In recent years, more and more patients have asked me: Can my disease be treated with “minimally invasive surgery”? It is evident that the concept of minimally invasive surgery has gradually spread from the industry to the whole society, so I think it is necessary to write a short article to popularize the concept of “minimally invasive” in cardiac surgery. The concept of minimally invasive has been controversial in the academic world, and there is no precise definition to distinguish what kind of surgery is considered minimally invasive and what kind of surgery is not. For example, the early radical mastectomy or even extended radical mastectomy, with its extensive resection, huge trauma and more postoperative dysfunction, has been gradually replaced by breast-conserving surgery with smaller and smaller resection areas. All these achievements are closely related to the in-depth understanding of the disease, the progress of surgical techniques and the development of treatment concepts. In other words, minimally invasive surgery is a way to achieve the same or better quality of life than traditional surgery by reducing surgical trauma. Cardiac surgery is a discipline that started late and developed fast in surgery. The emergence of extracorporeal circulation technology in the 1950s only brought about the rapid progress of cardiac surgery, which is the congenital deficiency of cardiac surgery. Therefore, to this day, in an era when other minimally invasive surgical procedures are soaring, minimally invasive cardiac surgery remains at a relatively low level, which stems from the fact that the underlying treatment techniques have not made a breakthrough. The current minimally invasive treatment in cardiac surgery includes the following aspects: 1. Median small incision surgery. It refers to simple precordial disease correction, coronary artery bypass and valve replacement surgery through a smaller incision than traditional median open-heart surgery, partially splitting the sternum to reveal the area that needs surgical operation. The advantages of this type of surgery are that the integrity of the sternum is partially preserved, the chance of postoperative sternal fracture and wound infection is reduced, and the amount of bleeding is relatively small, the postoperative drainage is less, and the patient recovers faster. Its disadvantage is that it is relatively difficult to reveal, the surgical operation is more difficult, and the treatment of complex lesions cannot be performed. For example, coronary artery bypass grafting is generally used only for patients with single anterior descending branch lesions. If right coronary artery lesions and gyrus branch lesions need to be treated, it is very difficult to reveal the lesion with this incision, and proximal anastomosis is very difficult and sometimes impossible to complete. In addition, for some patients with heart valve disease, this incision is also not suitable if the valve lesion is very severe and the heart enlargement is very serious. 2. Small right-sided axillary incision surgery. This is a procedure in which the patient is placed in the left lateral position during surgery, and instead of splitting the sternum, the surgery is performed through an intercostal incision in the right axilla to enter the chest cavity, and then from the chest cavity into the pericardial cavity to reveal the heart. This type of surgery is only suitable for corrective surgery for congenital heart disease in infants and children, including atrial septal defect repair, ventricular septal defect repair and even correction of tetralogy of Fallot, while more complex surgery is not possible. Adults are also generally not considered for this approach because of the difficulty of taking this surgical approach again due to the deep chest cavity. Its advantage is that the incision is concealed and ordinary clothes can effectively conceal the incision, which is especially suitable for little girls. At the same time, because the sternum is not split, the integrity of the thorax is preserved and postoperative hypoplasia such as pectus excavatum can be avoided, and the need for a second cardiac surgery in the future provides an opportunity for the traditional median open-heart approach. Its disadvantage is that more complex surgery cannot be completed. 3. Small right anterolateral incision. It is a small incisional approach to the intercostal space next to the anterior sternum for surgical procedures including simple precordial correction and valve replacement. This incision is smaller than the median mini-incision, so the lesions that can be treated are more limited, and requires another incision in the groin for femoral arterial cannulation to establish extracorporeal circulation. In other words, although there is only one small incision in the chest, there is actually another incision in the groin that is invisible to others. It has the advantage of being aesthetically pleasing, but the difficulty of the operation is simply unbearable. As the saying goes, “the patient is minimally invasive, the doctor is heavily invasive”, so it is only a matter of time before this minimally invasive approach is eliminated. 