微创右胸小切口修补房间隔缺损(附31例报告)

报告自1997年5月至1998年11月期间采用微创右胸小切口修补房间隔缺损31例的结果。原发孔房间隔缺损合并二尖瓣大瓣裂缺1例,继发孔房间隔缺损30例,其中,中央型缺损25例,上腔型缺损1例,下腔型缺损2例,合并室间隔缺损2例,合并右肺静脉异位引流2例。手术通过右胸第四肋间小切口(7～10cm)在体外循环下完成,全组无手术死亡和并发症,病人恢复快。结论:右胸小切口修补房间隔缺损是可行的,并且比传统切口具有更多的优点     

Right axillary incision: a cosmetically superior approach to repair a wide range of congenital cardiac defects

OBJECTIVES: We sought to evaluate the safety of a right axillary incision, a cosmetically superior approach than anterolateral thoracotomy, to repair various congenital heart defects. METHODS: All the patients who were approached with this incision between March 2001 and October 2004 were included in the study. There were 80 patients (median age, 4 years) with atrial septal defect closure (38 patients), repair of partial abnormal pulmonary venous return (14 patients), partial atrioventricular canal (16 patients), and perimembranous ventricular septal defect (12 patients). The surgical technique involved peripheral and central cannulation for institution of cardiopulmonary bypass. Electrically induced ventricular fibrillation was used for defects located in front of the atrioventricular valves, and cardioplegic arrest was used for those located at the level or behind these valves. RESULTS: The repair was possible without need for conversion to another approach. One patient sustained a transient neurologic deficit. The patients were all in excellent condition after a mean follow-up of 14 months. The cardiac defect was repaired with no residual defect in 75 patients and with trivial residual defect in 5 patients (3 with mitral valve regurgitation, 1 with atrial septal defect, and 1 with ventricular septal defect). The incision healed properly in all, and the thorax showed no deformity. CONCLUSION: The right axillary incision provides a quality of repair for various congenital defects similar to that obtained by using standard surgical approaches. Because it lies more laterally and is hidden by the resting arm, it provides superior cosmetic results compared with conventional incisions, including the anterolateral thoracotomy. Finally, the incision is unlikely to interfere with subsequent development of the breast.     

Repair of atrial septal defect through a right posterolateral thoracotomy: a cosmetic approach for female patients

Background. Because the operation for atrial septal defect is considered a low-risk procedure, the cosmetic result has become an important issue. Principally for cosmetic reasons, anterolateral thoracotomy is frequently used for closure of atrial septal defect in young female patients. However, in anterolateral thoracotomy, the skin incision frequently crosses the future breast line, which may cause breast and pectoral muscle maldevelopment.

Methods. We review the long-term results of a consecutive series of 126 patients in whom the atrial septal defect was closed through a right posterolateral thoracotomy. The mean age at operation was 7.1 years (range, 1 to 15 years), and the mean body weight was 23.9 kg (range, 6.9 to 56 kg). Defects repaired included 121 ostium secundum (central type), 3 sinus venosus, and 2 ostium secundum without inferior margin.

Results. The average cardiopulmonary bypass time was 65 minutes (range, 37 to 130 minutes), with an average fibrillation time of 41 minutes (range, 23 to 70 minutes). There was no operative or late mortality. A majority of patients were pleased with their cosmetic results. There were no other late complications.

Conclusions. Atrial septal defect can be safely repaired through a right posterolateral thoracotomy approach. This approach offers the benefit of a total absence of scarring and cosmetic disfigurement of the anterior chest wall.     

Closure of atrial septal defects via limited right anterolateral thoracotomy as a minimal invasive approach in female patients.

