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Ann Thorac Surg 2006;81:2336-2337
© 2006 The Society of Thoracic Surgeons

Correspondence

Minimally Invasive Thoracic Retractors

Massimo Massetti, MD a , Dimitrios Buklas, MD a , Samuele Bichi, MD a , Eugenio Neri, MD b

a Thoracic and Cardiovascular Surgery, University Hospital Caen France, CHU Avenue de la "Cote de Nacre", Caen, 14033 France
b Ospedale le "Scotte" Via delle Scotte Siena, 53100 Italy

(Email: massetti-m{at}chu-caen.fr; euxneri{at}tin.it).

To the Editor:


Dr Massetti discloses that he has a financial relationship with Geister.

 

We read with interest the article by Boaron [1] concerning the use of a "new retraction-suspension device" in thoracic surgery. This device has been specially designed to optimize exposure through a limited upper sternotomy performed to approach masses in the upper mediastinum. Although the device seems to be original, the concept was already described some years ago. As the minimally invasive thoracic surgery started to develop, many surgical techniques have been described worldwide, and the common problem was the exposure through a limited approach. Classical thoracic retractors seemed too cumbersome, and pediatric instruments brought about technical difficulties.

Our group, since the end of 1996, developed a routine approach to valve surgery through a mini-sternotomy, and to date more than 450 patients have been operated on. Later, our group introduced this less invasive approach to resect anterior tumors of mediastinum [2]. The surgical technique has been described in this journal together with the clinical results [3]. In order to facilitate the exposure and vision, a special adapted retractor (MP, Geister Medizintechnik GmbH [Tuttlingen, Germany]) has been conceived for mini-sternotomy incisions [4]. This retractor can be used for both cardiac operations and procedures in the anterior mediastinum. After a short skin incision (4 to 10 cm), the sternum is sewn in the center as far as the xiphoid appendix and a "V"-shaped sternotomy is accomplished according to the previously described technique [4], and depending on the incision length, the retractor is inserted with the appropriate blades. For the cardiac procedures, the asymmetrical blades are positioned to elevate and rotate clockwise the heart and base of the great vessels. The spreading of the two sternal edges is limited to a few centimeters and the self-retaining blades for the cranial and caudal edge of incision provide excellent exposure during the intrathoracic manipulations. This system allows for optimal vision above and below the incision; the median retraction valve is displaced in such a way as to apply traction toward the base of the cutaneous opening. A number of centimeters of vision are won, and all the maneuvers carried out at this level can be more easily performed.

This ideal less-invasive incision will permit access to all the target anatomical areas, does not require a modification of surgical techniques, and enables the patient to resume normal activities more quickly. After a decade of clinical experience, the adoption of smaller incisions in thoracic surgery seems to produce fewer traumas and less pain, reduces the risk of wound infection, and facilitates a shorter recovery time and hospital stay, further reducing the total hospital cost. On the other hand, these minimally invasive approaches have the disadvantage of producing a smaller surgical field. The surgeon has to face the challenge of finding a way to perform operations with the same number and type of instruments as with conventional surgical intervention, without increasing the size of the small incision and the amount of dissection. The use of special dedicated retractors is crucial to perform shorter incisions safely and expeditiously without compromising the quality of surgery.


   References
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 References
 

  1. Boaron MA. A new retraction-suspension device for limited upper sternotomy Ann Thorac Surg 2004;77:1107-1108.[Abstract/Free Full Text]
  2. Icard P, Le Page O, Massetti M, Alkofer B, Le Rochais JP, Khayat A. Resection of anterior mediastinal tumor through a ministernotomypreliminary experience with ten cases. J Thorac Cardiovasc Surg 2003;125(2):432-434.[Free Full Text]
  3. Massetti M, Babatasi G, Lotti A, Bhoyroo S, Le Page O, Khayat A. Less invasive cardiac operations through a median sternotomy100 consecutive cases. Ann Thorac Surg 1998;66(3):1050-1054.[Abstract/Free Full Text]
  4. Massetti M, Babatasi G, Bhoyroo S, Le Page O, Khayat A. A special adapted retractor for the mini-sternotomy approach Ann Thorac Surg 1999;68(1):274-277.[Abstract/Free Full Text]



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Ann. Thorac. Surg., June 1, 2006; 81(6): 2337 - 2338.
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