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ORIGINAL ARTICLE |
Sri Ramachandra Medical College and Research Institute Chennai, India
Baskar Ranjith Karthekeyan, MD Tel: +91 98411 36568 Fax: +9144 24769033 Email: ranjithb73{at}gmail.com, Sri Ramachandra Medical College and Research Institute, No. 1 Ramachandra Nagar, Porur, Chennai–600116, Tamilnadu, India.
ABSTRACT
We report our experience with a 3–5-cm lower ministernotomy incision for closure of atrial septal defect in 53 patients. Fibrillatory arrest was used in 19 patients, and crossclamping with cardioplegia in 33. One patient had to be converted from fibrillatory arrest to crossclamping with cardioplegic arrest. The mean bypass time was 39.6 ± 13.1 min, arrest time was 9.9 ± 4.5 min, and crossclamp time was 20.7 ± 8.69 min. All patients recovered without adverse events. They were fast tracked to recovery and extubated after 63.4 ± 9.2 min. The mean intensive care unit stay was 1.07 ± 0.33 days, and hospital stay was 3.07 ± 0.38 days. The ministernotomy approach was used successfully in 51 patients; in the other 2, it had to be converted to a full sternotomy because of technical difficulties. Our experience confirms that this technique offers satisfactory cosmetic results, stable sternal reconstruction, good surgical exposure, minimal interference with respiratory mechanics, and minimal pain, allowing extubation in the operating room and a speedy recovery.
Key Words: Atrial Septal Defect • Heart Defects • Congenital • Heart Septal Defects • Atrial • Surgical Procedures • Minimally Invasive
INTRODUCTION
Various minimally invasive techniques have been developed for cardiac surgery. The reduction of perioperative complications, improved postoperative recovery, shortened postoperative hospital stay with resultant lower costs, as well as reduction of pain and improved cosmetic results have led to widespread acceptance of these techniques, even in adults.1 Cosmetic incisions for repair of atrial septal defect (ASD) include a minithoracotomy, ministernotomy, subxiphoid incision, and lower ministernotomy.2 We report our experience of a lower ministernotomy for ASD closure.
PATIENTS AND METHODS
Between January and July 2009, 53 patients with ASD underwent surgical repair via a ministernotomy. The mean age of these patients was 14.4 ± 12.6 years; 26 (49%) were <10 years-old. There were 37 females and 16 males. Their mean weight was 28.5 ± 19.4 kg.
Anesthesia was carried out in the conventional manner. All patients were positioned supine with a shoulder roll to aid exposure. A ministernotomy was performed by splitting the xiphisternum with a skin incision made at the lower end of sternum, measuring approximately 3 cm in children and 5 cm in adults (Figure 1
). Minimal skin flaps were raised in the prepectoral plane, and the xiphoid was completely divided to the junction with the bony sternum. The pericardium was opened, and a pericardial patch was harvested. An aortic stay suture was placed 1 cm above the aortic annulus, and the aorta was pulled inferiorly and anteriorly towards the skin incision. A pursestring suture was placed 1 cm below the aortic-pericardial reflection. The aorta was cannulated in the usual manner. For cardioplegic arrest, a special bulldog/Neuro Clip type of clamp was used. The diaphragmatic attachments were mobilized laterally, particularly on the right side, to facilitate cannulation of the inferior vena cava. A pediatric sternal retractor was used to spread the partial sternotomy (Figure 2). Superior vena caval cannulation was performed using a metal-tipped right-angle venous cannula directly, or through the right atrial appendage using a straight venous cannula. The inferior vena cava was cannulated using a metal-tipped venous cannula, but it was brought through a separate stab incision in the right subcostal region, which was then used as a drain port postoperatively (Figure 3). A vented cardioplegia cannula was placed in the ascending aorta to deliver cardioplegia in patients undergoing cardioplegic arrest. A left ventricular vent was used in all patients, and inserted through the ASD. Antegrade cold blood cardioplegia was infused into the aortic root and the heart was arrested in diastole; in cases of fibrillatory arrest, the heart was fibrillated at this point. A right atriotomy was performed, and the ASD was closed with an autologous pericardial patch (10 patients) or directly with continuous 6/0 Prolene sutures (43 patients). The left heart and aortic root were de-aired, and the aortic clamp was released in cases treated under cardioplegic arrest. The patients were rewarmed completely and weaned off cardiopulmonary bypass with nitroglycerine infusion. The inferior vena caval cannula was removed first, followed by the right atrial cannula in the superior vena cava.
