The choice of surgical incision for precordial disease
“Dr. Li, we have consulted many doctors, and they all say different things. Li Pingyuan, Department of Pediatric Cardiac Surgery, Fu Wai Hospital, Beijing
As a surgeon, I knew very well that all surgical procedures are inseparable from the issue of incision, and the incision of a child with precordial disease is a matter of greater concern to the surgeon and the child (the patient) and his family. I comforted Tinker Bell’s father and said, “Don’t worry, let me tell you slowly and we will face it together.”
Congenital heart disease has always been an important part of the congenital diseases of infants and children, about 7‰-11‰ of newborn babies in China suffer from congenital heart disease every year, and there are about 150,000 newborn children with congenital heart disease every year, and currently there are about 7 million patients with congenital heart disease in China. In recent years, congenital heart disease has become the first place of neonatal defects and the leading cause of death in children under 5 years old.
Congenital heart diseases are subdivided into simple precocious heart diseases (e.g., atrial septal defect, ventricular septal defect, and patent ductus arteriosus) and complex precocious heart diseases (e.g., tetralogy of Fallot, pulmonary atresia, right ventricular double outlet, complete transposition of the great arteries, and complete endocardial cushion defect). For most complex precardiac diseases, because of the limited effectiveness of surgical treatment, both doctors and the child’s family tend to consider more the effectiveness of treatment and the child’s long-term prognosis, and may not be able to choose between the aesthetics of the incision and the size of the trauma of the treatment plan, but rather those parents who can choose between both will be very torn by this issue.
I have written about how to choose an incision before, but it seems that some parents still don’t know and understand the criteria for choosing an incision, so today Tinker Bell’s father came to ask me, so I will take this opportunity to tell all parents of children.
First of all, I want to make one thing clear: no matter what kind of incision, the operation is to be performed under extracorporeal circulation and cardiac arrest, and the incision should be able to completely reveal the intracardiac malformation.
We usually classify three types of incisions for precardiac surgery.
First, the median surgical incision: this is the most classic and traditional surgical incision, which has been tested for more than 60 years and has proven to be safe, reliable, effective, and has real long-term efficacy.
The advantages of the median incision are
1, the widest scope of application: regardless of age, defect location, whether combined with other malformations such as tricuspid valve insufficiency, can be handled by this procedure; once the surgical accident occurs, it is also the most comfortable to handle, and can deal with almost all cardiac surgical disorders.
2. The most definite long-term effect of surgery: This procedure has a history of more than 60 years, and a large sample of evidence-based medical evidence is perfect for the long term after surgery.
3, low complication rate: direct vision surgery can accurately avoid damage to the surrounding valves and conduction block, and the chance of third-degree AV block and valve incomplete closure is significantly lower than other surgical procedures.
The picture above shows the median incision
The disadvantages are as follows.
1, the biggest problem is that the surgical incision is large, located in the middle of the chest, the wound will be left with an incision mark after healing, later as long as the exposed chest, or perform chest X-ray examination, will let bystanders see that there has been congenital heart disease, had a major surgery, if the patient is scar body, the scar on the incision will be like a centipede protrusion, unsightly, more affected children (the person) a psychological burden. So this disadvantage has been less acceptable to patients, especially the families of infants and girls.
2, the most traumatic, need to split the sternum longitudinally, the operation time is long, recovery is slow, generally 5-7 days discharge, postoperative need to take cardiac diuretic drugs 1-3 months, full recovery takes 3 months – 6 months.
3, after surgery, under 5 years old can be fixed with special sternal sutures, above 5 years old need to wire fixed sternum, after the wound is healed, the presence of metal foreign body, there will be unable to do nuclear magnetic examination or chest film can obviously see the wire and so on.
Despite such disadvantages, this is still the favorite of doctors because it is safe and if other accidents are found doctors can deal with it easily and quickly, so if it is a complex or more specific congenital heart disease, patients and their families should always consider this incision first for the sake of the child’s future and life safety, after all, life is bigger than everything.
The picture above shows the median incision
The advantage of this small incision is that the incision is smaller, and compared to the classic traditional surgical incision, the operation time and the degree of destruction of the sternum are significantly improved without damaging the bony structure of the thorax, and the hospital stay is about 5-7 days, and the full recovery takes 3 months. The lower position also meets the aesthetic requirements and is easier to achieve if the incision needs to be extended to deal with more complex cases. The scar is smaller and more aesthetically pleasing, the surgical incision is generally 3-125px, more concealed, the incision is easily covered with a shirt, necklace, and the satisfaction of the child’s family is higher.
There are two problems, one is that people still think that the incision is not small enough, and the other is that for some more complicated surgeries, such as high ventricular defects still poorly revealed, or for smaller infants (less than 7 kg) the incision may cause deformation and dislocation of the joint between the ribs and the sternum under tension, so it should be chosen with caution. In addition, when simple atrial septal defect is combined with other intracardiac malformations, such as atrial defect combined with pulmonary vein ectopic drainage, ventricular defect combined with arteriovenous stenosis and different degrees of pulmonary valve stenosis or right ventricular outflow tract stenosis, which require exploration and more extensive operation, the small median incision cannot fully reveal the patient site, which will bring more risk to the operation and to the patient, so this minimally invasive incision should not be used, but for This incision can be considered for simple atrial septal defect and ventricular septal defect, so the surgeon should be consulted for the specific case.
