A minimal transverse incision with low median sternotomy for pediatric congenital heart surgery.

OBJECTIVES: Median sternotomy is the incision of choice for most cardiac surgical procedures, but the full-length vertical skin incision generally leaves an unsightly scar. In certain patients undergoing short, low-risk procedures, cosmetic considerations are of relatively greater importance. METHODS: A minimal transverse curvilinear skin incision with low median sternotomy is described which gives adequate exposure for selected open-heart procedures. Since September 1997, this approach has been used in 22 pediatric patients undergoing open-heart surgery including five cases of Fallot's tetralogy. We also compared the operation time and result with other approaches. RESULTS: Using this modified method, the exposure of the heart was good enough, and there were no difficulties in cannulating the ascending aorta for cardiopulmonary bypass. Although it took a longer time to close the wound, the operation time was similar to the standard approach. The small transverse wound was not visible under conventional clothes. CONCLUSIONS: A minimal transverse incision with low median sternotomy provides an alternative approach for small wound open-heart surgery in patients with a simple congenital cardiac defect. It is technically feasible and has a good cosmetic result.     

Lower mid-line skin incision and minimal sternotomy in pediatric open heart surgery--an alternative cosmetic approach

Full median sternotomy has been the standard approach for open heart surgery. However, it leaves an unsightly surgical scar. We therefore designed a lower mid-line skin incision and minimal sternotomy approach as a cosmetic alternative. Since February 1993, 78 pediatric patients with congenital heart disease have undergone this open heart surgery procedure. Their ages ranged from 1 month to 13 years (median: 2 years and 7 months) and body weights ranged from 2.4 to 43 kg (median: 11.5 kg). Thirty-one patients had atrial septal defect, 34 perimembranous ventricular septal defect, 9 subpulmonary ventricular septal defect, and 4 other cardiac anomalies. All cannulations for cardiopulmonary bypass could be performed through this approach. No patients required conversion to standard median sternotomy and no peri- or postoperative complications related to this approach, such as injury to the great artery and vein, air embolism, or sternal deherence, were noted. This approach is technically easy and an excellent cosmetic approach in pediatric open heart surgery.     

Full sternotomy with minimal skin incision for congenital heart surgery

PURPOSE: The purpose of this paper is to analyze the feasibility of the full sternotomy with minimal skin incision and its related complications and risks. METHODS: A total of 405 patients with simple congenital heart disease underwent open heart surgery exclusively under full sternotomy with minimal skin incision. We reviewed the available medical records of the patients retrospectively. Bypass time, aorta cross clamp time, and period of hospital stay were compared with the control group (223 patients with standard long skin incision). RESULTS: Full sternotomy with minimal skin incision provided adequate surgical views and successful repair was done in all patients. There was no mortality. One patient had chylopericardium after the operation and another patient had a postoperative bleeding at the sternum. Minimal skin incision took the similar aorta cross-clamp time and total cardiopulmonary bypass time compared with full skin incision in atrial septal defect patients. Among the ventricular septal defect patients, minimal skin incision took a little longer aorta cross-clamp time (10%), but similar total cardiopulmonary bypass time compared with full skin incision. CONCLUSION: Minimal skin incision with full sternotomy provides improved cosmetic results. There was no increased mortality and morbidity using minimal access. It can be applied to more complex congenital heart disease contrast to other minimal invasive techniques for atrial septal defect.     

Partial sternotomy ("C" incision) as standard access for full range of adult cardiac operations.

OBJECTIVE: In our institute, partial sternotomy has been adopted for standard access in the full range of adult cardiac operations, including coronary artery bypass grafting. In this study, our clinical experience is reviewed. METHODS: Since April 1998, of 100 cardiac surgical patients, 64 underwent partial sternotomy, while 36 patients had the traditional full sternotomy because of high surgical risk factors or anatomical reasons. Most of the patients having minimal access had a "C" incision, that is, a left lower partial sternotomy. RESULTS: The procedures performed with the "C" incision were coronary artery bypass grafting, valve surgery, aortic root replacement, closure of atrial septal defect, and so on. There were two hospital deaths after partial sternotomy. Compared with full sternotomy patients, partial sternotomy patients had a shorter hospital stay, while their bypass times were longer. Their skin incisions were 11.7 cm on average. CONCLUSION: The "C" incision can provide satisfying results and can serve as the standard approach in the full range of cardiac operations.     

