Original Article
Minimally invasive pediatric surgery in uncomplicated congenital heart disease
Asian Cardiovascular & Thoracic Annals 21(4) 414–417 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312454669 aan.sagepub.com
Faruk Cingoz1, Murat Tavlasoglu2, Mehmet Ali Sahin1, Mustafa Kurkluoglu3, Adem Guler1, Celalettin Gu¨nay1 and Mehmet Arslan1
Abstract Background: We aimed to highlight the use of a minimally invasive approach in uncomplicated congenital heart surgery. Patients and methods: We investigated retrospectively 32 children below 10 years of age who underwent elective closure of ostium secundum type (n = 27), sinus venosus type (n = 4) and ostium primum type (n = 1) atrial septal defects through a limited skin incision and partial lower sternotomy between August 2001 and December 2008. All patients had cannulation through the same incision for cardiopulmonary bypass. Results: A pericardial patch was used to close the defect in 8 patients and direct suturing in 24. The mean time from the skin incision to cannulation was 56 23 min. Total bypass time was 27 12 min, and crossclamp time was 15 8 min. Mean length of hospital stay was 4 2 days. We did not encounter any complications or mortality. Conclusions: A minimally invasive approach, consisting of a limited skin incision and partial lower sternotomy, is a safe, reliable, and cosmetically advantageous method in uncomplicated congenital heart disease surgery, which can be performed widely, and may replace the standard approach without increasing mortality and morbidity.
Keywords Cardiac surgical procedures, heart defects, congenital, heart septal defects, atrial, sternotomy, surgical procedures, minimally invasive
Introduction Over the last decades, mortality and morbidity after pediatric congenital heart surgery have continued to decline, making minimally invasive approaches a new challenge for surgeons, and increasing the expectation of better cosmetic results. Anterior thoracotomy and minimal sternal division, either upper or lower, with or without video assistance, and the use of femoral artery cannulation to achieve cardiopulmonary bypass (CPB) are some of these approaches in the pediatric population.1–3 The goals during congenital heart disease surgery are adequate exposure for a precise intracardiac repair, safe application of cardiopulmonary bypass through a central or peripheral site, adequate myocardial protection, and effective deairing before resumption of cardiac ejection. A limited skin incision and partial sternotomy represent a very simple method for repair of congenital heart defects.4,5 We have preferred a mini-skin incision and low median sternotomy
technique in children undergoing low-risk cardiac surgical procedures in our center since 2001. This approach allows direct visualization of the surgical area and cannulation of the great vessels, without requiring special instruments to perform the repair. We conducted a retrospective study of patients operated on via a partial lower sternotomy at our institution, to determine the pros and cons of this technique. 1 Department of Cardiovascular Surgery, Gulhane Military Medical Academy, Etlik, Ankara, Turkey 2 Department of Cardiovascular Surgery, Diyarbakir Military Medical Hospital, Diyarbakır, Turkey 3 Department of Cardiovascular Surgery, Children’s National Heart Institute, Children’s National Medical Center, Washington, USA
Corresponding author: Murat Tavlasoglu, MD, Department of Cardiovascular Surgery, Diyarbakir Military Medical Hospital, 21100 Yenis¸ehir, Diyarbakir, Turkey. Email: [email protected]
Downloaded from aan.sagepub.com at UNIV OF NORTH DAKOTA on May 26, 2015
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Figure 1. Healed incision lines and measurements in 2 patients.
