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Ann Thorac Surg 2005;79:1827-1828
© 2005 The Society of Thoracic Surgeons
a Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165 Rome, Italy
b University of Milan, Via Vittoria Colonna 19, 20419 Milan, Italy
c European Institute of Oncology, Via Ripamonti 435, , 20141 Milan, Italy
(E-mail: emmanuel.villa{at}voila.fr).
The publication by Vicente and colleagues [1] describes an original approach to patent ductus arteriosus (PDA) closure in premature neonates. Although PDA treatment has historically been a field in which pediatric surgery and cardiology have pioneered new techniques, we believe that the reported surgical procedure does not offer clear advantages.
Very low birth weight (< 1,500 g) infants are an extremely fragile group of patients, and concerns about morbidity of our therapeutic acts are particularly important [2]. A thoracotomy is always an invasive act, even if performed with a minimally invasive intent. Muscle cutting, rib spreading, and lung manipulation are components of the dorsal approach; besides, it is performed close to the spine, the hinge of the thoracic cage. We fear that posterior incision can augment the risk of complications such as scoliosis, rib deformities, and shoulder dysfunction [2]. Blunt dissection by q-tips does not warrant pleural integrity: actually "parietal pleural lacerations" were said to be "common" in the article [1]. Thus it is logical to suppose the occurrence of pneumothorax, but incidence and techniques of drainage are not reported. Another drawback is the prone position of the patient with potential problems of airway control, endotracheal tube displacement, management of perfusion, and monitoring lines. It was not reported where the operation was performed, but transfer to the operating room of such patients who are frequently unstable, in addition to temperature management can be very demanding.
Last year The Annals of Thoracic Surgery published a consistent experience of a video-assisted thoracoscopic clipping of the PDA in very low birth weight infants [3]. This represents a very attractive approach, but its application is limited to institutions in which thoracoscopic surgery has been already performed in older children, and it is also limited to the availability of small thoracoscopy instruments [3]. However, alternatives to a conventional thoracotomy approach could also be adopted in neonates. In 2002 we proposed clipping the PDA by an anterior extrapleural approach trough a small longitudinal incision at the level of the sternal notch [4]. Because of our initial experience, we have modified our technique by changing the cutaneous incision into a transversal low-lying cervicotomy (Fig 1). Retraction, suspension, and a 1-cm long median splitting of the manubrium allows extrapleural duct isolation and ligation. With a simple set of traditional instruments, this operation is carried on in the neonatal intensive care unit without interruption of care. The baby lies in a safe, supine position; the maneuvers are extrapleural without lung manipulation; body heat dispersion does not occur; and conversion to a full sternotomy, if required, is easily accomplished. Data collection are still ongoing, but safety and absence of chest wall trauma are evident.
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  B. Srinivasan, S. K. Thingnam, D. Das, and H. Singh Approach to Patent Ductus Arteriosus Ann. Thorac. Surg., August 1, 2006; 82(2): 769 - 769. [Full Text] [PDF]
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