Minimal sternotomy approach for congenital heart operations

BACKGROUND: In recent years, minimal access cardiac operations have increased in application in both the adult and pediatric population. As our experience has grown with these approaches to atrial septal defect closure, we have expanded the same approach to the repair of more complex congenital heart disease. METHODS: At the Children's Hospital in Boston, from August 1996 to November 1999, a minimal sternotomy approach was used to surgically correct 104 children with congenital heart defects other than atrial septal defect. The approach, in most patients, consisted of a skin incision based over the xiphisternum, 3.5 to 5 cm in length, with division of the xiphoid only and elevation of the sternum by fixed retractor. All patients underwent cannulation for cardiopulmonary bypass through the great vessels in the chest using this same incision. The lesions corrected included ventricular septal defect in 41 patients, tetralogy of Fallot in 27, common atrioventricular canal in 15, mitral valve operation in 3.5, and other defects in 18 patients. There were 53 male and 51 female patients. Mean age at operation was 1.4 years (range, 2 weeks to 11 years). RESULTS: There were no deaths. The mean cardiopulmonary bypass time was 71 minutes (standard deviation, 19 minutes), mean cross-clamp times 40.8 minutes (standard deviation, 13 minutes), and length of stay 4.5 days (standard deviation, 1.9 days). Complications included transient atrioventricular block in 2 patients, pleural effusion requiring drainage in 4, and pericardial effusion in 3 patients. When compared to similar lesions repaired using a full sternotomy approach there was no difference in operating times and length of stay tended to be shorter in the minimal sternotomy group. CONCLUSIONS: A minimal sternotomy approach can be used to repair congenital cardiac lesions other than atrial septal defects. It gives good exposure, particularly for transatrial repairs, does not prolong ischemic times, and may lead to shorter hospital stay.     

Minimal access approach for the repair of atrial septal defect: the initial 135 patients

BACKGROUND: From May 1996 to August 1998 a minimal access approach was used for 135 of 200 consecutive surgical atrial septal defects closures in children through young adults ranging in age from 6 months to 25 years (median 5 years). METHODS: A 3.5- to 5-cm midline incision was centered over the xiphoid with division of the xiphoid alone (transxiphoid) or of the lower sternum (ministernotomy); both groups underwent bicaval venous cannulation through the incision. Cardioplegia and aortic cross-clamping were administered through the incision. Cephalad retraction of the sternum with a fixed-arm retractor aided exposure. RESULTS: There have been no early or late deaths and no bleeding or wound complications. No procedure required conversion to a full sternotomy, and no cannulation attempt was abandoned for an alternate site. Cross-clamp and cardiopulmonary bypass times were equivalent to those in the full sternotomy group. The mean length of hospital stay in the ministernotomy group was 2.7 days. CONCLUSIONS: The closure of atrial septal defects can be performed through a transxiphoid or ministernotomy approach, conferring a satisfactory cosmetic result without compromising the safety or accuracy of the repair.     

Coronary surgery through partial sternotomy in a patient with tracheostoma.

We report successful coronary artery bypass grafting through a lower partial sternotomy for a patient with a tracheostoma. He required a tracheotomy for serious laryngeal edema which developed during anesthetic induction prior to elective conventional coronary surgery. A safe alternative approach, comprising a lower midline skin incision with a lower partial sternotomy distant from the stoma, facilitated coronary artery bypass grafting to the left and right coronary arteries after four weeks.     