Patients and methods The hospital ethics committee approved this study based on retrospective data retrieval, waiving individual consent. Between August 2001 and December 2008, 32 children below 10 years of age underwent elective closure of an ostium secundum type of atrial septal defect (ASD; n = 27), sinus venosus type (n = 4), and ostium primum type (n = 1) through a limited skin incision and partial lower sternotomy. There were 12 boys and 20 girls. Their ages ranged between 20 months and 9 years (mean age, 4 0.5 years). The diagnosis was made by preoperative echocardiography. The ASD were repaired by direct closure in 24 cases and by patch closure in 8. All patients were placed in the supine position, and a roll was used to elevate the inferior portion of the chest to improve exposure. The length of the skin incision was decided by the ratio of the incision (cm) to the patient’s height (m), to obtain a ratio of 5.0–6.0. The mean length was 5.5 1.2 cm. Skin flaps were raised to mobilize the incision. The lower sternum was divided vertically in the midline, using a standard sternotomy saw, from the xiphoid process to the 3rd intercostal space, taking a J or T shape. The upper sternum remained intact. A standard pediatric sternal retractor was used to spread the partial sternotomy. No instruments were used for cephalad retraction. The thymus was partially resected, and the pericardium was opened. The pericardial sac was opened in the midline and divided up to the aortic reflection, leaving enough pericardium on the left side for a possible patch. The retraction stitches placed on the upper edge of the pericardium were attached to the upper skin flap and both edges of the saw-opened sternum. They not only served to elevate the heart anteriorly but also to pull the pericardial cradle downward for better exposure of the upper mediastinal structures. Cannulation pursestring sutures were placed on the ascending aorta, the right atrial appendage, and the atrial-inferior vena caval junction. Following heparinization, aortic cannulation
was performed with the root of the ascending aorta carefully retracted with forceps. The inferior vena cava was drained with a straight venous cannula, and the superior vena cava was intubated through the right atrial appendage with a malleable cannula. After CPB was established, the venae cavae were snared in preparation for total CPB. A cardioplegia cannula was placed in the ascending aorta to deliver antegrade cardioplegia. The aorta was clamped through the incision with a standard crossclamp, and hypothermic cardioplegic arrest was obtained. Defect repair was performed through the right atriotomy, and exposure was adequate for ostium secundum, ostium primum, and sinus venosus types of ASD. We used pericardial patches in 8 cases, and direct suture was the choice in 24. The crossclamp was removed after de-airing through a left ventricular puncture, and air removal was continued through the aortic root. CPB was terminated when rewarming was complete, and the pericardium overlying the great vessels was partially closed. A mediastinal drain was inserted, and the sternotomy was closed with nonabsorbable sutures. Subcutaneous tissue was approximated, and the skin was closed using an intracutaneous running suture method (Figure 1).
Results No intraoperative or perioperative complication occurred, and minimal blood transfusion was needed. No patient required extension of the ministernotomy to improve surgical exposure due to unexpected intraoperative difficulties. There were no deaths in this series. No patient required conversion to a full sternotomy, and there was no reoperation indicated by complications or residual lesions. The mean CPB time was 27 12 min, and crossclamp time was 15 8 min. Drainage ranged between 40 and 110 mL (mean, 66 18 mL). The mean time to extubation was 110 25 min. The mean intensive care unit stay was 18 3 h, and hospital stay was 4 2 days.
Downloaded from aan.sagepub.com at UNIV OF NORTH DAKOTA on May 26, 2015
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Asian Cardiovascular & Thoracic Annals 21(4)
Echocardiography was performed on all the patients postoperatively, and there were no significant residual lesions. The length of the skin incision varied between 3.8 and 10 cm, according to the size of the patient. The ratio of mean skin incision (cm) to mean height (m) was 5.0–6.0, the mean length was 5.5 1.2 cm. The cosmetic results were satisfying.
