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Ann Thorac Surg 2003;75:1358-1359
© 2003 The Society of Thoracic Surgeons

Correspondence

Alternative inferior vena cava cannulation facilitates ministernotomy procedures

Laxmanan Mohanakrishnan, Mch, Koyilil Vijayakumar, Mch, Ponnusamy Sukumaran, Mch, Narendra Menon, MD, Govinden Santhanam, DA

Division of Cardiovascular Surgery, Sri Ramakrishna Hospital, 395, Sarojini Naidu Rd, New Sidhapudur, Coimbatore-641 044, Tamil Nadu, India

To the Editor:

We read with great interest the article written by Yoshimura and colleagues [1] on a cosmetic approach for atrial septal defects. We agree with the authors that for prepubescent girls whose breast tissue is not well developed right posterolateral thoracotomy is the best approach. We have been doing this for the past 4 years. The results are good.

For the rest of our patients we use a small midline incision extending from the angle of Louis to the level of the fourth intercostal space. The sternum is cut from the sternal notch to the level of the fourth intercostal space and then transversely into the fourth right intercostal space. Yoshimura and colleagues [1] say that a small incision makes a simple, safe operation difficult and unsafe. We now describe how we overcame this difficulty. In the ministernotomy approach for closure of atrial septal defect, the inferior vena caval (IVC) cannula restricts the field of work. The aortic and the superior vena caval cannulas are away from the area of the atrial septal defect.

We use a modified technique of cannulation of the IVC so that the cannula does not intrude into the field of operation. A small 1-cm incision is made posterior to the anterior axillary line. The IVC cannula is introduced through this incision into the pleural cavity. A small cruciate incision is made in the pericardium about 1 cm anterior to the pericardiophrenic vessels. Traversing the pleural cavity, the cannula enters the pericardial cavity through this cruciate incision and then into the IVC through a pursestring suture. As the cannula comes into the atrium laterally, it stays away from the atrial septal defect and does not compromise the operative field (Fig 1). After the procedure we insert two drainage tubes. One, directed to the pericardium, takes the same route used for the IVC canula. Another small incision made posterior to the previous one is used to introduce a basal pleural drain.



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  		Fig 1. The entry of the inferior vena caval cannula from the axillary area. The arrow (A) shows the entry of the cannula into the inferior vena cava after reaching the pericardial cavity.

 
Alternative femoral and iliac vessel cannulations have been suggested to facilitate operating through ministernotomy. This involves invading an unoperated area. Complications such as thrombosis have been reported after cannulations in these peripheral vessels. Our alternative technique of IVC cannulation is easy to perform and does not carry any added risk. No complications have been encountered so far in any case.

References

  1. Yoshimura N., Yamaguchi M., Oshima Y., Oka S., Ootaki Y., Yoshida M. Repair of atrial septal defect through a right posterolateral thoracotomy: a cosmetic approach to female patients. Ann Thorac Surg 2001;72:2103-2105.[Abstract/Free Full Text]




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