Cardiac valve operations using a partial sternotomy (lower half) technique

BACKGROUND AND AIM: Operations on cardiac valves are being performed more frequently through smaller incisions than traditional midline sternotomy. A variety of alternate incisions have been used, but most of the interest appears to focus on partial sternotomy. The purpose of the study was to review results using a partial lower sternotomy for cardiac valve operations. METHODS: A standard partial lower one-half or two-thirds sternotomy was used for cardiac valve operations in 112 patients. The sternum was divided transversely in the third or second intercostal space and vertically from that point through the xyphoid process. Standard instruments and retraction devices were used. This incision provided adequate exposure for even complex operations to be performed. Small cannulae were placed into the aorta and heart through the primary incision for cardiopulmonary bypass. Vacuum-assisted venous drainage was used. RESULTS: Seventy-four single valve operations were performed. There were 35 double valve and 5 triple valve operations (35.4%) performed. Operative mortality (5.3%) and major complication rates were comparable to full the sternotomy approach. CONCLUSIONS: Partial sternotomy (lower half) provides a smaller incision through which virtually all cardiac valve operations may be performed. Results achieved with this approach are similar to those associated with full sternotomy. The smaller incision is appreciated by patients.     

Partial median sternotomy for pediatric cardiac surgery

In order to minimize scarring and thereby improve the postoperative cosmetic appearance of pediatric cardiac surgery patients, we perform partial median sternotomy incisions. A short midline skin incision, from 1 to 2 cm below the articular notch of the second rib to the xiphoid process, is made. The sternum was divided from the xiphoid process to the articular notch of the second rib. The thymus is mobilized and the pericardium incised longitudinally. The aorta and superior and inferior vena cava are mobilized to facilitate direct cannulation. Cardiopulmonary bypass is instituted in the usual fashion. Twenty-four pediatric patients underwent repair of cardiac anomalies through a partial median sternotomy incision at our institution between June 1997 and September 1998. The average age of the patients was 4 years and 4 months (range, 4 days to 12 years) and the average weight was 16.0 kg (range, 3.2 to 40.5 kg). Cases included 13 VSD (ventricular septal defect) [including one DCRV (double chambered right ventricle) and one PS (pulmonary stenosis)], 9 ASD (atrial septal defect), one ECD (endocardial cushion defect), and one DORV (double outlet right ventricle) with mitral atresia. All patients were extubated within 3 hours after surgery and the average length of the ICU stay was within 24 hours (except for one 4-day-old baby who died of LOS (low cardiac output syndrome) on the 16th postoperative day). There were no wound infections or hospital mortalities. In our experience, this approach is safe, provides good exposure, and provides excellent cosmetic results.     

Submammary median sternotomy

A vertical skin incision is used as routine approach for sternotomy. The resulting scar is often disappointing and the top is visible and unpleasant, especially for young women. In 35 women ranging from 10 to 48 years (mean 29.2 years), median sternotomy was performed via a submammary skin incision. In all cases an open heart surgical procedure was performed. Adequate exposure of the heart was achieved in every case and there were no technical problems related to this approach, no hospital mortality or major complications. The cosmetic result is excellent and this approach is certainly justified in open heart surgery for young women.     

Partial median sternotomy as a minimal access for off-pump coronary artery bypass grafting: feasibility of the lower-end sternal splitting approach

BACKGROUND: Off-pump coronary artery bypass grafting (OPCAB) can be performed in several ways using a minimally invasive approach (MIDCAB). Using the left anterior small thoracotomy (LAST) approach, only the LAD can be grafted. To expand the indications for MIDCAB from single-vessel disease to double-vessel disease, we have used a partial sternotomy without a transverse cut, namely, the lower-end sternal splitting (LESS) approach. Through this approach, the LAD and RCA can be revascularized by means of a single small incision without the risk of damaging the tissue around the intercostal space during harvesting of ITA when the sternum is transversely divided. The purpose of this study was to demonstrate the feasibility and safety of this technique. METHODS: Between November 1999 and November 2000, a total of 22 patients underwent MIDCAB through a lower midline skin incision from the fourth intercostal space to the xiphoid process with longitudinal division of the lower half sternum up to the 3rd rib, without either a T- or reversed L-shaped division of the sternum. Of the patients, 14 had LAD disease only, 5 had both LAD and RCA disease, 2 had RCA disease only, and 1 had left main trunk disease. Two of the operations were of redo coronary artery bypass grafting. The mean age was 69.5 +/- 6.1 years (range 58 to 77 years). RESULTS: The mean length of the skin incision was 8.5 +/- 1.4 cm (range 7 to 12 cm). No hospital death or morbidity was observed. All patients had arterial conduits: LIMA in 20 patients, RIMA in 3, RGEA in 4, and RA in 1. The mean number of grafts per patient was 1.3 +/- 0.6 (range 1 to 3). No blood transfusion was required perioperatively. The patency rate was 96%. All patients were in New York Heart Association class I and no wound complications or postoperative pain occurred during follow-up. CONCLUSIONS: Our experience demonstrates that the LESS approach for MIDCAB is technically feasible for revascularizing not only the LAD but also the RCA system, with the same small incision using IMA and GEA. It can be used with excellent cosmetic results and safety. Although our experience is limited, we conclude that this less invasive surgical technique can be used as an alternative approach for MIDCAB in patients with LAD or RCA disease.     