Discussion Uncomplicated congenital heart diseases, consisting of isolated lesions such as ASD or ventricular septal defect, are repaired with very low mortality and morbidity rates nowadays. In certain patients undergoing short low-risk procedures, cosmetic considerations are of relatively greater importance. Minimally invasive approaches include a range of parasternal or peristernal incisions, partial sternotomies, anterior small thoracotomies, and port-access procedures.6–8 Some of these techniques require special instruments that most surgeons are unfamiliar with; some others require peripheral access to establish CPB, which can jeopardize extremity perfusion in pediatric patients or complicate the surgery. Although this approach is far from novel and is being used in many centers now, the minimally invasive approach in pediatric cardiac surgery is not the standard approach preferred worldwide, and may need standardization; such literature may contribute to improvement. Hence, most of these minimally invasive procedures can be performed only in high-experience centers. We described our experience during the last 8 years with a technique not very different from the standard procedure. A limited skin incision and a partial inferior sternotomy assured perfect exposure of the surgical area. Aortic cannulation and antegrade cardioplegia were performed in the standard fashion quiet easily, while the right atrial exposure was perfect for transatrial procedures. No further equipment was required, and the crossclamp, CPB, and entire procedure times were satisfying. We think that this technique can be performed without difficulty in many centers involved in pediatric congenital heart surgery, and may be considered as a standard procedure for uncomplicated isolated lesions. The small skin incision described in this report is invisible with most casual clothing, satisfying the patients’ and parents’ expectations. Other incisions such as an anterior thoracotomy can be hazardous on a female child’s undeveloped breast, while smaller or inferiorly made incisions can complicate the exposure and the procedure. Moreover, phrenic nerve injury has been reported following ASD closure through an anterior right thoracotomy, and pectoral muscle and breast maldevelopment have been reported after a transverse
infra-mammary incision, along with paresthesia around the breast tissue.9,10 These approaches do not always allow central cannulation for CPB or cardioplegic delivery during intracardiac repair, and require peripheral incisions, increasing the complication rates and worsening cosmetic results.11 Although in a prospective study, Laussen and colleagues12 demonstrated that patient recovery did not differ between a full-length sternotomy and a minimally invasive incision, we think that an inferior ministernotomy can provide better sternal fixation. It is also advantageous in terms of pulmonary mechanics and pain management in these patients, and a larger cohort of patients may reveal a measurable difference in recovery time. There is no need to perform a full sternotomy because a ministernotomy from the xiphoid process to the 3rd intercostal space procures adequate exposure. This limited surgical approach was not associated with an increase in operative or postoperative morbidity. We did not encounter any wound-related complication such as skin necrosis, infection, or widespread ecchymosis. These uncomfortable consequences can occur after excessive spreading or subcutaneous tissue dissection. The moderate spreading and dissection used in our study were sufficient for exposure and surgery. Because this type of uncomplicated surgical procedure generally has a low complication rate, a much larger sample size is necessary to compare specific outcome variables. Nevertheless, from the outcome in our experience we conclude that minimal access surgery can be performed safely without compromising exposure or surgical conditions, and gives improved cosmetic results. It can easily be performed by all surgeons practicing pediatric congenital heart surgery, without advanced equipment or further training. We have preferred this approach since 2001, and it may become the standard approach for simple congenital heart defects, leading to further improvement in complex congenital heart surgery. The new approaches in minimally invasive pediatric surgery include a right axillary thoracotomy and right anterior minithoracotomy. Nguyen and colleagues13 demonstrated successful repair of congenital heart defects in pediatric patients through an axillary incision, and Mishaly and colleagues14 described a right anterior minithoracotomy approach. The study volume may not be large, but there are enough reports to encourage us to perform this minimal invasive approach in pediatric patients with uncomplicated congenital heart disease. For complicated congenital heart disease, more clinical reports and prospective randomized trials may be necessary to promote the development and clinical applications of a minimal invasive approach. This minimally invasive approach may encourage surgeons to perform a
Downloaded from aan.sagepub.com at UNIV OF NORTH DAKOTA on May 26, 2015
Cingoz et al.
417
port-access procedure for better cosmetic results and less complications in pediatric patients. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Rosengart TK and Stark JF. Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg 1993; 55: 1138–1140. 2. Luciani GB, Piccin C and Mazzucco A. Minimal-access median sternotomy for repair of congenital heart defects. J Thorac Cardiovasc Surg 1998; 116: 357–358. 3. Chang CH, Lin PJ, Chu JJ, Liu HP, Tsai FC, Lin FC, et al. Video-assisted cardiac surgery in closure of atrial septal defect. Ann Thorac Surg 1996; 62: 697–701. 4. Wilson WR, Ilbawi MN, DeLeon SY, Piccione W, Tubeszewski K and Cutilletta AF. Partial median sternotomy for repair of heart defects: a cosmetic approach. Ann Thorac Surg 1992; 54: 892–893. 5. Komai H, Naito Y, Fujikawa K, Takagaki Y, Nishimura Y, Kawasaki S, et al. Lower mid-line skin incision and minimal sternotomy-a more cosmetic challenge for pediatric surgery. Cardiol Young 1996;6:76–9. Available at: http://journals.cambridge.org/action/ displayAbstract?fromPage=online&aid=1645084&fulltextType=RA&fileId=S1047951100003292. Accessed June 22, 2012. 6. Cosgrove 3rd DM and Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996; 62: 596–597.