4. Thoracoscopic surgery. Thoracoscopy was first popularized in thoracic surgery, from the earliest alveolar resection and partial lobectomy to the radical treatment of esophageal cancer, and its application is becoming more and more widespread. However, the application of thoracoscopy in cardiac surgery still has a relatively short history. The procedures that can be done now include simple precordial correction, mitral valvuloplasty, mitral valve replacement, tricuspid valvuloplasty, aortic valve replacement (difficult), atrial mucinous aneurysm removal, and radiofrequency ablation of atrial fibrillation. Its advantage is that the incision is further reduced, with only two 1-2 cm eyes and a 4 cm incision, but the surgical field of view is very well revealed, and due to the application of the camera, it is often possible to obtain a clearer operative field than the naked eye during direct intracardiac view; another advantage is that the closing after the operation is very rapid, without the extremely difficult process of closing the chest in traditional open-heart surgery, with little bleeding, which is very beneficial for postoperative management, and This is very beneficial for postoperative management and patient recovery. Its disadvantage is that the surgical field is two-dimensional planarized, which requires some training for the surgeon to adapt, and has a longer learning curve than traditional surgery; in addition, the surgical instruments are specially designed, unlike the instruments held directly by traditional surgery. Although some units have tried to perform thoracoscopic coronary artery bypass surgery, it is limited to the anastomosis of a single lesion such as the left internal mammary artery-anterior descending branch, and it is not yet possible to complete the anastomosis of more vessels, and the long-term results are not known. Another disadvantage of thoracoscopic surgery is that it requires no history of surgery in the patient’s lungs (mainly the right lung) and good lung function, because if there is a history of surgery in the right lung, there are adhesions in the pleural cavity, and it is impossible to place thoracoscopic instruments, and during surgery, the right lung needs to collapse to provide visual field exposure, so it requires one-lung ventilation through the left lung only. Patients with poor lung function who cannot tolerate one-lung ventilation are not eligible for this procedure. In addition, thoracoscopic surgery also requires an incision in the groin to establish extracorporeal circulation through a femoral arterial cannula. Although the total time for thoracoscopic surgery is comparable to that of conventional surgery after proficiency, the two most important times in cardiac surgery: extracorporeal circulation time and aortic block time are significantly longer than conventional surgery, which means that your heart needs to stop beating for a longer period of time during the procedure, which is somehow contrary to the the concept of minimally invasive. But overall, thoracoscopy is still the most cost effective (why cost effective?) procedure at this stage. Because it is a high-functioning technique that will be mentioned later) and has the best future in minimally invasive cardiac surgery. 5. Robot-assisted cardiac surgery. The robot here is the da Vinci surgical robot system, which is the product of American research in space technology, and is now widely used in urology, obstetrics and gynecology, general surgery, cardiac surgery can be used for simple precordial disease correction, mitral valvuloplasty and replacement, aortic valve replacement, tricuspid valvuloplasty and replacement, atrial mucinous tumor removal, atrial fibrillation radiofrequency ablation, coronary artery bypass surgery, so to speak The da Vinci system is a more advanced thoracoscope. All procedures that can be done under the thoracoscope can be done through the da Vinci system, and procedures that are difficult to operate under the thoracoscope can often be done easily with the da Vinci system. This is because the da Vinci system provides a three-dimensional surgical field of view, which is the same as the three-dimensional effect of the surgeon’s direct vision with the naked eye, as well as the magnification effect, which makes the surgical field clearer. It can be said that the da Vinci system is the perfect application of modern high technology in medicine, and it is the top level of minimally invasive cardiac surgery at this stage. So, is the da Vinci System so perfect that it can replace traditional surgical procedures? Unfortunately, the answer is no. First of all, the da Vinci system is the only one in the world, there is no other branch, want to install the machine, 20 million yuan acquisition costs, and maintenance costs later, is a considerable investment, the general hospital can not afford, and can not be popularized on a large scale, while the mechanical arm belongs to the medical supplies, after 10 times will automatically lock up, can only buy new (capitalists really black ah), this part of the cost can only be passed on to the patient to This part of the cost can only be passed on to the patient to bear, expensive surgery costs will certainly exceed the ability of most people to pay and the national health insurance payment capacity. Secondly, the intervention of the robot makes the surgeon and the patient no longer in direct contact, but through the role of the machine, the