Less-invasive sublabial unilateral transseptal approach for transsphenoidal surgery

A less-invasive sublabial approach was developed to overcome the disadvantages associated with the conventional sublabial approach. The basic differences between this modified sublabial approach and the conventional approach are: a smaller incision (1-1.5 cm long) and almost midline vertical skin incision underneath the upper lip; minimal development of an inferior tunnel; no widening of the maxillary rim of the piriform aperture; and a strictly unilateral approach. This less-invasive approach uses a slim and small nasal speculum originally designed for the transnasal approach. This modified sublabial approach was applied to 41 of 133 patients who underwent transsphenoidal surgery between August 1998 and the end of 2000. These cases confirmed that this approach is a simple, rapid, and less-invasive technique with significantly fewer mucosal complications compared to the conventional approach. We conclude that this modified sublabial approach offers a good alternative to the conventional standard sublabial approach.     

Evaluation of sternal deformity after pediatric minimally invasive cardiac surgery

Sternal shape is one of the most important esthetic factors of the chest appearance after pediatric minimally invasive cardiac surgery (pMICS) as well as length of skin wound. We evaluated the grade of postoperative sternal deformity in 20 patients who underwent total repair of pediatric congenital heart disease [atrial septal defect (ASD): 17, ventricular septal defect (VSD): 2, partial anomalous pulmonary venous connection (PAPVC): 1] with minimal skin incision and lower partial median sternotomy. The sternum was closed with stainless wire in 3 patients, with absorbable polydioxanone (PDS) cord in 5 patients, with combined use of reabsorbable radiolucent poly (L-lactate) acid sternal pin and absorbable PDS cord in 12 patients. The evaluation of postoperative sternal deformity was made according to the vertebral index (VI) and frontosagittal index (FSI) in 3 groups with each sternal closure method. VI and FSI of the 3 groups showed no significant difference. Sternal deformity in the group with sternal closure with PDS cord group was more severe than that in other 2 groups. The combined use of sternal pin with PDS cord offered the most sufficient fixative strength for sternal closure.     

Partial median sternotomy as a minimal access for the closure of subarterial ventricular septal defect. Feasibility of transpulmonary approach.

BACKGROUND: Minimally invasive techniques in congenital heart surgery have evolved steadily over the past few years, but documentation in the literature is rare. The majority of reported techniques involve thoracoscopic approach and partial sternotomy. We have employed a lower partial sternotomy as a minimal-access procedure for the closure of subarterial ventricular septal defect, for situation where this approach would be unsuitable for adequate exposure of the pulmonary artery. The purpose of this study is to demonstrate the feasibility and safety of this technique and report its superior cosmetic result. SUBJECTS AND METHODS: Beginning in 1997, we began approaching the closure of subarterial ventricular septal defect through a lower sternal split incision using a 6 to 10 cm skin opening, associated with a reversed L incision at the left second intercostal space. A total of consecutive 12 patients (6 male and 6 female) have been operated on using this approach. The patients ranged in age from 6 to 21 years (mean, 12.8 +/- 5.0 years). The straight cannula with stylet was used for aortic cannulation. RESULTS: There was no mortality or morbidity, except for late pericardial effusion in 4 cases. The durations of cardiopulmonary bypass and aortic cross-clamping ranged from 94 to 206 (mean, 131 +/- 33) minutes and from 40 to 122 (mean, 70 +/- 26) minutes, respectively. Ten of 12 patients were extubated in the operating room, and no patient required blood transfusion. The postoperative hospital stay ranged from 8 to 21 (mean, 13.4 +/- 4.2) days. No patient developed deterioration of aortic regurgitation or residual ventricular septal defect. CONCLUSIONS: Our experience demonstrates that the lower partial sternotomy for the closure of subarterial ventricular septal defect is technically feasible and can be used with excellent cosmetic results and safety. Although experience is limited and follow-up is relatively short, this less invasive surgical technique may become a beneficial option for the management of subarterial ventricular septal defect.     