7. Calafiore AM, Di Giammarco GD, Teodori G, Bosco G, D’Annunzio E, Barsotti A, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996; 61: 1658–1663. 8. Stevens JH, Burdon TA, Peters WS, Siegel LC, Pompili MF, Vierra MA, et al. Port-access coronary artery bypasses grafting: a proposed surgical method. J Thorac Cardiovasc Surg 1996; 111: 567–573. 9. Helps BA, Ross-Russell RI, Dicks-Mireaux and Elliott MJ. Phrenic nerve damage via a right thoracotomy in older children with secundum ASD. Ann Thorac Surg 1993 56: 328–330. 10. Cherup LL, Siewers RD and Futrell JW. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg 1986 41: 492–497. 11. Lin PJ, Chang CH, Chu JJ, Liu HP, Tsai FC, Su WJ, et al. Minimally invasive cardiac surgical techniques in the closure of ventricular septal defect: an alternative approach. Ann Thorac Surg 1998 65: 165–169. 12. Laussen PC, Bichell DP, McGowan FX, Zurakowski D, DeMaso DR and del Nido PJ. Postoperative Recovery in Children After Minimum Versus Full-Length Sternotomy. Ann Thorac Surg 2000 69: 591–596. 13. Nguyen K, Chin C, Lee DS, Mittnacht A, Srivastava S, Umesh J, et al. The axillary incision: a cosmetic approach in congenital cardiac surgery. J Thorac Cardiovasc Surg 2007 134: 1358–1360. 14. Mishaly D, Ghosh P and Preisman S. Minimally invasive congenital cardiac surgery through right anterior minithoracotomy approach. Ann Thorac Surg 2008 85: 831–835.
Downloaded from aan.sagepub.com at UNIV OF NORTH DAKOTA on May 26, 2015
Minimally invasive pediatric surgery in uncomplicated congenital heart disease
Asian Cardiovascular & Thoracic Annals 21(4) 414–417 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312454669 aan.sagepub.com
Faruk Cingoz1, Murat Tavlasoglu2, Mehmet Ali Sahin1, Mustafa Kurkluoglu3, Adem Guler1, Celalettin Gu¨nay1 and Mehmet Arslan1
Abstract Background: We aimed to highlight the use of a minimally invasive approach in uncomplicated congenital heart surgery. Patients and methods: We investigated retrospectively 32 children below 10 years of age who underwent elective closure of ostium secundum type (n = 27), sinus venosus type (n = 4) and ostium primum type (n = 1) atrial septal defects through a limited skin incision and partial lower sternotomy between August 2001 and December 2008. All patients had cannulation through the same incision for cardiopulmonary bypass. Results: A pericardial patch was used to close the defect in 8 patients and direct suturing in 24. The mean time from the skin incision to cannulation was 56 23 min. Total bypass time was 27 12 min, and crossclamp time was 15 8 min. Mean length of hospital stay was 4 2 days. We did not encounter any complications or mortality. Conclusions: A minimally invasive approach, consisting of a limited skin incision and partial lower sternotomy, is a safe, reliable, and cosmetically advantageous method in uncomplicated congenital heart disease surgery, which can be performed widely, and may replace the standard approach without increasing mortality and morbidity.