The above picture shows the small incision in the lower sternum
Third, the right axillary mini-incision: the above treatment methods have their inevitable huge shortcomings, therefore, in the past decade or so, surgeons have been looking for minimally invasive surgery based on surgery, improving the incision access, reducing scarring and trauma, and so far, the right axillary mini-incision is the most mature and accepted by the families of children.
The right axillary mini-incision, which is a more satisfactory incision method, may be asked, the heart is on the left side, why is the incision on the right side? To explain, although the heart is generally located on the left side, cardiac surgery requires extracorporeal circulation, cannulation through the aorta and upper and lower vena cava, and the aorta and upper and lower vena cava are located on the right side, so the right side is chosen.
The advantages of the lateral axillary incision are that the incision is concealed in the armpit, so you don’t have to worry about exposing the incision when wearing clothes; the incision is indeed concealed and cosmetic; the surgery is performed via intercostal transthoracic, which does not damage the ribs and sternum and is not likely to lead to a chicken breast; no wire fixation is needed after surgery, and taking chest films or passing security checks will not reveal a past history of preexisting heart disease; but the disadvantages are also obvious: the scope of surgical adaptation is small. Personally, I am conservative and usually use it for atrial septal defects, and septal defects are only applied to membranous septal defects and subcrural septal defects. Some doctors apply it to areas such as tetralogy of Fallot, which I personally feel is more dangerous and a bit uneconomical. The radical treatment of tetralogy of Fallot requires excision of the right ventricular hypertrophic muscle and widening of the pulmonary artery. This lateral incision cannot fully reveal the lateral operating area of the pulmonary artery, which greatly compromises the surgical effect and makes it difficult to ensure long-term results, so none of the complex precordial diseases are recommended for a minimally invasive right axillary incision.
In addition, this minimally invasive incision is also not recommended when simple atrioventricular defect is combined with other intracardiac malformations, such as atrioventricular defect combined with pulmonary vein ectopic drainage, ventricular defect combined with patent ductus arteriosus and different degrees of pulmonary valve stenosis or right ventricular outflow tract stenosis, which require exploration and wider operation, so this incision is not recommended for all complex precordial diseases.
If a patient is considering a small right axillary incision, please seek the opinion of the attending surgeon for details. The use of this incision requires a high level of experience and the ability to handle accidents if they occur. In addition, if an intraoperative accident occurs, or if the condition is found to be more serious and there is a deviation from the preoperative judgment, it may be possible to change to a median incision. If this happens, please make sure that the family understands that this is necessary to save the patient.
The picture above shows the small incision in the right axilla
“Dr. Li, thank you so much, I got it all clear after listening to you, Ding Ding is one year old, his condition is atrial and ventricular defects coexist, there is also some pulmonary hypertension, this kind of complicated situation, it is better to open the chest, on the one hand, under direct vision, the surgical area is clearly exposed, on the other hand, if other abnormalities are found, it can be easily dealt with, also can reduce the postoperative pulmonary Complications.” Looking at Tink’s father’s sad face, I said with relief, “Yes, that’s right.”
“Dr. Li, is it possible to make a small axillary incision for Doudou, who has a simple case in the next bed?”
Doudou’s case is a ventricular septal defect (sub-stem type), although her case is just a simple malformation, this sub-stem type ventricular septal defect is still rather special and cannot be minimally invasive, because underneath is the aortic valve, if intervention is done, the blocker will wear out the aortic valve leaflet, once the aortic valve leaflet is damaged, we have to perform aortic valve replacement, the consequences are very bad, so the best way is to open the chest, which is It is safe and less likely to injure the aortic leaflets. The right axillary small incision is good, but not suitable for sub-stem ventricular septal defect, the location is too far and too deep, once something is not easy to deal with. So Doudou’s case is best for open-heart surgery.
“Oh, so that’s how it is, I only knew one thing but not the other before, now I understand, you talk so well, thank you so much!
Patients and their families can rest assured that the doctor must follow all the principles that are beneficial to the patient when doing the surgery, everything when the perfect repair of intracardiac deformity as the premise, safety and long-term results are the most important, in order to meet this premise and then take into account the aesthetic, and not the so-called cosmetic incision in the first place, and reduce the safety of surgery and surgical results, the doctor will choose the optimal plan after comprehensive judgment. Only by strictly grasping the indications of various surgical incisions can we take into account the requirements of surgical safety, long-term results and aesthetics. We will develop an individualized surgical plan for each child (patient) to perfectly correct the intracardiac malformation with the most appropriate incision.
For simple precardiac disease, there are several new minimally invasive treatment modalities such as percutaneous atrial septal defect closure and transthoracic small-incision atrial septal defect closure that have emerged in the last decade. Therefore, the size of the trauma, the choice of incision, and the presence of foreign body residue in the body are now the main concerns of the families of children with simple precordial disease.
In summary, different treatment options have their inherent advantages and disadvantages, and parents should consider and choose according to their child’s condition and their requirements in all aspects after full communication with the surgeon. We hope that the above information will help you in your choice of surgical options. You can also consult me if you are not sure about your child’s condition.
I wish the child (person) a speedy recovery!
This article is published with the authorization of Dr. Li Pingyuan.