Hou Mai, Hou Mai, Cardiovascular Surgery Department, Air Force General Hospital
With the continuous improvement of cardiovascular surgery technology, it has become a trend in the development of cardiovascular surgery to minimize surgical trauma to achieve effective and aesthetic treatment results while fully ensuring surgical safety. This paper summarizes the experience of applying small median incisions to correct congenital heart disease, and discusses the surgical indications for applying this procedure and its methods and techniques.
Data and Methods
Clinical data There were 38 patients with congenital heart disease in this group, 17 males and 21 females, aged from 3 to 42 years old, with an average of 12±5.6 years. Among them, 16 cases had atrial septal defect, 15 cases had ventricular septal defect, 2 cases had right ventricular double chamber heart combined with ventricular septal defect, 3 cases had pulmonary valve stenosis, and 2 cases had partial type endocardial cushion defect, which were clearly diagnosed according to clinical manifestations, echocardiography, electrocardiography and chest radiography.
Surgical method A median sternal skin incision was made with the upper margin 1 cm from the sternal angle and the lower margin to the glabellar process. The length of the incision is about 5-6 cm in children and 7-10 cm in adolescents and adults, and the sternum is transected to the right with a chainsaw to the second rib space, preserving the continuity of the sternal stalk above the sternal angle. The sternum was propped open with a chest opener, and the suspended pericardium was incised. Direct cardiac surgery is performed using the same extracorporeal circulation intubation and myocardial protection methods as the conventional median incision, and the atrial septal defect is repaired using the heart without stopping. In the management of right ventricular outflow tract or pulmonary artery stenosis, the visualization and surgical manipulation are facilitated by suspending the pericardium and placing a traction wire.
Results
All cases in this group were cured without major complications such as respiratory circulation. The surgical incision was well concealed, the pain response was mild, there was no incision infection or healing of sternal deformity, and the surgical hospital stay was 7-9 days. At 6-month postoperative review, cardiac function was normal, there was no residual shunt, and the incision healed beautifully.
DISCUSSION
The median thoracic incision has been a routine incision for cardiovascular surgery, providing good visualization of the heart and great vessels. However, this incision requires complete splitting of the sternum, and therefore has the shortcomings of large trauma, poor stability of the thorax and aesthetic impact. In recent years, with the improvement of cardiac surgery technology and patient demand, various aesthetic small cardiovascular incisions such as median small incision, parasternal incision, right axillary incision, and right anterolateral incision have been innovated and carried out.
Clinical practice has revealed that the exposure of the cardiac surgical site is mainly located posterior to the lower 2/3 of the sternum, and this anatomical feature provides a feasible theoretical basis for performing cardiac surgery using a small median sternal incision. We believe that the small median sternal incision is not only a small surgical incision with aesthetic effect, but also has the following advantages: the integrity of the thorax and upper sternum is preserved, which is conducive to sternal healing and avoids complications such as sternal fracture and mediastinal infection; postoperative pain is significantly reduced, which is conducive to the recovery of respiratory function and reduces pulmonary complications; the sternum and posterior sternal trauma are small, which reduces postoperative blood leakage and transfusion; the surgical field of view is It is suitable for most conventional congenital heart surgery and can be expanded to a conventional median sternal incision by sawing the sternum at any time in the event of an accident during surgery.
Compared with a small median sternotomy, a parasternal or right-sided chest wall incision can also achieve an aesthetically pleasing incision, but a right-sided open chest can cause complications such as lung injury and pulmonary atelectasis. For patients with combined pulmonary hypertension, the postoperative recovery is not favorable. This type of incision is only suitable for surgery of atrial septal defects and membranous ventricular septal defects that are close to the right chest wall. If a combined left superior vena cava malformation, arteriovenous ductus arteriosus, subdural ventricular septal defect, pulmonary valve stenosis and other malformations are encountered intraoperatively, it is difficult to reveal the operative field and the incision has to be extended, which aggravates the trauma. Moreover, such incisions damage the chest muscles, which are not conducive to postoperative cough and sputum; they also have adverse effects on breast development such as deformation and hyposensitivity (4,5).
We experience that the small median sternal incision is poor for revealing the base of the heart, aorta, and pulmonary artery. For this reason, when establishing extracorporeal circulation for suturing the aortic load and aortic cannulation, a medium-curved hemostatic clamp can be used to hold the epicardium of the ascending aorta and pull it downward to fully expose the aorta for easy manipulation. The superior and inferior vena cava are well exposed and usually do not interfere with cannulation. In the management of right ventricular outflow tract or pulmonary artery stenosis, effective suspension of the pericardium and placement of a traction wire facilitates visualization and surgical manipulation.
In conclusion, the small median sternal incision is suitable for the surgical correction of most congenital heart diseases, which not only has the advantages of small incision, aesthetic appearance, postoperative patient pain relief and less complications. Moreover, the incision is safe, reliable, and does not require complex special instruments, and the operation is simple and easy.