Keywords Cardiac surgical procedures, heart defects, congenital, heart septal defects, atrial, sternotomy, surgical procedures, minimally invasive
Introduction Over the last decades, mortality and morbidity after pediatric congenital heart surgery have continued to decline, making minimally invasive approaches a new challenge for surgeons, and increasing the expectation of better cosmetic results. Anterior thoracotomy and minimal sternal division, either upper or lower, with or without video assistance, and the use of femoral artery cannulation to achieve cardiopulmonary bypass (CPB) are some of these approaches in the pediatric population.1–3 The goals during congenital heart disease surgery are adequate exposure for a precise intracardiac repair, safe application of cardiopulmonary bypass through a central or peripheral site, adequate myocardial protection, and effective deairing before resumption of cardiac ejection. A limited skin incision and partial sternotomy represent a very simple method for repair of congenital heart defects.4,5 We have preferred a mini-skin incision and low median sternotomy
technique in children undergoing low-risk cardiac surgical procedures in our center since 2001. This approach allows direct visualization of the surgical area and cannulation of the great vessels, without requiring special instruments to perform the repair. We conducted a retrospective study of patients operated on via a partial lower sternotomy at our institution, to determine the pros and cons of this technique. 1 Department of Cardiovascular Surgery, Gulhane Military Medical Academy, Etlik, Ankara, Turkey 2 Department of Cardiovascular Surgery, Diyarbakir Military Medical Hospital, Diyarbakır, Turkey 3 Department of Cardiovascular Surgery, Children’s National Heart Institute, Children’s National Medical Center, Washington, USA
Corresponding author: Murat Tavlasoglu, MD, Department of Cardiovascular Surgery, Diyarbakir Military Medical Hospital, 21100 Yenis¸ehir, Diyarbakir, Turkey. Email: [email protected]
Downloaded from aan.sagepub.com at UNIV OF NORTH DAKOTA on May 26, 2015
Cingoz et al.
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Figure 1. Healed incision lines and measurements in 2 patients.
Patients and methods The hospital ethics committee approved this study based on retrospective data retrieval, waiving individual consent. Between August 2001 and December 2008, 32 children below 10 years of age underwent elective closure of an ostium secundum type of atrial septal defect (ASD; n = 27), sinus venosus type (n = 4), and ostium primum type (n = 1) through a limited skin incision and partial lower sternotomy. There were 12 boys and 20 girls. Their ages ranged between 20 months and 9 years (mean age, 4 0.5 years). The diagnosis was made by preoperative echocardiography. The ASD were repaired by direct closure in 24 cases and by patch closure in 8. All patients were placed in the supine position, and a roll was used to elevate the inferior portion of the chest to improve exposure. The length of the skin incision was decided by the ratio of the incision (cm) to the patient’s height (m), to obtain a ratio of 5.0–6.0. The mean length was 5.5 1.2 cm. Skin flaps were raised to mobilize the incision. The lower sternum was divided vertically in the midline, using a standard sternotomy saw, from the xiphoid process to the 3rd intercostal space, taking a J or T shape. The upper sternum remained intact. A standard pediatric sternal retractor was used to spread the partial sternotomy. No instruments were used for cephalad retraction. The thymus was partially resected, and the pericardium was opened. The pericardial sac was opened in the midline and divided up to the aortic reflection, leaving enough pericardium on the left side for a possible patch. The retraction stitches placed on the upper edge of the pericardium were attached to the upper skin flap and both edges of the saw-opened sternum. They not only served to elevate the heart anteriorly but also to pull the pericardial cradle downward for better exposure of the upper mediastinal structures. Cannulation pursestring sutures were placed on the ascending aorta, the right atrial appendage, and the atrial-inferior vena caval junction. Following heparinization, aortic cannulation
was performed with the root of the ascending aorta carefully retracted with forceps. The inferior vena cava was drained with a straight venous cannula, and the superior vena cava was intubated through the right atrial appendage with a malleable cannula. After CPB was established, the venae cavae were snared in preparation for total CPB. A cardioplegia cannula was placed in the ascending aorta to deliver antegrade cardioplegia. The aorta was clamped through the incision with a standard crossclamp, and hypothermic cardioplegic arrest was obtained. Defect repair was performed through the right atriotomy, and exposure was adequate for ostium secundum, ostium primum, and sinus venosus types of ASD. We used pericardial patches in 8 cases, and direct suture was the choice in 24. The crossclamp was removed after de-airing through a left ventricular puncture, and air removal was continued through the aortic root. CPB was terminated when rewarming was complete, and the pericardium overlying the great vessels was partially closed. A mediastinal drain was inserted, and the sternotomy was closed with nonabsorbable sutures. Subcutaneous tissue was approximated, and the skin was closed using an intracutaneous running suture method (Figure 1).
