Minimally Invasive Valve Operations

Background. To reduce the morbidity from valvular heart operations, a right parasternal approach was introduced. We report our initial experience with the procedure.

Methods. From January 1996 through July 1996, 115 patients underwent primary isolated valve procedures. One hundred (85%) patients underwent the operation through a right parasternal incision.

Results. There was one hospital death secondary to a stroke on the fifth postoperative day. Three patients (two with aortic valve operations and one having a mitral valve procedure) required conversion to sternotomy. Mean aortic occlusion time was 71 minutes; mean cardiopulmonary bypass time was 93 minutes. Mean stay in the intensive care unit was 27 hours and mean hospital postoperative stay was 5.7 days. Seventy-seven percent of the patients did not receive blood transfusions. Comparison with median sternotomy demonstrated a reduction in both postoperative length of stay and direct hospital costs.

Conclusions. We conclude that this minimally invasive approach is safe for a variety of valve procedures and is effective in reducing surgical trauma and cost.     

Minimally Invasive Techniques for Bladder Reconstruction

Purpose of Review

Bladder reconstruction surgery is a key component of neurogenic lower urinary tract dysfunction (nLUTD) management. Traditionally, given the complexity and unpredictable operative challenges of bladder reconstruction in this patient population, little consideration has been given to performing lower urinary tract reconstruction in a minimally invasive approach.

Recent Findings

We describe the innovative minimally invasive surgical techniques in four major categories of reconstructive procedures for nLUTD: (A) ileal bladder augmentation, the use of a low morbidity open Pfannenstiel incision and the use of laparoscopy and robotics; (B) creation of a catheterizable channel, the use of laparoscopy and robotics for Mitrofanoff procedures; (C) creation of both a bladder augmentation and catheterizable channel, the use of a hand-assisted approach for the creation of a continent cutaneous ileocystoplasty; and (D) bladder neck artificial urinary sphincter implantation: the use of a robotics.

Summary

Patients with nLUTD need surgical solutions that can improve their quality of life over several decades. As experience with robotics increases and as technology provides us with new tools to ease minimally invasive bladder reconstruction, we can expect that the field will continue to grow and improve.

     

面部年轻化的综合微创技术

目的探求微创有效的上、中面部年轻化方法。方法2006年7月～2009年9月,对38例采用内镜下额部和颞部发际内小切口行上、中面部除皱结合面部吸脂等综合治疗,对其中25例进行3个月～2年的随访,通过观察面部皱纹的消失/减少程度、面部下垂的改善程度及患者的满意度等来综合评价该术式的效果。结果内镜辅助下经额部小切口和颞部发际内切口行上、中面部除皱结合面部吸脂等综合手段可以有效地去除或减轻面部皱纹,改善面部下垂,对额纹(2.3±07vs0.8±0.4)、眉间纹(2.3±0.6vs0.9±0.5)、鱼尾纹(2.0±0.7vs0.6±0.5)、鼻唇沟纹(2.3±0.6vs1.1±0.6)改善明显(t值分别为9.4,11.4,8.3,6.4,P=0.00),患者满意度高。结论内镜辅助下经额部小切口和颞部发际内切口行上、中面部除皱结合面部吸脂等综合手段,能微创、有效减少或去掉面部皱纹,改善面部下垂,对面部皮肤弹性较好的中年人是理想的选择。     

Application of Right Bronchial Occlusion under Artificial Pneumothorax in the Thoracic Phase of Minimally Invasive McKeown Esophagectomy

Purpose: To evaluate the feasibility and safety of single-lumen endotracheal intubation combined with right bronchial occlusion (SLET) under artificial pneumothorax in minimally invasive McKeown esophagectomy.Methods: A total of 165 patients who underwent minimally invasive McKeown esophagectomy at Peking Union Medical College Hospital were retrospectively analyzed. In all, 48 patients received double-lumen endotracheal intubation (DLET group), and 117 patients received SLET-B (SLET-B group). Clinical data, intraoperative hemodynamics, surgical variables, and postoperative complications were analyzed and compared.Results: Compared with the DLET group, a shorter intubation time and lower tube dislocation rate were found in the SLET-B group. In the thoracic phase, with the application of artificial pneumothorax, patients in the SLET-B group had lower partial pressure of carbon dioxide (PaCO₂) and end-tidal carbon dioxide pressure (PetCO₂) values and higher pH than those in the DLET group. Patients in the SLET-B group had shorter thoracic phase times and hospital stays and less intraoperative hemorrhage than those in the DLET group. The numbers of thoracic and bilateral recurrent laryngeal lymph nodes harvested were significantly higher in the SLET-B group.Conclusion: SLET under artificial pneumothorax is feasible and safe in minimally invasive McKeown esophagectomy.     

Safety and Applicability of Continuous Retrograde Cardioplegia in Minimally Invasive Aortic Valve Replacement: New Approaches

Purpose: To discuss minimally invasive cardiac surgery aortic valve replacement (MICS-AVR) approach via anterior thoracotomy using continuous retrograde cardioplegia. Continuous retrograde cardioplegia facilitates excellent continuous homogeneous cooling of the heart during cardiac arrest.Methods: We performed AVR using the proposed method in nine patients between June 2018 and September 2019. The median age of the patients was 73 (range: 43–84) years. The pleural space was entered via anterior thoracotomy. After opening of the right atrium, a retrograde cardioplegic cannula was inserted into the coronary sinus with a purse-string suture. Continuous cold blood retrograde cardioplegia was initiated at 700 mL/h.Results: Extubation in the operating room was performed in five (56%) patients. No new decreased function of the left and right ventricles was observed in intraoperative transesophageal echography or transthoracic echocardiogram.Conclusion: MICA-AVR through continuous retrograde cardioplegia is a safe technique.     

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.     

Minimally Invasive Techniques for the Management of Adult UPJ Obstruction

Ureteropelvic junction obstruction (UPJO) is a common congenital abnormality that often presents in adulthood. Open dismembered pyeloplasty was considered the gold standard for the management of this condition; however, recent advancements in laparoscopic and robotic surgery have dramatically shifted the landscape to more minimally invasive techniques. A literature search of ureteropelvic junction obstruction, pyeloplasty, endopyelotomy, laparoscopic pyeloplasty, robotic pyeloplasty, and microlaparoscopic pyeloplasty was performed. A focus was placed on literature published since 2013. Minimally invasive laparoscopic and robotic techniques have become the gold standard for the management of UPJO. With the rise of robotic pyeloplasty, open repairs are becoming less frequent, while endoscopic treatments have remained stable. Minimally invasive (robotic) techniques have become the gold standard for the management of UPJO. Newer, even less-invasive techniques are also showing promise, but technical challenges still exist.