Ann Thorac Surg 1997;64:1492-1494
© 1997 The Society of Thoracic Surgeons
How To Do It
Videothoracoscopic Surgical Interruption of Patent Ductus Arteriosus
Emmanuel Le Bret, MD,
Thierry A. Folliguet, MD,
François Laborde, MD
Department of Cardiopediatric Surgery, L'Institut Mutualiste Montsouris, Paris, France
Accepted for publication May 28, 1997.
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Abstract
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A videothoracoscopic surgical technique for closure of patent ductus arteriosus in children is described. Only three ports of access are necessary to dissect the patent ductus arteriosus from the surrounding tissues and to apply the two titanium clips. The advantages given are the technique's low morbidity, lack of mortality, and reliable closure. We believe that the videothoracoscopic surgical approach is the technique of choice for patent ductus arteriosus closure in children.
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Introduction
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Patent ductus arteriosus (PDA) was first surgically ligated in 1939 by Gross and Hubbard [1]. Since then, the surgical technique of choice has been left thoracotomy with simple ligation, multiple transfixed ligatures, titanium clipping occlusion, or suture and division. The advantages given are its low lack of mortality and reliable PDA closure, but the potential morbidity of thoracotomy is important, especially in infants. Postthoracotomy pain remains an important problem, because 55% of patients complain of pain at 1 year, and 30% at 4 years [2, 3], and therefore the risk of postoperative pulmonary complications represented by atelectasis and pneumonia is increased [4]. In addition, the incidence of thoracic scoliosis as a long-term complication in premature infants [5] is greater than 20% to 30%.
Percutaneous catheter closure of the PDA was first described in 1971 [6]. The advantage offered by this technique is avoidance of any incision, but the main disadvantage remains persistent shunting, at a rate on the order of 27% at 6-week follow-up, which decreases generally to 15% at 6 months. In addition, this technique is applicable only for patients weighing more than 10 kg because the size of these small vessels makes the use of the device difficult [7].
To circumvent these problems, we present here our technique [8] of PDA closure by videothoracoscopic surgery in infants and children, which involves less discomfort and morbidity than the classic surgical thoracotomy and which provides an optimal rate of success.
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Technique
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Anesthesia and Preparation
General anesthesia is performed with pentothal at a dose of 5 to 10 mg/kg, vecuronium at a dose of 0.1 mg/kg, fentanyl at a dose of 0.5 to 1 mg/kg, and 1% to 2% enflurane. A central line is placed via the jugular vein without any arterial line. An electrocardiographic monitor, oximeter, and capnograph are routinely placed.
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Procedure
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After induction of general anesthesia and standard intubation, the patient is positioned on his or her right side, as for a posterolateral thoracotomy. The skin is prepared with two povidone iodine scrubs, and a regular drape is placed. The surgeon and the scrub nurse are on the left side of the patient, the assistant on the right.
Two small incisions with an 11 blade are made in the left hemithorax: the first incision is made just posterior to the scapula in the third intercostal space for the videothoracoscope (4 mm in diameter) introduced via a 5-mm trocar. A second incision is performed in the fourth intercostal space underneath the angle of the scapula for the electrocautery hook introduced via a 5-mm trocar. Two or three 60-degree angled hooks, 1 mm in diameter, are introduced directly through the third intercostal space in its middle part, just in front of the scapula, for lung retraction (Fig 1
).
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Fig 1. . (A) Position of the patient and setup of the various ports: (1) angled hook retractor (1 mm), (2) electrocautery hook (5 mm), and (3) camera (5 mm). (B) Illustration showing ports and instruments for videothoracoscopic closure of patent ductus arteriosus.
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The monitor is placed on the right side of the patient facing the surgeon; the cables come also from the right side and are clamped to the drape. Instruments used for the videothoracoscopic operation include scissors, dissectors, electrocautery hooks, a clip applier, a lung retractor, and a suction device. The operative field is viewed on the video screen by means of the video camera, and the picture can be stored on a video recorder.
The upper lobe of the left lung is retracted inferomedially with the angled hooks, the PDA is identified, and the mediastinal pleura is opened with the electrocautery hook. The PDA is dissected from the surrounding tissues and the aorta is dissected at its junction with the PDA. The pericardium is dissected on the pulmonary side to protect the recurrent laryngeal nerve from any traumatic injury (Fig 2). It is essential to dissect on both sides of the PDA to place the clip adequately. The clip applier is then introduced without any trocar through the access of the fourth intercostal space. A first titanium clip (9 mm) is placed as distal as possible from the aortic junction on the pulmonary side of the PDA (Fig 3A), and a second clip is applied on the side close to the aorta (Fig 3B). After visual confirmation that both clips are well in place, the lung is inflated and a 2-mm-diameter pleural suction catheter is placed before closure of the 5-mm skin incisions with sutures (Fig 4).