Results No intraoperative or perioperative complication occurred, and minimal blood transfusion was needed. No patient required extension of the ministernotomy to improve surgical exposure due to unexpected intraoperative difficulties. There were no deaths in this series. No patient required conversion to a full sternotomy, and there was no reoperation indicated by complications or residual lesions. The mean CPB time was 27 12 min, and crossclamp time was 15 8 min. Drainage ranged between 40 and 110 mL (mean, 66 18 mL). The mean time to extubation was 110 25 min. The mean intensive care unit stay was 18 3 h, and hospital stay was 4 2 days.
Downloaded from aan.sagepub.com at UNIV OF NORTH DAKOTA on May 26, 2015
416
Asian Cardiovascular & Thoracic Annals 21(4)
Echocardiography was performed on all the patients postoperatively, and there were no significant residual lesions. The length of the skin incision varied between 3.8 and 10 cm, according to the size of the patient. The ratio of mean skin incision (cm) to mean height (m) was 5.0–6.0, the mean length was 5.5 1.2 cm. The cosmetic results were satisfying.
Discussion Uncomplicated congenital heart diseases, consisting of isolated lesions such as ASD or ventricular septal defect, are repaired with very low mortality and morbidity rates nowadays. In certain patients undergoing short low-risk procedures, cosmetic considerations are of relatively greater importance. Minimally invasive approaches include a range of parasternal or peristernal incisions, partial sternotomies, anterior small thoracotomies, and port-access procedures.6–8 Some of these techniques require special instruments that most surgeons are unfamiliar with; some others require peripheral access to establish CPB, which can jeopardize extremity perfusion in pediatric patients or complicate the surgery. Although this approach is far from novel and is being used in many centers now, the minimally invasive approach in pediatric cardiac surgery is not the standard approach preferred worldwide, and may need standardization; such literature may contribute to improvement. Hence, most of these minimally invasive procedures can be performed only in high-experience centers. We described our experience during the last 8 years with a technique not very different from the standard procedure. A limited skin incision and a partial inferior sternotomy assured perfect exposure of the surgical area. Aortic cannulation and antegrade cardioplegia were performed in the standard fashion quiet easily, while the right atrial exposure was perfect for transatrial procedures. No further equipment was required, and the crossclamp, CPB, and entire procedure times were satisfying. We think that this technique can be performed without difficulty in many centers involved in pediatric congenital heart surgery, and may be considered as a standard procedure for uncomplicated isolated lesions. The small skin incision described in this report is invisible with most casual clothing, satisfying the patients’ and parents’ expectations. Other incisions such as an anterior thoracotomy can be hazardous on a female child’s undeveloped breast, while smaller or inferiorly made incisions can complicate the exposure and the procedure. Moreover, phrenic nerve injury has been reported following ASD closure through an anterior right thoracotomy, and pectoral muscle and breast maldevelopment have been reported after a transverse
infra-mammary incision, along with paresthesia around the breast tissue.9,10 These approaches do not always allow central cannulation for CPB or cardioplegic delivery during intracardiac repair, and require peripheral incisions, increasing the complication rates and worsening cosmetic results.11 Although in a prospective study, Laussen and colleagues12 demonstrated that patient recovery did not differ between a full-length sternotomy and a minimally invasive incision, we think that an inferior ministernotomy can provide better sternal fixation. It is also advantageous in terms of pulmonary mechanics and pain management in these patients, and a larger cohort of patients may reveal a measurable difference in recovery time. There is no need to perform a full sternotomy because a ministernotomy from the xiphoid process to the 3rd intercostal space procures adequate exposure. This limited surgical approach was not associated with an increase in operative or postoperative morbidity. We did not encounter any wound-related complication such as skin necrosis, infection, or widespread ecchymosis. These uncomfortable consequences can occur after excessive spreading or subcutaneous tissue dissection. The moderate spreading and dissection used in our study were sufficient for exposure and surgery. Because this type of uncomplicated surgical procedure generally has a low complication rate, a much larger sample size is necessary to compare specific outcome variables. Nevertheless, from the outcome in our experience we conclude that minimal access surgery can be performed safely without compromising exposure or surgical conditions, and gives improved cosmetic results. It can easily be performed by all surgeons practicing pediatric congenital heart surgery, without advanced equipment or further training. We have preferred this approach since 2001, and it may become the standard approach for simple congenital heart defects, leading to further improvement in complex congenital heart surgery. The new approaches in minimally invasive pediatric surgery include a right axillary thoracotomy and right anterior minithoracotomy. Nguyen and colleagues13 demonstrated successful repair of congenital heart defects in pediatric patients through an axillary incision, and Mishaly and colleagues14 described a right anterior minithoracotomy approach. The study volume may not be large, but there are enough reports to encourage us to perform this minimal invasive approach in pediatric patients with uncomplicated congenital heart disease. For complicated congenital heart disease, more clinical reports and prospective randomized trials may be necessary to promote the development and clinical applications of a minimal invasive approach. This minimally invasive approach may encourage surgeons to perform a
Downloaded from aan.sagepub.com at UNIV OF NORTH DAKOTA on May 26, 2015
Cingoz et al.