OBJECTIVE: The closure of atrial septal defects via sternotomy is a low-risk and high-benefit procedure. Limited right anterolateral thoracotomy is an alternative approach with regard to cosmetic aspects. However, it is discussed that a lateral approach is not appropriate for more complex lesions and is associated with an increased incidence of phrenic nerve damage. METHODS AND RESULTS: The perioperative and long-term outcomes (mean follow-up time: 73.2 months) of 87 female patients, mean age 20.4 years (range: 3-56 years), operated on for all types of atrial septal defects via limited right anterolateral thoracotomy between 1982 and 1993, were analysed retrospectively. Special features of the operation technique were a limited skin incision, protection of mammary gland tissue, prevention of phrenic nerve damage, and aortic cannulation in all patients. There were no intraoperative complications. Postoperative complications occurred in 12/87 patients including one rethoracotomy for postoperative bleeding and one late pericardial tamponade due to coumadine overdose. Follow-up was assessed by a survey obtained by the patients or their parents, and their family doctors in 79 patients (90.8%) Cardiac symptoms, mostly supraventricular arrhythmias, were observed in 13.9%. Echocardiography revealed mild tricuspid valve regurgitation (one patient) and mild mitral valve incompetence (one patient with ostium primum defect); there were no residual shunts. Cosmetic results were considered good and excellent in 87.3% and satisfactory in 8.9%. Three patients (3.8%) complained of a broad scar. Anaesthetic areas and optional scar pain were quite frequent (16.5%), whereas restriction of shoulder movement, breast asymmetry and scoliosis were rare. In summary, only one patient, suffering from intercostal neuralgia, would prefer sternotomy. CONCLUSION: Limited right anterolateral thoracotomy has a high cosmetic acceptance and was proven to be safe and effective for closure of any kind of atrial septal defects. Therefore, it is recommended as standard approach for atrial septal defects especially in female patients. reserved.     

Repair of partial atrioventricular septal defect through a minimal right vertical infra-axillary thoracotomy

OBJECTIVE: To report a new minimally invasive and cosmetic approach for partial atrioventricular septal defect (PAVSD) repair. METHODS: From November 1997 to January 2000, six patients with a mean age of 19.2 +/- 7.7 years underwent minimal right vertical infra-axillary thoracotomy for PAVSD repair. Left atrioventricular (AV) valve regurgitation was assessed on the beating heart before and after valvuloplasty. Commissuroplasty of the left AV valve and atrial septum repair were done in all patients. RESULTS: There were no operative or late mortality, and no morbidity directly related to the thoracotomy approach. The average length of the incision was 8.3 +/- 131 cm. The arrest times averaged 32.8 +/- 8.3 minutes, and the cardiopulmonary bypass times averaged 66.0 +/- 9.0 minutes. One patient had a mild to moderate left AV valve regurgitation postoperatively. All patients were free of symptoms during the follow-up. CONCLUSION: The minimal right vertical infra-axillary thoracotomy is a safer, more cosmetic and less invasive approach than median sternotomy for the repair of PAVSD.     

Repair of partial atrioventricular septal defect through a minimal right vertical infra-axillary thoracotomy

OBJECTIVE: To report a new minimally invasive and cosmetic approach for partial atrioventricular septal defect (PAVSD) repair. METHODS: From November 1997 to January 2000, six patients with a mean age of 19.2 +/- 7.7 years underwent minimal right vertical infra-axillary thoracotomy (VIAT) for PAVSD repair. Left atrioventricular (AV) valve regurgitation was tested on the beating heart before and after valvuloplasty. Commissuroplasty of the left AV valve and atrial septum repair were done in all patients. RESULTS: There was no operative or late mortality, and no morbidity directly related to the thoracotomy approach. The average length of the incision was 8.3 +/- 1.3 cm. The arrest times averaged 32.8 +/- 8.3 minutes, and the cardiopulmonary bypass times averaged 66.0 +/- 9.0 minutes. One patient had mild-to-moderate left AV valve regurgitation postoperatively. All patients were free of symptoms during follow-up. CONCLUSION: Minimal right VIAT is a safe, more cosmetic, and less invasive approach than median sternotomy for the repair of PAVSD.     

