation for bleeding. A 7-year-old girl had delayed recovery with no localized signs, which led to a hospital stay of 14 days and superficial wound infection, without any long-term morbidity. Two others had superficial wound infections. None needed femoral cannulation. There was no other procedure-related morbidity. The hospital stay was < 5 days in 108 (88%) patients. All patients had a 7–9 cm scar strictly on the back, without any additional scars (no drain openings). There were no somatic symptoms or signs due to the patient’s position, and all regained normal limb movements within a few days on routine postoperative physiotherapy. The mean duration of follow-up was 17.3 ± 4.6 months.
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DISCUSSION
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The median sternotomy has long been the preferred approach for open-heart surgery, due to easy accessibility of all parts of the heart. Compared to a thoracotomy, complete healing takes longer after a sternotomy, and there can be some serious complications that despite being rare, might affect the patient’s day-to-day life as in case of sternal instability, or even threaten life as with mediastinitis. A lateral thoracotomy was the original approach for cardiac procedures, and modifications of this have been used in reoperations or for cosmetic purposes, especially in females. Among the techniques developed were a submammary anterolateral thoracotomy, posterolateral thoracotomy, axillary approach, and a posterior thoracotomy. After an initial phase of enthusiasm, the submammary approach has been rarely used for cosmetic purposes due to frequent development of breast and chest wall muscle deformity.5 The right posterior thoracotomy was introduced in the 1990s for ASD closure in females.1 Several studies reported it to be safe for ASD closure, with better cosmesis.6,7 The author started using this approach in young females with an ASD unsuitable for percutaneous closure, and gradually extended it to small ventricular septal defects expected to be closed with direct sutures, then to sinus venosus ASDs. There was no difficulty applying the technique to other pathological indications, and it might be extended further. The patients in this series were < 16-years old, except for a small female aged 32 years who requested surgery by this approach.
There are 3 critical technical factors in this approach. First is the choice of which intercostal space should be incised for the best exposure. One or more chest radiographs should be examined to decide this. It should be midway between the aorta and the IVC. A higher space makes IVC control more difficult, while a lower one leads to difficult aortic cannulation. In this series, the 4th intercostal space was used most often (116 patients; 94%). In the other 7 patients, the ribs were less oblique, so the 5th space was used. The second factor is aortic cannulation which can be facilitated by suspending the pericardium to the ribs, pulling the aorta caudally, and using a longer and firmer cannula. Thirdly, IVC taping should be carried out only on bypass, using a less curved clamp directed from up to down. Sasidharan and colleagues8 reported massive left-sided pneumothorax in an 8-year-old girl, leading to cardiac herniation into the right pleural space after ASD closure through a right posterior thoracotomy. Closing the pericardium with interrupted stitches and inserting a synthetic patch if necessary, can eliminate this risk and decrease adhesions, which may be helpful if reoperations are required, as in the case of mitral valve lesions.
Surprisingly, it was found that exposure of the left atrium and the mitral valve were better through this approach than via a median sternotomy. It was also noted that the smaller the chest cavity the easier the approach, due to the wider exposure and shorter working distance. When the patient is in the lateral decubitus position, the interatrial septum lies in the line of vision of the surgeon, or parallel to it, while it is almost perpendicular to the plane of the valves, giving better exposure and greater ease of manipulation. The minimally invasive right posterior thoracotomy is superior to the conventional sternotomy as it heals faster with a smaller scar and avoids the rare but serious complications of sternotomy, leading to earlier ambulation, a smoother immediate postoperative period, and shorter hospital stay. The cosmetic results are superior to all other thoracotomy approaches, leaving only a fine posterior scar not seen by the patient. This had marked psychological benefits for female patients whose dressing habits were not altered.
The minimally invasive right posterior approach can be used in many simple intracardiac pathologies. It represents a safe, cosmetically better, and more cost-effective approach in properly selected patients. The size of the thoracic cage and the position of the lesion in relation to the line of vision are important points to be considered during the decision making. Application of this technique might be extended to other indications.
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ACKNOWLEDGMENTS
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I thank Dr. Dominique Metras, Dr. Bernard Kreitmann, and Dr. Alberto Reberi of the Department of Cardiac Surgery, La Timone Children’s Hospital, who trained me to perform the posterior thoracotomy during my fellowship in the University of Marseille, France.
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REFERENCES
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ABSTRACT
INTRODUCTION