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The mean (± standard deviation) bypass time was 39.6 ± 13.1 min. Fibrillatory arrest was used in 19 patients and crossclamping with cardioplegia was used in 33. In one patient, fibrillatory arrest had to be converted to crossclamping with cardioplegic arrest. The mean fibrillatory arrest time was 9.9 ± 4.5 min, and the crossclamp time was 20.7 ± 8.69 min. The duration of surgery was 129 ± 39.1 min. All patients recovered without adverse events. The patients were fast tracked and extubated 63.4 ± 9.2 min after the end of the procedure; 5 patients were extubated on the operating table, and 17 were extubated within 30 min. The maximum duration of ventilation was 6 h. There was no incidence of arrhythmias or inotropic usage. All patients remained in sinus rhythm, and no cardiac or neurologic complications occurred. The mean intensive care unit stay was 1.07 ± 0.33 days, and hospital stay was 3.07 ± 0.38 days. There were no cases of wound dehiscence or infection. ASD closure was successful via a ministernotomy in 51 patients. The other 2 patients had to be converted to a full sternotomy due to technical difficulties: inability to cannulate the aorta in one, and the other was found to have a superior vena caval type of sinus venous ASD, which was missed in the preoperative echocardiogram. All patients were satisfied with the cosmetic result. Echocardiography showed no residual shunts at 1 month after the operation.
DISCUSSION
As the mortality and morbidity after surgery for congenital heart disease has continued to decline, variables such as recovery time, pain and discomfort, length of hospital stay, cost effectiveness, and cosmesis have become important markers of patient outcome.3 Minimal access cardiac surgery for both adults and children has been advocated over recent years to reduce costs related to intensive care unit and hospital stay and improve cosmetic results. Faster recovery with less respiratory function compromise and reduced pain has been reported.4 The widespread introduction of laparoscopic techniques in various surgical disciplines has resulted in enhanced patient awareness and desire for minimally invasive procedures. To facilitate minimal access cardiac surgery, companies were rapidly formed to provide specialist equipment to access the heart through smaller incisions, often relying on femoral cannulation to achieve cardiopulmonary bypass. New incisions to access portions of the heart were also developed.4 Although important contributions continue to accrue, our group became convinced that access to the heart could be achieved by modifying the traditional sternotomy, incorporating traditional cannulation techniques with more limited exposure of the heart.
There is no doubt that cosmetic results are important to pediatric patients who undergo cardiac surgery, but the most important factors are optimal correction of the cardiac anomaly and avoidance of postoperative complications. As different approaches have been used over the years to correct congenital heart defects in the pediatric population, it is necessary to review their clinical results and reconsider their indications.5 ASD, especially in adults, is a common congenital heart defect in developing countries. Approaches used for closure of ASD in adults include a full sternotomy (18–25 cm), right minithoracotomy (10–12 cm), and lower right-sided sternotomy (10–12 cm);2 however, there is much scope for shorting the length of these incisions. Several attempts have been made to alleviate the psychological sequelae of the unsatisfactory cosmetic results of ASD closure with a conventional sternotomy in otherwise healthy individuals. A right thoracotomy has been considered for several years, especially for female patients. With the aid of new retractors and specially adapted cannulas, a lower ministernotomy has become applicable.6 In our technique, steps were taken to make the incision shorter (<5 cm) compared to those in previous reports. There are several advantages of a lower ministernotomy over other approaches: the right atrium lies directly under the lower sternum, thus exposure is better and manipulation more comfortable; it is easier to convert to a full sternotomy if necessary; it maintains the stability of the sternum without mobilization of breast tissue; and it is less painful than a minithoracotomy.2 Furthermore, there is a better cosmetic result after a 3–5 cm incision.
Patient’s improved self-esteem with better cosmesis, success of the surgical repair, and overall safety of the technique remain paramount goals in any minimally invasive cardiac surgery.7 Although several alternative incisions are currently available, some facilitated with femoral arterial or venous cannulation, we believe that the lower ministernotomy is superior for most patients, based on overall safety and reproducibility with no increase in operative time. Issues for the surgeon, particularly in congenital heart disease, are adequate exposure, safe application of cardiopulmonary bypass through a central or peripheral site, effective myocardial protection, and de-airing before resumption of cardiac ejection.8 The exposure afforded by a lower minister-notomy allows for repair of cardiac malformations such as ventricular septal defect, fibromuscular obstruction of the right ventricular outflow tract, atrioventricular valve abnormalities, and endocardial cushion defects.3 We have used this approach successfully in 2 cases of ventricular septal defect.