Right postero-lateral thoracotomy for atrial septal defect closure; a comparative analysis with median sternotomy

Introduction In a low risk procedure like ASD closure Right Posterolateral thoracotomy approach aims at the cosmetic results as compared to median sternotomy. This paper illustrates our approach for a standardised Right Posterolateral thoracotomy in ostium secundum ASD repair and the analysis of the outcome. Methods Right Posterolateral thoracotomy (RPLT) was offered as a cosmetic alternative for atrial septal defect (ASD) closure in children, and selected adult patients below 30 years with lean body build. A retrospective study comparing these patients with median sternotomy approach during the same period (2000–2003) was performed. Exclusion criteria included preoperative diagnosis of complex ASD, obesity and chest wall deformity. Common variables were considered for analysis. Results There were 96 patients (66 females and 30 males) with an average age of 13yrs (range 3 to 27 years) in RPLT group and 225 patients (95 females and 130 males) with average age of 36 years (range 2 to 46 years) in sternotomy group. Extra corporeal time was 32 minutes (28 to 45) and aortic cross clamp time was 14 minutes (8 to 36) in RPLT while the values were 46 minutes (37 to 90) and 22 minutes (18 to 36) in Median sternotomy approach. Blood loss in postoperative period was 160 ml (20 ml to 400 ml) in thoracotomy group compared to 210 ml (40ml to 600 ml) in sternotomy group. There was no mortality or recurrence after repair of ASD during the follow-up. Significant postoperative morbidity was persisting pain and shoulder movement restriction in 12 patients. The scar was cosmetic in RPLT. Conclusion In selected patients with lean body build Right posterolateral thoracotomy is suitable for ostium secundum atrial septal defect closure. The final appearance has definite cosmetic advantage over sternotomy. Presented at the 50^th Annual Meeting of IACTS, New Delhi, Feb., 2004.     

Laparoscopic Transabdominal Preperitoneal Repair of Ventral Hernia: A Step Towards Physiological Repair

The laparoscopic ventral hernia repair with preperitoneal placement of mesh minimizes the complications related to the intraperitoneal position of mesh and fixating devices. It allows safe use of conventional and less expensive polypropylene mesh. The prospectively collected data of 68 patients who underwent laparoscopic transabdominal preperitoneal mesh hernioplasty, for different types of ventral hernias between January 2005 and December 2009 was retrospectively reviewed. The study included 68 patients, 16 males and 52 females with a mean age 51.1 ± 11.1 years (range 23–74 years). Most of the hernias (67.6%) were in the midline position. The mean size of the defect was 30.8 ± 24.4 cm2 (range, 4–144 cm2) and the mean mesh size was 237.8 ± 66.8 cm2 (range, 144–484 cm2). The mean operating time was 96.7 ± 16.7 min (range 70–150 min). All repairs were done with polypropylene mesh. The mean postoperative hospital stay was 1.5 ± 0.6 days (range, 1–4 days). Nineteen patients (27.9%) suffered from postoperative complications. Four patients (5.8%) were detected to have seroma formation. There were two recurrences (2.9%). The mean follow up was 22.7 ± 13.4 months (range, 6–48 months). The laparoscopic preperitoneal ventral hernia repair with polypropylene mesh is cheaper and has acceptable postoperative outcomes. Peritoneal coverage of the mesh not only acts as a barrier between mesh and bowel and thereby prevents adhesions, it also provides an additional security of fixation. This is a safe and feasible option of ventral hernia repair in expert hands. However, for proper validation of these conclusions a long term prospective clinical trial is required.     