417
port-access procedure for better cosmetic results and less complications in pediatric patients. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Rosengart TK and Stark JF. Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg 1993; 55: 1138–1140. 2. Luciani GB, Piccin C and Mazzucco A. Minimal-access median sternotomy for repair of congenital heart defects. J Thorac Cardiovasc Surg 1998; 116: 357–358. 3. Chang CH, Lin PJ, Chu JJ, Liu HP, Tsai FC, Lin FC, et al. Video-assisted cardiac surgery in closure of atrial septal defect. Ann Thorac Surg 1996; 62: 697–701. 4. Wilson WR, Ilbawi MN, DeLeon SY, Piccione W, Tubeszewski K and Cutilletta AF. Partial median sternotomy for repair of heart defects: a cosmetic approach. Ann Thorac Surg 1992; 54: 892–893. 5. Komai H, Naito Y, Fujikawa K, Takagaki Y, Nishimura Y, Kawasaki S, et al. Lower mid-line skin incision and minimal sternotomy-a more cosmetic challenge for pediatric surgery. Cardiol Young 1996;6:76–9. Available at: http://journals.cambridge.org/action/ displayAbstract?fromPage=online&aid=1645084&fulltextType=RA&fileId=S1047951100003292. Accessed June 22, 2012. 6. Cosgrove 3rd DM and Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996; 62: 596–597.
7. Calafiore AM, Di Giammarco GD, Teodori G, Bosco G, D’Annunzio E, Barsotti A, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996; 61: 1658–1663. 8. Stevens JH, Burdon TA, Peters WS, Siegel LC, Pompili MF, Vierra MA, et al. Port-access coronary artery bypasses grafting: a proposed surgical method. J Thorac Cardiovasc Surg 1996; 111: 567–573. 9. Helps BA, Ross-Russell RI, Dicks-Mireaux and Elliott MJ. Phrenic nerve damage via a right thoracotomy in older children with secundum ASD. Ann Thorac Surg 1993 56: 328–330. 10. Cherup LL, Siewers RD and Futrell JW. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg 1986 41: 492–497. 11. Lin PJ, Chang CH, Chu JJ, Liu HP, Tsai FC, Su WJ, et al. Minimally invasive cardiac surgical techniques in the closure of ventricular septal defect: an alternative approach. Ann Thorac Surg 1998 65: 165–169. 12. Laussen PC, Bichell DP, McGowan FX, Zurakowski D, DeMaso DR and del Nido PJ. Postoperative Recovery in Children After Minimum Versus Full-Length Sternotomy. Ann Thorac Surg 2000 69: 591–596. 13. Nguyen K, Chin C, Lee DS, Mittnacht A, Srivastava S, Umesh J, et al. The axillary incision: a cosmetic approach in congenital cardiac surgery. J Thorac Cardiovasc Surg 2007 134: 1358–1360. 14. Mishaly D, Ghosh P and Preisman S. Minimally invasive congenital cardiac surgery through right anterior minithoracotomy approach. Ann Thorac Surg 2008 85: 831–835.
Downloaded from aan.sagepub.com at UNIV OF NORTH DAKOTA on May 26, 2015