Partial median sternotomy as a minimal access for the closure of subarterial ventricular septal defect

Background: Minimally invasive techniques in congenital heart surgery have evolved steadily over the past few years, but documentation in the literature is rare. The majority of reported techniques involve thoracoscopic approach and partial sternotomy. We have employed a lower partial sternotomy as a minimal-access procedure for the closure of subarterial ventricular septal defect, for situation where this approach would be unsuitable for adequate exposure of the pulmonary artery. The purpose of this study is to demonstrate the feasibility and safety of this technique and report its superior cosmetic result. Subjects and Methods: Beginning in 1997, we began approaching the closure of subarterial ventricular septal defect through a lower sternal split incision using a 6 to 10 cm skin opening, associated with a reversed L incision at the left second intercostal space. A total of consecutive 12 patients (6 male and 6 female) have been operated on using this approach. The patients ranged in age from 6 to 21 years (mean, 12.8 ± 5.0 years). The straight cannula with stylet was used for aortic cannulation. Results: There was no mortality or morbidity, except for late pericardial effusion in 4 cases. The durations of cardiopulmonary bypass and aortic cross-clamping ranged from 94 to 206 (mean, 131 ±33) minutes and from 40 to 122 (mean, 70 ± 26) minutes, respectively. Ten of 12 patients were extubated in the operating room, and no patient required blood transfusion. The postoperative hospital stay ranged from 8 to 21 (mean, 13.4 ± 4.2) days. No patient developed deterioration of aortic regurgitation or residual ventricular septal defect. Conclusions: Our experience demonstrates that the lower partial sternotomy for the closure of subarterial ventricular septal defect is technically feasible and can be used with excellent cosmetic results and safety. Although experience is limited and follow-up is relatively short, this less invasive surgical technique may become a beneficial option for the management of subarterial ventricular septal defect.     

Clinical profile of post-operative ductal aneurysm and usefulness of sternotomy and circulatory arrest for its repair.

OBJECTIVE: Post-operative ductal aneurysm is a rare but fatal condition. We retrospectively analyzed the clinical profile of post-operative ductal aneurysm and outcome of their repair with different surgical approaches. METHODS: From January 1976 to December 2002, 13 patients underwent repair of post-operative ductal aneurysm. The case data of the patients operated were analyzed and survivors were followed-up. Three patients underwent repair through left thoracotomy, femoro-femoral bypass and 10 patients underwent patch aortoplasty through sternotomy using total circulatory arrest with minimal dissection. Among the sternotomy group, nine patients had midline sternotomy and one patient had transverse sternotomy with the patient in semi-right-lateral position. Hemoptysis (69%) was the commonest presenting symptom. Ten patients had ligation and three patients had division of ductus. Mean age at ductus interruption was 13.7+/-8.2 years; mean time interval for development of aneurysm was 3.6+/-4.2 years; mean age at aneurysm surgery was 16.9+/-8.8 years. Residual left to right shunt was detected in 6 (46%) patients. RESULTS: Three patients repaired through left thoracotomy with femoro-femoral bypass died during surgery due to rupture of aneurysm during dissection and profuse bleeding. Thirty-day survival in patients operated through sternotomy using circulatory arrest was 90% (9/10). Two patients required additional incision in second left intercostal space along with midline sternotomy, for access to descending thoracic aorta. Of these two patients, one patient had bleeding from friable aorta and died; another patient developed left hemiplegia; circulatory arrest time was prolonged in this patient. Mean follow-up period was 9.6+/-5.3 years. Persistent left vocal cord palsy was seen in one patient. One patient was lost to follow-up after 3-years. Remaining eight patients were asymptomatic at follow-up. CONCLUSION: Repair of postoperative ductal aneurysm through left thoracotomy is difficult due to extreme fragility of aneurysm and because of reoperative difficulties. The immediate and long-term outcome of the cases operated through sternotomy using total circulatory arrest with minimal dissection is good. Midline sternotomy limits approach to descending thoracic aorta that can be circumvented by using transverse sternotomy with semi-right-lateral positioning of the patient.     