右外侧小切口部胸小儿先天性心脏畸形矫治术319体会

目的 介绍经右外侧小切口剖胸体外循环小儿心脏直视手术的经验。方法 １９９４年１０月至１９９７年４月,共完成经右外侧第４或第３肋间进胸,体外循环下先天性心脏畸形矫治术３１９例。患儿年龄３．４４±１．５９岁（５个月￣８岁）,体重１３．６６±３．９８（６￣２６）ｋｇ。修补房间隔缺损８７例（合并左上腔静脉１例,肺动脉瓣狭窄６例,部分肺静脉畸形引流５例）,空间隔缺损２００例（合并动脉导管未闭７例,二尖瓣关闭     

Two Different Minimally Invasive Techniques for Female Patients with Atrial Septal Defects: Totally Thoracoscopic Technique and Right Anterolateral Thoracotomy Technique

Background: To compare the outcomes of totally thoracoscopic technique (TTS) vs. right anterolateral thoracotomy technique (RALT) in female patients undergoing minimal invasive atrial septal defect (ASD) correction.Methods: From March 2011 to January 2013, 125 female patients underwent minimally invasive atrial septal defect closure, of whom 62 patients were in the TTS group and 63 were in the RALT group.Results: Procedures were performed successfully in all patients without in-hospital mortality or major complications. cardiopulmonary bypass (CPB) time were 48.95 ± 15.63 min in TTS group, 31.4 ± 8.04 min in RALT group (p <0.001); the cross-clamp time were 26.92 ± 11.84 min in TTS group and 18.51 ± 6.11 min in RALT group (p <0.001). The length of incision in RALT group (6.02 ± 1.03 cm) was longer than TTS group (5.31 ± 0.68 cm) and the difference was significant (p <0.001). The overall satisfaction rate for the cosmetic results of TTS was 100% and was 96.83% (61/63 patients) in RALT patients. During follow-up, all patients in TTS group were satisfied expect two patients complained that scar was too long at groin. Reasons for a lower score in RALT group included the long scar in the chest; a RALT incision that was located too medially (coming off the bra line) and asymmetrical breast development.Conclusions: Both TTS and RALT are valid and reliable cosmetic surgical techniques for repairing ASDs in female patients. Both techniques allow excellent cosmetic and functional results in most female patients. The totally thoracoscopic technique may gain shorter incision and cosmetic results compared with RALT.     

Totally endoscopic sublay (TES) repair for midline ventral hernia: surgical technique and preliminary results

The Rives–Stoppa procedure is used for ventral hernia repair but requires a large midline incision. This report describes a new, totally endoscopic approach to the retromuscular plane, corresponding to a reversed totally extraperitoneal procedure, to perform sublay repair of primary and secondary ventral hernias. This totally endoscopic sublay (TES) repair is described in detail, and its safety and efficacy were evaluated. In this prospective study, we assessed 26 consecutive primary and secondary epigastric midline ventral hernias that were repaired between July 2017 and July 2018 using the TES procedure. A large mesh was placed in the retrorectus position using this minimally invasive approach. Indications for this procedure include umbilical, epigastric, incisional hernias, and rectus diastasis. All TES procedures were successfully performed without conversion to an open operation. The mean operative time was 106.6 ± 29.1 min (range 75–205), with average mesh area of 318.8 cm2 for an average defect area of 26.5 cm2. Postoperative pain was mild, and the mean visual analog scale (VAS) under physical stress (e.g., climbing stairs) was 2.4 at the third postoperative day. The average postoperative hospital stay was 2.8 ± 0.8 days (range 2–5). Two patients developed postoperative seroma, with no final adverse effect. No recurrence nor readmissions within 30 days was observed during a mean follow-up of 9.2 ± 4.4 months. Initial experiences with this technique show that the TES procedure is safe and reliable, requires no specific instruments, and is highly reproducible. There is no need for an expensive anti-adhesion mesh or fixation device, making it cost-effective.     

