经右腋下微创直切口体外循环下直视心脏手术治疗小儿先天性心脏病

目的总结经右腋下直切口行体外循环直视心脏手术的临床经验，探讨其适应证及技术要点。方法2008年6月至2011年1月我们共完成79例经右腋下直切口的sJ,JL体外循环心脏直视手术，患者年龄6个月至12岁，平均（7．4±3.3）岁，体重6．5-42．0（17．8±8．7）kg。其中房间隔缺损19例，同期行三尖瓣成形5例；室间隔缺损55例，其中合并动脉导管未闭2例；部分房室管畸形5例。所有手术均在全身麻醉、体外循环下进行（房间隔缺损修补在不停跳下进行）。患者取左侧卧位，切口位于右侧第3肋间腋中线与第5肋间腋前线之间，皮肤切VI长度3．5-6．0（4．7±1．3）12111，经第3或第4肋间进胸，切开并悬吊心包，行升主动脉及上、下腔静脉插管建立体外循环，经主动脉根部灌注心脏停搏液，单纯房间隔缺损采用心脏不停跳下手术，经右心房切口修补房、室缺及三尖瓣成形。结果全组手术均顺利完成，无手术死亡；1例因术后心内膜炎致室缺残余漏，再次正中开胸行室缺残余漏修补术。体外循环时间（63．4±18．2）min，主动脉阻断时间（37．6±14-3）min，术后24h胸腔引流40-130（85．3±26．5）ml。68例患者术后未输血。全组无其他严重并发症。结论右腋下小切口直视心脏手术安全、可靠，可减少用血量，术后切口隐蔽美观，患儿及家属满意率高，值得临床椎广。

Open heart surgery on CPB through right armpit minimally invasive incision for pediatric congenital heart disease

Objective To summarize the clinic experience, indication and surgical technical point of pediatric congenital heart disease surgery through right armpit incision. Methods We have done pediatric congenital heart disease operations through right armpit incisions for 79 patients from June 2008 to January 2011. The ages of patients were 6 months-12 years old （7.4±3.3）years, the body weight was 6.5-42.0 （17.8±8.7）kg. 19 patients were ASDs, 5 of whom had taken tricuspid valve repair simultaneously, 55 patients were VSDs, 2 of whom complicated with PDA, 5 patients were partial atrioventricular anomaly. All the patients had taken the operations un- der general anaesthesia and extracorporeal circulation （ASDs were repaired in the beating hearts ）. The incisions were between right 3rd intercostal space-midaxillary line and 5th intercostal space-preaxillary line, the length of the icisions was 3.5-6,0 （4.7±1.3）cm. We got into the chest spaces through the 3rd or 4th intercostal space, suspended pericardium and cannulated ascending aorte, superior vena cava and inferior vena cava routinely. Cardio- plegic solutions were delivered in a prograde manner into the aortic root, simple ASDs were repaired in beating hearts. All the operation was performed through right atrial incisions. Results There was no in-hospital mortality. One patient was found residual VSD after operation because of SBE, and had taken re-operation through midlinesternotomy to repair residual VSD. The time of extracorporeal circulation was （63.4＋18.2）min, time of aortic cross-clamping was（37.6±14.3）min, the drainage in 24 h postoperation was 40-130（85.3±26.5）ml. Conclusion Pediatric congenital heart disease surgery through right armpit incision was safe, can reduce blood transfusion. The incision was secluding and beautiful outlook.