I. Concepts, methods, characteristics and current application of minimally invasive cardiac surgery.
Minimally invasive cardiac surgery in a broad sense includes catheter interventions in internal medicine, all surgical procedures performed under direct vision with small incisions, thoracoscopic and robotic completion. In this paper, we only introduce minimally invasive surgery in the field of surgery.
1. Minimally invasive surgery under direct vision.
(1) Traditional small-incision surgery.
Since Wilson et al. reported partial sternotomy in 1992, gradually a large number of small incisions have been used in clinical practice, and these incisions have been well received by patients because of their small postoperative scars and more aesthetic appearance. The strong desire of patients is the direct motivation for surgeons to perform small incision surgery.
Since small incision surgery does not require special auxiliary equipment, it is relatively easy to apply clinically, and this has led to the widespread implementation of small incision surgery. There have been a large number of reports on small-incision cardiac surgery abroad, and most of the units that perform cardiac surgery in China have also performed or tried small-incision cardiac surgery. Most of the small-incision surgeries carried out in China currently use small upper sternal incisions, small parasternal incisions, complete transection of the sternum, lower sternal approach, right sternal window approach and left sternal window approach.
Firstly, the extracorporeal circulation cannula is inserted through the surgical incision, which inevitably enlarges the incision; secondly, almost all of these small incisions have to cut off the sternum or ribs, and some of them have to destroy important blood vessels or tissues, which causes the contradiction that although the incision is relatively small in appearance, the internal trauma is not small, which is against the original intention of minimally invasive. Therefore, in recent years, it has been gradually replaced by the following “true” minimally invasive surgery.
(2) Minimally invasive direct vision surgery in the “true sense”.
Conventional surgical incisions of 4-6 cm are almost always made through an intercostal pathway to the heart surgery site, without cutting the sternum or ribs, and extracorporeal circulation cannulae are placed through the femoral artery and internal jugular vein (closed negative pressure extracorporeal circulation technique), and most heart surgeries are performed with the help of specially designed surgical instruments, including all valve surgeries (single, double, triple valve replacement and/or repair + Radiofrequency ablation), correction of most precardiac diseases, coronary artery bypass grafting for single and multiple vessel lesions, and radiofrequency ablation of atrial fibrillation.
This kind of direct vision minimally invasive surgery performed by special surgical instruments has obvious advantages: wide range of applications (can complete most of the cardiac surgery), less trauma, most patients do not need intraoperative blood, shorter time to return to normal work life, and better postoperative aesthetic effect, so it is now the internationally commonly used direct vision minimally invasive surgery technology. In China, some cardiac centers are gradually adopting this new direct vision minimally invasive surgery technique.
Anzhen Hospital is currently the most mature hospital for direct vision minimally invasive cardiac surgery, where Director You Bin’s medical group now routinely uses minimally invasive techniques for valve disease, including mitral valve replacement or repair, mitral + aortic valve replacement + tricuspid valvuloplasty + radiofrequency ablation. The vast majority of patients with congenital atrial septal defect, ventricular septal defect, endocardial cushion defect, intracardiac type pulmonary vein malformation drainage, tricuspid valve malformation, etc., and some bypass patients who cannot tolerate large open-heart surgery or require minimally invasive surgery, choose minimally invasive surgery.
2.TV thoracoscopy
Aided cardiac surgery people’s awareness of surgical incision and surgical access trauma is the main reason why thoracoscopy is used in clinical cardiac surgery, and this surgery is called TV thoracoscopy-assisted cardiac surgery. Its use can be twofold, one is as an adjunct for improved visualization only; the other use is for fully thoracoscopic cardiac surgery. This procedure was first reported by Chang et al. in 1996, and has been attempted by many authors since then, with completed procedures including atrial septal defect repair, partial septal defect repair, simple aortic valve surgery or mitral valve surgery and single branch coronary artery bypass surgery.
Thoracoscopy provides good visualization, allowing surgical operations to be performed through non-traditional incisions, which further minimizes injury. The advantages of this procedure include small incision, relatively concealed, less injury, and less bleeding, and most authors consider this procedure to be a more definite minimally invasive surgery. However, as far as the literature reported in China shows, only one atrial septal defect repair requires three incisions, and the total length of the incision is around 5 cm.
Television-assisted cardiac surgery requires some specific technical support, which include.
(1) skilled thoracoscopic technique;
(2) Techniques to establish and maintain extracorporeal circulation in specific situations;
(3) emergency treatment plan in case of emergency, etc.
3.Surgery done by robotic arm
-The robotic surgeon can perform atrial septal defect, partial ventricular septal defect repair, unclosed arterial catheter ligation, mitral valve replacement or molding surgery, single anterior descending branch or diagonal branch coronary artery bypass grafting, etc. The disadvantage is that expensive robots need to be purchased, the operation is very expensive, and the scope of application is small. At present, there is still a big controversy about the application prospect of robotic surgery at home and abroad. There are a few hospitals in China try to carry out the operation, with the PLA General Hospital carried out earlier and more.
4, the application of interventional methods in cardiac surgery hybrid surgery, mainly applicable to coronary artery bypass grafting. Both the use of percutaneous catheter intervention to deal with the gyral branch or right coronary lesions, minimally invasive method to complete the left internal mammary artery – anterior descending branch anastomosis, has been more literature good results. However, the cost of treatment is relatively increased.
II. Minimally invasive cardiac surgery
In summary, the application and research of minimally invasive cardiac surgery has achieved promising results, but there are still many clinical problems that need to be solved.
Research on the following will be of great significance to the development of minimally invasive cardiac surgery.
(1) The study of trauma mechanism of cardiac surgery can provide theoretical basis for further reduction of trauma;
(2) Research on myocardial protection, which can help to reduce the trauma of myocardium during surgery;
(3) The improvement of related surgical instruments can make the corresponding minimally invasive surgery easier to carry out;
(4) Clarify the indications for surgical treatment of various cardiac surgical diseases, which is conducive to the selection of the most reasonable minimally invasive treatment means;
(5) To explore new minimally invasive treatment methods.
The advantages of our minimally invasive surgery include: small trauma (incision length is only 5 cm on average), fast recovery (normal work and study life can be resumed in 3 weeks on average after surgery), wide range of surgical indications (most valve diseases, precordial diseases and some coronary heart diseases can be treated by minimally invasive surgery), and easy to be applied in hospitals with certain cardiac surgery foundation.
After continuous exploration and practice, we have established a complete set of operation routines and a well coordinated hand and body anesthesia monitoring team, making minimally invasive cardiac surgery a routine operation and a feature of the cardiac surgery department of Anzhen Hospital.