Surgical approach to atrial septal defect in the female. Right thoracotomy versus sternotomy

Repair of atrial septal defect (ASD) remains a high-benefit, low-risk procedure due to technologic improvements. From July 1981 to December 1986, 35 females (age, 7 months to 28 years) had repair of ASD; 20 by right thoracotomy and aortic cannulation (group 1) and fifteen by median sternotomy (group 2). In general, right thoracotomy was applied to patients with secundum ASD two years or older and without associated lesions, while median sternotomy was applied to patients with ostium primum lesions and/or associated lesions. Patients or their families perceived the cosmetic results superior to the right thoracotomy approach over the median sternotomy. We feel that a right thoracotomy and aortic cannulation is effective in females (2 years and older) with secundum ASD for a superior cosmetic result over median sternotomy. However, females with ostium primum and/or associated lesions should undergo median sternotomy for better cardiac access and safety.     

Limited posterior thoracotomy for the correction of intra cardiac anomalies–current perspectives

Background Though the use of median stermotomy has been fairly standardized for the approach to the heart and great vessels, since the advent of cosmetically appealing incisions, thoracotomy has come to be a justifiable alternative incision. This paper presents our experience with this approach and the advantages over the conventional approach as well as over other incisions for the correction of intra-cardiac anomalies. Methods 93 patients underwent open cardiac procedures using the posterior thoracotomy approach since June 1997 to December 2000. There were 69 patients with ostium secundum atrial septal defects and 12 patients with sinus venous defects. Other anomalies included perimembranous ventricular septal defects in 3 patients, partial atrioventricular septal defects in 3 patients and transitional atrioventricular septal defects in 2 patients. Besides these, one patient each underwent atrial septectomy with right modified Blaloc—Taussing shunt and correction of hemianomalous pulmonary venous connection with intact atrial septum using this approach. The median age of the patients was 8 years with a range of 10 months to 41 years. 10 patients were males. Results The median operation time (skin to skin) was 236 minutes. Median bypass times and aortic cross clamp times were 63 minutes and 31.5 minutes respectively. The median ICU stay was 25.2 hours. There were no significant immediate post operative complications requiring intervention in any patient. The mean chest drainage was 80 ml per 24 hours. One patient had a superficial wound dehiscence which healed with daily dressings One patient had atelectasis of the right upper lobe which recovered with chest physiotherapy. All patients are on regular follow up to assess the status of their scars. One patients developed a mass on the right atrial free wall following closure of atrial septal defect one year earlier and the underwent reoperation for removal of the mass. Patients on follow up were interrogated and all were satisfied with the cosmesis of their scars. None of the patients had any physical disability due to their scars. Conclusions The limited posterior thoracotomy incision offers a cosmetically attractive approach to the heart in selected patients. The approach is easy and the techniques reproducible. The technique carries with it no additional risk and has the advantage of not interfering with future development of the breast in young pre pubertal girls.     

Repair of atrial septal defect through a minimal right vertical infra-axillary thoracotomy in a beating heart

We present a minimally invasive and cosmetic approach to repair atrial septal defect. Fifty-five atrial septal defects were successfully repaired through a minimal right vertical infra-axillary thoracotomy. Every repair was performed on the beating heart with continuous suction through aortic needle vents and with the head of the patient lowered. This approach can be used not only in adults but also in young girls.     

右腋下直切口手术治疗先天性心脏病

目的 通过右腋下直切口治疗先天性心脏病可以达到创伤小、疼痛轻、美观的目的。方法 本组４０例患者中,进行单纯型继发孔房间隔缺损修复１８例,房间隔缺损并二尖瓣关闭不全修复３例,室间隔缺损修复１５例,法洛四联症心内台术２例,心内型完全性肺静脉异位引流和部分房室管畸形修复各１例,结果 全组无手术死亡。体外循环时间１８～６６分３０秒,主动脉阻断时间３～５２分,术后６～１２天出院。结论 微创伤切口先天性心脏病     

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.     