surgeon’s operating instructions to the robot arm for surgery, and the machine must have a failure, the United States has had machine failure in the course of surgery, resulting in adverse events for patients reported. Finally, the da Vinci system is still a lumpectomy and still needs to be selected for the right patient population, some patients with complex lesions are not destined to have access to it. The contraindications for thoracoscopic surgery are basically the same as it, and the force is also half-hearted, for example, it is still only suitable to complete the left internal mammary artery-anterior descending branch anastomosis for a single lesion in the anterior descending branch, and still cannot complete coronary artery bypass grafting for multiple vessels well. 6. Endoluminal intervention. Aren’t we talking about cardiac surgery? How did we move to interventional therapy? Yes, the brutal growth of endoluminal interventions is eating away at the viability of cardiac surgery. Let’s turn the clock back 40 years, in the 70s when coronary artery bypass surgery first appeared, the treatment of coronary heart disease is mainly led by surgeons, then interventional technology, coronary stents gradually shake the dominance of coronary artery bypass, today if you suffer from coronary heart disease, unless the brain burned confused, it is impossible to come directly to the surgeon to do bypass surgery for you, must first go to internal medicine to see if interventional The first step is to go to internal medicine to see if intervention is possible. So far, the treatment of coronary artery disease is still a three-legged battle between drug therapy, interventional therapy and coronary artery bypass, but the suitable population for coronary artery bypass already belongs to the high-risk patients who have been screened by drug therapy and interventional therapy. Will there come a day when interventional therapy is so advanced that all coronary heart diseases can be treated satisfactorily with interventional therapy? It is entirely possible. Another major disease area where interventional techniques have made a big splash in the last decade is transcatheter aortic valve implantation (TAVI), which is called implantation rather than replacement because the original valve is not removed, but rather the newly implanted prosthetic valve is squeezed aside with brute force. Even so, there is a high rate of complications as well as mortality, so it is currently used only in patients with aortic valve lesions who are at high risk, elderly, and not candidates for surgical valve replacement. Younger patients with aortic valve disease are better and safer with traditional surgery. Transcatheter mitral valvuloplasty is also a form of treatment for mitral valve insufficiency, and this technique is more “simple and brutal,” using a specially designed “clip” to enter the heart cavity under ultrasound guidance and clip the anterior and posterior mitral valve leaflets where regurgitation is heaviest. The regurgitation is reduced and the patient will be able to get by for a few years, and then consider surgical valve replacement in the future when the regurgitation is aggravated again. This approach is indeed less invasive and quicker to recover, but it completely eliminates the possibility of mitral valvuloplasty (repair), and it is worthwhile for everyone to ponder whether this minimally invasive concept is right or wrong. In precordial disease, basically 99% of arteriovenous ductus arteriosus can be satisfactorily treated by interventional occlusion, and a significant proportion of atrial septal defects can be occluded. Interventional occlusion of ventricular septal defects is not recommended at present because interventional occlusion of perimembranous septal defects is likely to damage the conduction technique leading to third-degree AV block, which requires a permanent pacemaker; interventional occlusion of subdural septal defects is likely to damage the aortic valve leading to incomplete aortic valve closure, which may require replacement of the aortic valve in the long term, and both of these risks are also present in traditional open-heart surgery, but the chance is very low. More complex precordial diseases can only be treated by open-heart surgery, and interventional techniques are currently completely incompetent and powerless. To summarize, minimally invasive is an ideal that every surgeon should pursue throughout his life. When we start to cut the appendix as a young surgeon, we may make a relatively large incision in order to reveal it more clearly. But no matter how small the incision is, a basic principle is that you have to have enough confidence to complete the surgery safely. When choosing a minimally invasive procedure, you must combine the resources you can control, the characteristics of the patient’s condition, and the severity of the condition to make the procedure that is most beneficial to the patient’s safety, without blindly pursuing a small incision. Patients also need to be careful to listen to their doctor’s advice. Everyone’s condition is not exactly the same, and his condition may be suitable for minimally invasive surgery while yours may not be, and future treatment technology and philosophy must be individualized, so never be superstitious and blind.