The introduction of the concept of minimally invasive surgery was a revolution in surgery that profoundly influenced the fundamental philosophy of surgery and permeated all specific specialties of surgery. In May 1997, the International Society for Minimally Invasive Cardiac Surgery was founded and its official journal, The Heart Surgery Forum, was established, making minimally invasive cardiac surgery appear as a new and independent specialty in the field of cardiac surgery, a landmark event in the cardiac surgery community. This was a landmark event in the field of cardiac surgery.
The purpose of minimally invasive cardiac surgery is to minimize the physical and psychological damage to patients by choosing new minimally invasive surgical pathways that are different from traditional surgical instruments and equipment to complete the same safe and reliable cardiac surgery, to reduce surgical trauma, to shorten hospitalization time, to speed up the recovery process of normal life and work status after surgery, and to increase aesthetic results.
At present, the concept of minimally invasive cardiac surgery has been widely accepted by doctors and patients in developed countries, and some national and large regional cardiac centers in China have already carried out minimally invasive cardiac surgery, for example, Beijing Anzhen Hospital and Shanghai Zhongshan Hospital have routinely carried out minimally invasive mitral valve repair or replacement, aortic valve replacement, atrial septal repair and other surgeries.
Among them, Beijing Anzhen Hospital’s minimally invasive mitral and aortic valve double valve replacement + tricuspid valvuloplasty + atrial fibrillation radiofrequency ablation, minimally invasive endocardial cushion defect and tricuspid valve subluxation deformity repair in precordial disease, and minimally invasive coronary artery tower bridge surgery for three branches of lesions have reached the international leading level.
I. Concepts, methods, characteristics and application status of minimally invasive cardiac surgery.
Minimally invasive cardiac surgery in a broad sense includes catheter interventions in internal medicine, all surgical procedures under direct vision with small incisions, thoracoscopic and robotic completion.
In this article, 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-incision surgeries have been used clinically, which are well received by patients because of the small postoperative scars and more aesthetic appearance of these types of incisions. The strong desire of patients is a 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) “True” direct vision minimally invasive surgery: the conventional incision is 4-6 cm, and almost all of them reach the heart surgery site via intercostal pathway without cutting off the sternum or ribs, and the extracorporeal circulation cannula is placed through the femoral artery and internal jugular vein (closed negative pressure extracorporeal circulation technique), and most of the cardiac surgeries are performed with the help of specially designed Most of the cardiac procedures are performed with the help of special instruments, including all valve procedures (single, double and triple valve replacement and/or repair + RF ablation), most of the corrective procedures for precardiac disease, coronary artery bypass grafting for single and multiple vessel lesions, and RF ablation for atrial fibrillation.
This kind of direct vision minimally invasive surgery performed by special surgical instruments has obvious advantages: wide range of applications (most cardiac surgeries can be completed), less trauma, most patients do not need intraoperative blood, shorter time to return to normal work life, and better postoperative aesthetic results, so it is now a minimally invasive direct vision surgical technique commonly used internationally. This new direct-view minimally invasive surgical technique is gradually being adopted by some cardiac centers in China.
Minimally invasive techniques are now routinely used in 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.Heart surgery assisted by TV thoracoscope
People’s awareness of the trauma of surgical incision and surgical access is the main reason why thoracoscopy is used in clinical cardiac surgery, which 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 125px.
Television-assisted cardiac surgery requires a number of specific technical skills, which include.
(1) skilled thoracoscopic technique;
(2) Techniques for the establishment and maintenance of extracorporeal circulation in specific situations;
(3) Emergency treatment plan in case of emergency, etc.
3. Surgery done by robot arm —- robotic surgery
The 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 that try to carry out the surgery, and the PLA General Hospital carries out the surgery earlier and more.
4, the application of interventional methods in cardiac surgery
Hybrid surgery, mainly applicable to coronary artery bypass grafting. Both percutaneous catheter intervention is used to deal with the gyral branch or right coronary lesion, and minimally invasive method is used to complete the left internal mammary artery-anastomosis of the anterior descending branch, which has been proven to be effective in more literature. However, the cost of treatment is relatively increased.
The direction of research and development of minimally invasive cardiac surgery
In summary, the current application and research on 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) To clarify the indications for the 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.