Minimally invasive and maximally safe approach to cardiac surgery

Background Minimally invasive approaches in cardiac surgery have been introduced in an attempt to limit post operative pain, allow prompt recovery, and reduce the cosmetic impact of the scar. We describe a surgical technique of limited skin incision with complete median sternotomy. Patients & Methods A comparative study was performed using two groups of 35 patients each in which a minimally invasive incision (Group I) was compared to a routine incision (Group II). Surgical procedures included atrial septal defect closure, mitral, aortic and tricuspid valve surgery. Results Incision length ranged from 6.9cm to 7.5cm (mean 7.1±0.2cm) in Group I and from 16.5cm to 21cm (mean 19.4 ±1.2cm) in Group II (Group I vs Group II, p<0.01). The operating time, cardiopulmonary bypass time, aortic cross clamp time were not significantly different in both the groups. Similarly, post-operative drainage was also not significantly different. The mean hospital stay of patients in Group I was 5.7±1.0 days operative mortality or morbidity. Conclusion This technique provides full, safe and easy access to all cardiac structures with acceptable cosmetic results. No special instruments are required.     

体外循环手术应用腋下及腋前外切口

自１９９５年３月至１９９６年８月作者应用腋下及腋前外切口进行体外循环手术５０例。房间隔缺损１７例，室间隔缺损２６例，二尖瓣狭窄及关闭不全３例，三房心、部分型心内膜垫缺损、双腔右心室、二尖瓣关闭不全各１例。全组手术顺利，主动脉阻断时间２２．５９±１１．０６分钟，体外循环时间４０．１９±１７．１７分钟。无手术死亡及并发症。创伤轻、出血少、恢复快、腋下切口看不见手术瘢痕、美容效果好。     

Right parasternal minithoracotomy for repair of atrial septal defect

Various surgical approaches for repair of atrial septal defect (ASD) have recently been introduced for superior cosmetic and less invasive results. A technique for repair of isolated ASD through a small right parasternal minithoracotomy is described. In spite of the smaller incision, there is no need to use femoral cannulation or video-assisted endoscopy. This approach is simple, less invasive, and cosmetic. We believe that right parasternal minithoracotomy is a suitable alternative to a median sternotomy for ASD closure, especially in young male patients.     

微创直视手术在成人先天性心脏病中的应用（附52例分析）

目的 初步评价微创直视心脏手术治疗成人先天性心脏病的安全性和有效性.方法 2010年4月～ 2012年12月,单组共完成微创直视先天性心脏病手术52例.建立闭式体外循环,做右胸前外侧切口3 ～～5 cm,经肋间入胸腔,剪开心包,进入心腔完成畸形矫治.实施手术包括房间隔缺损（ASD）修补术29例,室间隔缺损（VSD）修补术15例,部分型心内膜垫缺损（PECD）矫治术2例,Ebstein畸形矫治术2例,二次二尖瓣置换术（redo-MVR）1例,主动脉窦瘤修补1例,主动脉窦瘤修补联合主动脉瓣置换术（AVR）1例,二尖瓣成形术（MVP）1例.同期手术包括三尖瓣成形术（TVP）5例,射频消融术2例,肺动脉瓣狭窄（PS）球囊扩张术1例,MVR术1例.结果 手术均在闭式体外循环下完成,无转为传统胸正中切口开胸手术.手术时间（3.7±0.8）h.体外循环时间36 ～209 min,（76.9±31.3）min.心脏不停跳下完成手术25例;心脏停跳下完成手术27例,主动脉阻断时间13 ～ 138 min,（57.6±18.2）min,术后自动复跳23例.气管插管时间3～30 h,（10.9±4.0） h;ICU时间9～41 h,（16.7±4.4）h;术后住院时间3～14d,（5.4±4.1）d;切口长度3～5 cm,（4.5±0.6）cm;术后第1天引流量（349.5±294.2）ml;34例（65.4％）未输血.无围术期及出院后死亡,无二次开胸探查止血和切口感染.出院时心功能Ⅰ级45例,Ⅱ级6例,Ⅲ级1例.25例随访时间1 ～ 24月,（7.0±4.5）月,无明显并发症发生,心功能均为Ⅰ级.结论 微创直视手术在成人先心病应用的近期手术效果良好,适用范围相对广泛,具有创伤小、切口美观、无胸骨感染并发症等特点.