Ann Thorac Surg 2004;78:1856-1857
© 2004 The Society of Thoracic Surgeons
How to do it
Systematic Traction Techniques in Minimal-Access Pediatric Cardiac Surgery
Hiroshi Oiwa, MDa,*,
Ryoichi Ishida, MDa,
Kenichi Sudo, MDa
a Department of Cardiovascular Surgery, Kyorin University School of Medicine, Tokyo, Japan
Accepted for publication August 28, 2003.
* Address reprint requests to Dr Oiwa, Department of Cardiovascular Surgery, Kyorin University School of Medicine, 6-20-2, Shinkawa, Mitaka, Tokyo 181-8611, Japan
hiroshioiwa{at}hotmail.com
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Abstract
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Minimal-access pediatric cardiac surgery is now common in the treatment of simple congenital heart defects. However, methods of securing a good, unobstructed view for surgery and the difficulties of working in a deep, narrow field jeopardize safety in surgical procedures, especially for less experienced surgeons have been described. Our systematic, step-by-step traction techniques on the skin, the pericardium, the right atrial appendage, the aortic root, both venae cavae, and the free wall of the right ventricular outflow, using a mechanical retractor and traction sutures, facilitate surgical field exposure and the achievement of safety. As described below, our procedures are simple, allow direct inspection, and assist those working toward technical mastery.
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Introduction
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The subjects were 50 consecutive children with atrial septal defects, including the sinus venosus type (31 patients), partial anomalous pulmonary venous drainage (2 patients), and various ventricular septal defects such as the perimembranous, outlet muscular, and double committed types (17 patients). They had an average age of six years and four months (range, 9 months to 18 years) and an average weight of 22.5 kg (range, 6.2 to 81 kg).
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Technique
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The surgical procedure (Figs 1, 2) involved a skin incision (around 5% of patient height) just below the nipple level; the raising of sternal skin flaps between the second intercostal level and just below the xiphoid process to facilitate the use of a standard sternum saw; then, a partial sternotomy splitting the sternum in the midline below the third or fourth intercostal level to give it an inverted Y shape. During sternal division, careful and gradual opening is important for avoiding damage to the tissues connecting the chondral and bony parts of the sternum and to the costochondral junction.
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Fig 1. (A) Skin incision and sternal division. (B) Directions of traction. (IVC = inferior vena cava; SVC = superior vena cava.)
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The skin at the upper end of the incision was drawn cephalad with a mechanical winding retractor. The pericardium was opened vertically from 1 to 2 cm below the aortic reflection. Without resection, the thymus was partially separated from the pericardium. The upper edges of the vertical pericardial incision were drawn caudad and fixed to the upper sternum. The top of the pericardial incision was drawn caudad and secured to the upper end of the skin incision to draw the ascending aorta further into surgical view (Fig 1). The lower edges of the pericardial incision were drawn further caudad and fixed underneath the skin flap beyond the lower end of the skin incision.
The right appendage was drawn caudad with a pursestring suture to expose the area around the aortic root when tape was applied around the superior vena cava (SVC) and the aorta, and when aortic cannulation was subsequently performed. After two mattress sutures were secured in the fatty and epithelial tissue of the aortic root, drawn caudad, and fixed to improve aortic accessibility for safe cannulation, this cannulation was performed by the Seldinger method or with a cannula with a pencil-shaped stilet.
The superior vena cava was cannulated through the portion of the pursestring suture in the above-mentioned right appendage, and inferior vena cava cannulation traversed the lower right atrial wall. On insertion, each cannula contained a flexible stainless steel stilet. For the intracardiac procedure through the right atrium, both venae cavae were raised with tourniquet tapes, which were fixed to elevate the right atrial surgical field.
For procedures performed through the main pulmonary artery, such as repair of double committed ventricular septal defects, supravalvular pulmonary stenosis (PS), valvular PS, or stenoses of the right ventricular outflow (RVOT), left atrial venting collapses the left ventricle and facilitates an approach around the pulmonary bifurcation. The tissues around the pulmonary ligament were then dissected to draw the pulmonary trunk caudad. Two mattress sutures were secured in the free wall of the RVOT, drawn caudad, and fixed for better pulmonary trunk accessibility, as shown in Figure 2D.
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Fig 2. (A) Skin incision and sternal division. (B) Skin traction with a mechanical winding retractor, pericardial traction, and right appendage traction. (C) Aortic root traction. (D) Right ventricular free wall traction.
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No intraoperative or perioperative complication occurred, and only one blood transfusion was needed. Mediastinal infection occurred in one case, but disappeared on treatment.
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Comment
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For minimal-access pediatric cardiac surgery, various approaches such as a minimal transverse incision with lower median sternotomy, a transxiphoid approach without sternotomy, and a shorter lateral thoracotomy approach, have been reported [1–5]. Each has both merits and demerits. We used a small median skin incision below the nipple level and lower partial median sternotomy below the third intercostal level because this approach uses the same surgical instruments and cannulation method (through a single surgical field) as does conventional full sternotomy; and, because satisfactory cosmetic results can be achieved, with no injury to female breast tissue having growth potential, this approach can, of course, offer safety.
Exposure of the aortic root for aortic cannulation is a complicated procedure in minimal-access pediatric cardiac surgery. It is precisely our combined application of skin traction, pericardial traction, and aortic root traction that ensures a safe and easy aortic cannulation. When aortic cannulation is initially unsuccessful, the aortic root traction sutures facilitate the application of aortic side-clamps for reliable cannulation. In this risky situation, grasping the aortic adventitia with forceps or mosquitoes is difficult both when applying an aortic side-clamp and when drawing down the aortic root into the surgical field—and may demand more surgical manpower.
We have encountered some transpulmonary approaches for double committed ventricular septal defects (three cases), supravalvular PS accompanied with heart defect (one case), and valvular PS accompanied with heart defects (three cases), and seen ligation of the patent ductus arteriosus (PDA) (one case). Even through lower partial sternotomy, our RVOT free wall traction could simplify the treatment of cardiac defects, which should be approached through the main pulmonary artery and PDA. The procedures through the right ventricular free wall (three cases) are also easy with our approach.
As described above, our traction techniques facilitate exposure of the surgical field for minimal-access pediatric cardiac surgery, where a deep, narrow field makes safe execution difficult. Allowing excellent direct intracardiac visualization, our procedure is simple, and is an asset to any surgeon's repertoire.
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References
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- Chan CY, Chiu IS, Wu SJ, Hung CR. A minimal transverse incision with low median sternotomy for pediatric congenital heart surgery. Eur J Cardiothorac Surg. 2001;19:290–293[Abstract/Free Full Text]
- Nicholson IA, Bichell DP, Bacha EA, del Nido PJ. Minimal sternotomy approach for congenital heart operations. Ann Thorac Surg. 2001;71:469–472[Abstract/Free Full Text]
- van de Wal HJ, Barbero-Marcial M, Hulin S, Lecompte Y. Cardiac surgery by transxiphoid approach without sternotomy. Eur J Cardiothorac Surg. 1998;13:551–554[Abstract/Free Full Text]
- Komai H, Naito Y, Fujiwara K, Noguchi Y. Cosmetic benefits of lower midline skin incision for pediatric open heart operation: a review of 100 cases. Jpn J Thorac Cardiovasc Surg. 2002;50:55–58[Medline]
- Liu YL, Zhang HJ, Sun HS, et al. Repair of cardiac defects through a shorter right lateral thoracotomy in children. Ann Thorac Surg. 2000;70:738–741[Abstract/Free Full Text]
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