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Ann Thorac Surg 1999;68:2310-2313
© 1999 The Society of Thoracic Surgeons

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Original Articles

Role of limited posterior thoracotomy for open-heart surgery in the current era

^a Institute of Cardio-Vascular Diseases, Mogappair, Chennai, India

Address reprint requests to Dr Shivaprakasha, Division of Pediatric Cardiac Surgery, Institute of Cardio-Vascular Diseases, Mogappair, Chennai-600050, India

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. The earliest open-heart operations were performed employing the thoracotomy approach. Over the years, median sternotomy has become the routine way of approaching the heart. However, lately there has been progressive enthusiasm in minimally invasive techniques for accessing the heart. We present our technique of correction of congenital heart defects employing the limited posterior thoracotomy approach.

Methods. From June 1997 to April 1998, 27 patients underwent correction for various intracardiac defects without any mortality. There were 19 ostium secundum defects, with or without other associated anomalies. There were six sinus venosus defects with partial anomalous pulmonary venous connections. Two patients had perimembranous ventricular septal defects, while 2 patients had partial atrioventricular defects. In 2 other patients, pulmonary stenosis was repaired, using pulmonary valvotomy in 1 patient, whereas the other patient required short transannular patch.

Results. The median age was 7 years and the median weight was 20 kg. The median skin-to-skin time was 260 minutes. The median bypass time was 63.25 minutes and the median cross-clamp time was 35.0 minutes. All the patients were extubated within 12 hours following surgery and the median ICU stay was 24 hours. Three patients required blood transfusions in the ICU for significant blood loss and the mean chest drainage was 85 cc per 24 hours. None of the patients had phrenic nerve palsies. None of the patients required additional analgesics other than routine ibuprofen or ketorolac tromethamine. Short-term follow-up revealed no functional or physical disability of the thoracic wall and the right arm. All who underwent surgery with this approach were happy with the limited visibility of their scars.

Conclusions. Limited posterior thoracotomy offers a viable alternative for midsternotomy and submammary thoracotomy. It has the advantage of a scar in the back that does not impede the future growth of the breast tissue and the pectoralis major. Our approach does not need any new instruments and hence no contraptions are necessary to perform the operation with this approach. Our results have shown satisfactory short-term results and better cosmesis.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Minimally invasive surgical techniques are gaining in popularity as they continue to evolve [1]. In the earliest open-heart operations employing the heart-lung machine, submammary thoracotomy incision was routine [2]. However, over the years, median sternotomy has become the standard approach for accessing the heart during open-heart surgeries [3, 4]. Nonetheless, anterolateral thoracotomy has also gained acceptance, owing to its cosmetic superiority, and is being used for diverse indications [5]. However, our experience has shown that anterolateral thoracotomy frequently crosses the future breast tissue and becomes cosmetically disfiguring. Our paper discusses the utility of limited posterior thoracotomy in the current scenario for approaching the heart in addition to the existing approaches and discusses the advantage of the technique.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Between June 1997 and April 1998, 27 patients underwent open-heart procedures through posterior thoracotomy incision. All patients were given explanations of the various approaches for the surgical repair, and posterior thoracotomy was employed for those patients who were willing to undergo surgery with this approach. There were 6 male patients and 21 female patients. The median age was 7 years and the range varied from 2.1 years to 41 years. The median weight was 20.0 kg with a range of 10–64 kg The heart defects that needed correction are described, with the procedures performed, in Table 1.

View larger version (12K): [in this window] [in a new window]   Fig 1. Illustration showing the limited posterior thoracotomy.

View larger version (48K): [in this window] [in a new window]   Fig 2. Exposure of cardiac structures after the pericardial traction stitches.

View larger version (39K): [in this window] [in a new window]   Fig 3. Cardioplegia after the cardiopulmonary bypass with bicaval cannulation.

	Results

Top Abstract Introduction Material and methods Results Comment References

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
The posterolateral thoracotomy is one of the most frequently used incisions in closed cardiac and thoracic surgeries. However, the midsternotomy has been a successful way of approaching the heart since open-heart surgery started as a successful therapeutic option in medicine. Nonetheless, the concept of cosmesis in cardiac surgery started only when the safety of the open-heart surgery was beyond any doubt. We reported our experience with anterior thoracotomy approach for management of various open-heart procedures [6]. One of the important reasons behind use of that technique was better cosmesis with less incidence of keloid formation.