The mode of cannulation and access to the venae cavae are key issues in minimally invasive ASD closure. Limited exposure makes the procedure technically difficult.6 The duration of surgery, aortic clamping, and cardiopulmonary bypass vary according to the complexity of the interatrial shunt, the necessity for other procedures, and use of a pericardial patch.9 The small size of the incision makes suture placement more dependent on needle angles, and the rhythm of operating is more difficult to obtain than with the standard midline sternotomy incision. It is difficult when the heart is enlarged because of poor function or chronic arterial hypertension, in obese or deep-chested patients, and those with diffuse coronary disease.10 In contrast to our findings, Sampaio and colleagues9 reported longer durations of surgery, cardiopulmonary bypass, and ischemia with a ministernotomy, possibly because the procedures were performed by more than one surgeon and involved learning curves.
It is important to note that the pursestring sutures in the right atrium, used for cannulation of the inferior vena cava, are a potential source of bleeding in patients undergoing a ministernotomy. This problem can be avoided by first removing the cannula and placing a hemostatic suture with the atrium partially empty.9 We believe that this maneuver is essential to avoid postoperative bleeding. The size of the incision and the sternal division can be easily extended for better exposure if necessary; however, a 4-cm incision and division of the lower half of the sternum was sufficient in most cases. On the other hand, we believe that a transxiphoid approach without sternotomy compromises exposure of the ascending aorta and impairs crossclamping and de-airing. We strongly believe that efforts to minimize surgical access should not compromise safety. ASD closure is known to be a low-risk and high-benefit operation.1 The introduction of new technical devices such as special retractors, and further experience, may solve some of the problems. The skin incision was significantly shorter in our series compared to some other reports, but similar to that described by Sampaio and colleagues.9 Smaller incisions are becoming an expectation of patients and seem to provide accelerated physical recovery. The ideal minimally invasive incision should permit access to all areas of the heart, require a minimum of specialized equipment, and provide the patient with a rapid return to normal activities.10
The assessment of pain in pediatric cardiac surgery is difficult. It is known from adult surgery that a midline sternotomy and ministernotomy are less painful than a lateral thoracotomy; respiratory discomfort is more frequent after a lateral thoracotomy. However, an attempt to show differences in postoperative pain levels in children after minimally invasive ASD closure vs. full sternotomy failed to reach significance.3 Minimal-access surgery raises the issue of shorter hospital stay and cost reduction.11 In this series, the patients seemed to experience less pain, they were kept in the intensive care unit for 1 day, and all except 2 were discharged after 3 days, which is a relatively short period in our current healthcare system. Adequate conclusions about the influence of different surgical techniques on rehabilitation can be made by length of hospital stay. Early discharge after minimally invasive ASD closure is possible and safe. There is no doubt that the reduced in hospital stay in our study was comparable to the usually accepted minimally invasive standards.
Our experience confirms that this technique offers satisfactory cosmetic results, reduces cost, and affords stable sternal reconstruction, good surgical exposure, minimal interference with respiratory mechanics, and minimal pain, with extubation in the operating room and a speedy recovery. Despite the small number of nonrandomized patients, we believe that a limited lower ministernotomy does not compromise exposure of the great vessels and should be favored over other approaches.
ACKNOWLEDGMENTS
We sincerely thank Dr. Harish, Dr. Ramesh, Dr. Usha, and Prof Richard Saldanha for their help in preparing the manuscript.
REFERENCES
Asian Cardiovasc Thorac Ann 2010;
18:166-169
© 2010 by SAGE Publications
DOI: 10.1177/0218492310362004
This article has been cited by other articles:
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  B. R. Karthekeyan Minimally invasive approach for congenital cardiac defects: reply Asian Cardiovasc Thorac Ann, February 1, 2011; 19(1): 79 - 79. [Full Text] [PDF]
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N. Muthialu Minimally Invasive Approach for Congenital Cardiac Defects Asian Cardiovasc Thorac Ann, August 1, 2010; 18(4): 404 - 404. [Full Text] [PDF]
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