Submammary skin incision as a cosmetic approach to median sternotomy

Median sternotomy is the incision of choice to allow access to the anterior mediastinum, heart, or both lungs. The vertical skin incision leaves an unsightly scar for many female patients. A bilateral submammary horizontal skin incision with dissection of a flap including the subcutaneous tissue and breasts allows exposure of the sternum so that a median sternotomy can be performed. Since November 1981, we have used this incision 40 times in female patients undergoing open heart surgery. The exposure of the mediastinum was excellent, and there were no difficulties in cannulating the ascending aorta for cardiopulmonary bypass. Complications associated with this incision are insignificant if close attention is paid to details.     

小切口全胸骨切开心脏手术38例报告

目的总结38例小切口全胸骨切开心脏手术的经验。方法2004年6月-2005年12月，我们采用皮肤小切口，自剑突上缘1—2cm起，向上长7～10cm止于第3肋，全胸骨切开行择期心脏手术38例。结果38例手术均获成功。总手术时间175～359min，平均84min；引流量110～760ml，中位数380ml；术后住院7～32d，平均10d。术后早期并发症3例，其中1例心律失常，2例发热，均治愈；无开胸止血，切口感染等其他并发症，切口愈合良好。38例随访3—18个月，平均9个月，症状改善，左心室射血分数0．45-0．73，平均0．62。结论小切口全胸骨切开心脏手术安全，创伤小，无须特殊器械，操作简单，可获得良好的手术效果。     

Ministernotomy versus full sternotomy in congenital heart defects: a prospective randomized study

BACKGROUND: Although the ministernotomy is extensively used in the repair of congenital heart defects all over the world, whether this approach has additional advantages over the conventional full sternotomy is not well established. This prospective study was designed to evaluate the effects of lower ministernotomy in the repair of congenital heart defects. METHODS: One hundred patients who underwent repair of atrial or ventricular septal defects were randomly divided into two groups: lower ministernotomy group (n = 50), and full sternotomy group (n = 50). The clinical indexes of each procedure were recorded and analyzed. RESULTS: The age, sex, and types of cardiac defects were comparable between the two groups. Ischemic times, bypass times, intensive care unit stay, and ventilation duration were similar in both groups. The procedure time (from skin to skin) was longer in the lower ministernotomy group than in the full sternotomy group (p < 0.001). There was less drainage in the lower ministernotomy group than in the full sternotomy group for the first 24 hours after operation (186 +/- 99 mL/m2 versus 237 +/- 134 mL/m2, p = 0.03) but no significant difference in transfusions between the two groups. The hospital stay was shorter in the lower ministernotomy group than in the full sternotomy group (6.5 +/- 1.2 days versus 7.5 +/- 1.8 days, p = 0.02). CONCLUSIONS: Ministernotomy is as safe and effective as a full sternotomy in the repair of simple congenital heart defects in older children and adults. Furthermore, this small incision reduces the postoperative drainage, shortens hospital stay, and provides better cosmetic results. Operative times are longer.     

Minimal skin incision in living kidney transplantation

Usually, the transplanted kidney is placed into the right retroperitoneal iliac fossa through a right abdominal surgical skin incision. The skin incision may be oblique or inverted J-shaped known as the "hockey stick." The oblique or curvilinear incision, parallel to the inguinal ligament, known as the "pelvic Gibson incision," is also extended medially to the midline, just above the pubis. The most common incision for kidney transplantation in our center is a paramedian incision, which is parallel to rectus abdominis muscle and extends medially to the midline, just above the pubis symphysis ("hockey stick"). Nowadays, minimally invasive surgery is popular in various field of surgery; the number of patients who are concerned about cosmetic effects are increasing. We make the skin incision in the lower right abdomen from laterally below the anterior superior iliac spine to the midline just above the pubis in five young unmarried women whose body mass index was >25 and there were no anatomic variations. The lower transverse abdominal skin incision showed more favorable cosmetic results and there was no difference in postoperative factors, including renal function, compared with other routine renal transplant patients.