However, our experience with the anterior thoracotomy over the years revealed a drawback when the technique is employed in prepubertal age group of patients. The flaw is that it is very difficult to predict the quantum of the breast growth in individual female children after they attain puberty. Our experience has showed that anterior thoracotomy incision infrequently crosses the future breast line and becomes cosmetically disfiguring. The recognition of the maldevelopment of breast and pectoralis muscle spurred us to try this new approach. There are several earlier reports that have revealed this drawback associated with the periareolar numbness or hypoesthesia [5, 7, 8]. In addition, it is reported in the literature that the breast tissue extends beyond the nipple-areola complex; obviously this tissue is susceptible to anterior thoracotomy incision [9]. However, we initially applied the approach to all consecutive patients who presented to us for closure of atrial septal defects, irrespective of their gender and age. For a wider margin of safety, we selectively chose patients with lesions other than ASDs. Nonetheless, our experience has shown that this approach carries no additional morbidity. However, the surgeon should have expertise in anterolateral thoracotomies to employ this approach. We have employed the anterolateral thoracotomy approach for surgical interventions in diverse lesions, experience which has been previously published [6]. In addition, there are recent reports that advocate minimally invasive limited sternotomies with or without elaborate instruments to enhance the exposure, which we have found to be unnecessary [1, 10–13]. Moreover, as reported earlier, complete visualization of cephaloid structures may be restricted and anomalous pulmonary venous connection could require surgery if the anomalous vein drains more cephaloid into the superior vena cava and with these approaches, they could be a demanding surgical exercise [7]. In our experience with this approach, access to the aorta and the cavae was never a problem and hence none of the patients had femoral cannulation.

None of our patients had intractable pain because of the incision, because electively all the patients received oral ibuprofen or parental ketorolac tromethamine depending upon their feeding status. We presume the lower incidence of intractable pain is due to our more limited incision (compared to the incision used in a formal posterolateral thoracotomy). However, we hasten to add that we do not have objective evidence to support this claim. So far, we have not had phrenic nerve palsies, because the nerve is readily visible with our approach and the dissection always is carried out away from the nerve.

The repeat sternotomy carries always some morbidity vis-à-vis thoracotomy followed by sternotomy. Hence, it has been proposed that the thoracotomy as the initial/subsequent approach is a safer way of approaching the heart.

Additionally, the posterior thoracotomy offers the benefit of total absence of scarring in situations where the breast is undergrown during adulthood and wherein there is a high possibility of cosmetic disfigurement. Moreover, it allows access to the heart through the midline in the event the patient has to undergo a repeat open-heart surgery, without the chances of aortic or right-ventricular injury unlike in redo sternotomy. This is unlike that of a repeat sternotomy. To the best of our knowledge, English literature does not have any mention of this approach so far. Uva [14] and associates have reported in the French literature about their experiences with their approach. However, the ICU stay remains the same as that for anterolateral thoracotomies. The incidence of significant drainage and blood transfusions in the first 24 hours remains no different from that of other approaches.

In conclusion, we are convinced that this approach has given satisfactory short-term results in terms of cosmesis. In addition, it is the incision of choice in prepubescent girls, considering the breast line in anterolateral thoracotomy.

	Acknowledgments

 
At the time of publication, we have used this approach on 71 patients, which includes 1 atrial septectomy with a BT Shunt in a 10-month-old infant, 1 intermediate atrioventricular canal and 1 subpulmonary VSD. So far there has been no mortality.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Barbero-Marcial M., Tanamati C., Jatene M.B., Atik E., Jatene A.D. Transxiphoid approach without median sternotomy for repair of atrial septal defects. Ann Thorac Surg 1998;65:771-774.[Abstract/Free Full Text]
2. Cooley D.A. Techniques in cardiac surgery, 2nd ed. Philadelphia: WB Saunders, 1984.
3. Gerbode F., Braimbridge M.V., Melrose D.G. Median sternotomy for open cardiac surgery during total heart-lung bypass. Arch Surg 1958;76:821-824.
4. Julian O.C., Lopez-Beliom M., Dye W.S., Javid H., Grove W.V. The median sternal incision in intracardiac surgery with extracorporeal circulation. Surgery 1957;42:753-761.[Medline]
5. Dietl C.A., Torres A.R., Favalero R.G. Right submammarian thoracotomy in female patients with atrial septal defects and anomalous pulmonary venous connection. J Thorac Cardiovasc Surg 1992;104:723-727.[Abstract]
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7. Black M.D., Freedom R.M. Minimally invasive repair of atrial septal defects. Ann Thorac Surg 1998;65:765-767.[Abstract/Free Full Text]
8. Cherup L.L., Siewers R.D., Futrell J.W. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg 1986;41:492-497.[Abstract/Free Full Text]
9. Dehner L.P. The integumentary system. In: Kissane J.M., ed. Pathology of infancy and childhood. St. Louis: Mosby, 1975:1172-1194.
10. Levinson MM, Dewhurst T, Han MT, Fooks G, Fonger J. Cosmetic minimally invasive surgical closure of a patent foramen ovale. Report and surgical technique. In: The heart surgery forum. http://www.hsforum.com/Heart Surgery/Directories/ArticlesL/Levinson MM/MISAD/1996-12451.hsf.oct 15, 1996.
11. Tatebe S., Eguchi S., Miyamura H., et al. Limited vertical skin incision for median sternotomy. Ann Thorac Surg 1992;54:787-788.[Abstract/Free Full Text]
12. Komai H., Naito Y., Fujiwara K., et al. Lower midline skin incision and minimal sternotomy—a more cosmetic challenge for pediatric cardiac surgery. Cardiol Young 1996;6:76-79.
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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Claude Planche Kotturathu Mammen Cherian Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Shivaprakasha, K. Articles by Cherian, K. M. Search for Related Content PubMed PubMed Citation Articles by Shivaprakasha, K. Articles by Cherian, K. M.