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Ann Thorac Surg 1998;66:431-435
© 1998 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, Lahey Hitchcock Clinic, Burlington, Massachusetts, USA
Accepted for publication March 11, 1998.
Address reprint requests to Dr Svensson, Department of Thoracic and Cardiovascular Surgery, Lahey Hitchcock Clinic, 41 Mall Rd, Burlington, MA 01805
Background. We compared five current minimal-access approaches, namely, parasternal incision, transverse sternotomy, manubrial inverted "T" incision, incomplete mediastinotomy, and our "J/j" incision, to operations in matched patients, including aortic operations.
Methods. In a case-control study of 74 patients, 37 individuals consecutively underwent minimal-access operations (aortic valve, 18, including one mitral valve operation; composite valve graft, six, including one arch and one transaortic mitral valve operation for a patient with Marfan’s syndrome; ascending aorta operation, two; root repair/reconstruction, three; mitral valve repair/replacement, seven, including one maze operation; and atrioseptal defect repair, one). The patients were matched by sex, age, surgeon, and operation with 37 control patients who had standard incisions. Patients having the "J/j" incision (n = 25) had sternotomies from the first right intercostal space, or sternal notch, to the third to fifth right intercostal space.
Results. Minimal-access patients had a shorter postoperative hospital stay than standard incision patients (6.2 versus 8.2 days; p = 0.0055), and required similar volumes of blood (0.86 versus 1.03 units; p = 0.7243), postoperative morphine dosages (28 mg versus 40 mg, p = 0.0643), and oral narcotics (8.1 versus 10.0 doses; p = 0.3562). "J/j" incision patients, however, required less morphine (20.6 mg versus 40.9 mg; p = 0.0028), but not fewer doses of oral narcotics (7.5 versus 9.9 doses; p = 0.2640) and had the shortest postoperative stay (5.1 versus 8.1 days; p < 0.0001). No stroke or clinically noted neurocognitive deficit developed. One minimal-access patient (1/37, 2.7%) with severe preoperative pulmonary morbidity died of adult respiratory distress syndrome. Sternal nonunion developed in 1 patient with an inverted "T" manubrial incision. In a further seven patients, the "J/j" incision was used without a problem, for a total of 32 patients. This compared with a consecutive series of 125 aortic valve replacement operations without a death and 181 patients undergoing ascending arch operations with two 30-day hospital deaths (1.1%) and two strokes (1.1%).
Conclusion. Minimal-access incisions are associated with shorter hospital stays. For the "J/j" incision, even if used for more extensive double-valve, ascending aortic arch, or composite valve operations, postoperative pain appears to be less and patients are discharged even earlier.
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