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Fig 2. . The patent ductus arteriosus is dissected from surrounding tissues and the recurrent laryngeal nerve is visualized and respected.
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Fig 3. . (A) A first titanium clip (9 mm) is placed as distal as possible from the aortic junction. (B) View of the procedure with the two clips in place. (1 = pericardial reflection; 2 = titanium clips; 3 = upper left lung lobe; 4 = mediastinal pleura; 5 = recurrent nerve; 6 = descending thoracic aorta.)
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Postoperative Care
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Color-flow Doppler echocardiography is performed in the operating room or in the recovery room before extubation to assess the completeness of closure of the PDA. If there is a persistent shunt, the patient is taken back immediately to the operative room for reapplication of a new clip by videothoracoscopy. Otherwise, if complete interruption is seen, extubation is performed and patients are placed either in the intensive care unit or in a regular pediatric room, according to age and previous symptoms of pulmonary hypertension. The pleural suction catheter is removed a few hours after extubation, a routine chest roentgenogram is obtained, and a transthoracic echocardiogram is done before discharge. All patients are then regularly followed up by their own pediatric cardiologist, who performs a complete physical and transthoracic echocardiogram examination.
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Comment
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We have used this technique since 1991 in more than 340 patients. More than 29% were younger than 6 months, and the mean weight for the entire series was 12.8 kg, with 3 patients weighing less than 1.9 kg. The mean operating time for the last 300 patients was 20 minutes. There were no deaths, hemorrhages, transfusions required, or episodes of chylothorax. Five patients had a persistent PDA detected by echocardiography performed in the operating room, all early in our experience and related to insufficient dissection resulting in inadequate clip placement. Four had immediate clip repositioning by videothoracoscopy and one by thoracotomy. Subsequent echocardiography revealed complete closure in these patients. A residual PDA with minimal flow was discovered in 1 patient without symptoms after discharge. This patient is being regularly followed up with echocardiography and has no increase in flow. This complication cannot be seen actually, because we perform routine transthoracic echocardiography before extubation. Recurrent laryngeal nerve dysfunction was noted in 6 patients (transient in 5 and persistent in 1). No complications or sequelae occurred in our last 300 patients. We believe that dissection must be sufficient to place the clip correctly, but not too extensive to avoid a transient left vocal cord paralysis.
The only contraindication to this procedure is if the diameter of the ductus is greater than the size of the clip (9 mm) or if the ductus is calcified. Both of these situations can be encountered in older children or adults. In children, the only contraindication would be a previous thoracotomy with pleural adhesions. However, videothoracoscopic closure can also be performed after an attempt at percutaneous catheter closure with the device in place and a persistent shunt (as it was in 3 patients).
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Footnotes
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Address reprint requests to Dr Le Bret, Department of Cardiopediatric Surgery, Institut Mutualiste de la Porte de Choisy, 6 place Port au Prince, 75013 Paris, France.
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References
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- Gross RE, Hubbard JP. Surgical ligation of a patent ductus arteriosus. Report of first successful case. JAMA 1939;112:729–31.[Abstract/Free Full Text]
- Dajczman E, Gordon A, Kreisman H, Wolkove N. Long-term post-thoracotomy pain. Chest 1991;99:270–4.[Abstract/Free Full Text]
- Landreneau RJ, Mack MJ, Hazelrigg SR, et al. Prevalence of chronic pain after pulmonary resection by thoracotomy or video-assisted thoracic surgery. J Thorac Cardiovasc Surg 1994;107:1079–86.[Abstract/Free Full Text]
- Nomori H, Horio H, Fuyuno G, Kobayashi R, Yashima H. Respiratory muscle strength after lung resection with special reference to age and procedures of thoracotomy. Eur J Cardiothorac Surg 1996;10:352–8.[Abstract]
- Shelton JE, Walburg JR, Schneider E. Functional scoliosis as a long term complication of surgical ligation for patent ductus arteriosus in premature infant. J Pediatr Surg 1986;48A:855–7.
- Porstmann W, Wierny L, Warnake H, et al. Catheter closure of patent ductus arteriosus: 62 cases treated without thoracotomy. Radiol Clin North Am 1971;9:203–18.[Medline]
- Hosking MC, Benson LN, Musewe N, Dyck JD, Freedom RM. Transcatheter occlusion of the persistently patent ductus arteriosus: forty month follow-up and prevalence of residual shunting. Circulation 1991;84:2313–7.[Abstract/Free Full Text]
- Laborde F, Folliguet T, Batisse A, et al. Video-assisted thoracoscopic surgical interruption: the technique of choice for patent ductus arteriosus. J Thorac Cardiovasc Surg 1995;110:1681–5.[Abstract/Free Full Text]
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Abstract
Introduction
