Postoperative recovery in children after minimum versus full-length sternotomy

Extended sternotomy with lateral neck incision: An alternative approach for children with large apical chest masses with thoracic inlet involvement

Pediatric tumors in the apex of the thoracic cavity are often diagnosed late due to the absence of symptoms. These tumors can be quite large at presentation with involvement of the chest wall, sympathetic chain, spine, and aortic arch. The tumors can also extend into the thoracic inlet and encircle the brachial plexus. Depending on the diagnosis, treatment may involve chemotherapy with subsequent surgery or require primary resection. Optimal exposure to resect large apical tumors with thoracic inlet extension is a surgical challenge. To date, several surgical techniques have been described to resect these tumors - including both anterior and posterior thoracic approaches. Each of these techniques can be limited by inadequate exposure of the mass. We describe an alternative approach to surgical resection of these masses that employs an extended sternotomy with a lateral neck incision. This report details two successful resections of large left apical masses with thoracic inlet involvement in children using this technique (Level of evidence 4).

Effect of intercostal nerve block combined with general anesthesia on the stress response in patients undergoing minimally invasive mitral valve surgery

The aim of the present study was to investigate the effect of intercostal nerve block combined with general anesthesia on the stress response and postoperative recovery in patients undergoing minimally invasive mitral valve surgery (MIMVS). A total of 30 patients scheduled for MIMVS were randomly divided into two groups (n=15 each): Group A, which received intercostal nerve block combined with general anesthesia and group B, which received general anesthesia alone. Intercostal nerve block in group A was performed with 0.5% ropivacaine from T3 to T7 prior to anesthesia induction. In each group, general anesthesia was induced using midazolam, sufentanil, propofol and vecuronium. Central venous blood samples were collected to determine the concentrations of cortisol, glucose, interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) at the following time points: During central venous catheterization (T₁), 5 min prior to cardiopulmonary bypass (T₂), perioperative (T₃) and 24 h following surgery (T₄). Clinical data, including parameters of opioid (sufentanil) consumption, time of mechanical ventilation, duration of intensive care unit (ICU) stay, visual analog scale scores and any complications arising from intercostal nerve block, were recorded. Levels of cortisol, glucose, IL-6 and TNF-α in group A were significantly lower than those in group B at T₂ (all P<0.001; cortisol, P<0.05), T₃ (all P<0.001) and T₄ (all P<0.001; glucose, P<0.05), suggesting that intercostal nerve block combined with general anesthesia may inhibit the stress response to MIMVS. Additionally, intercostal nerve block combined with general anesthesia may significantly reduce sufentanil consumption (P<0.001), promote early tracheal extubation (P<0.001), shorten the duration of ICU stay (P<0.01) and attenuate postoperative pain (P<0.001), compared with general anesthesia alone. Thus, these results suggest that intercostal nerve block combined with general anesthesia conforms to the concept of rapid rehabilitation surgery and may be suitable for clinical practice.

Ministernotomy for correction of ventricular septal defect

Background

The development of minimally invasive surgery in the adult has created motivation for similar approaches in the congenital heart domain. Over the past 20 years, this type of surgery has been advocated in an effort to reduce costs related to hospital stay, and to improve the cosmetic results. We report our experience with ventricular septal defect repair utilizing a ministernotomy incision.

Methods

From August 2014 to August 2015, 26 patients underwent ministernotomy for correction of ventricular septal defect at our center. All patients were between the ages of 14 months-old to 24 years-old with weight ranged from 7.5 to 54 kg (median weight 12 kg). Diagnoses were confirmed with echocardiography. We analysed in-hospital and 6 months follow-up outcomes of the group.

Results

All defects were corrected successfully with satisfactory exposure. The median cardiopulmonary bypass time was 64 min, and median cross clamp time was 42 min. The intensive care unit stay ranged from 1 day to 3 days (median ICU stay, 1.5 days) and the hospital stay ranged from 4 to 13 days (median hospital stay, 5 days). There were no deaths during the operation or severe postoperative complications. No residual shunts were observed.

Conclusion

Our results demonstrated the safety and efficacy of ministernotomy for the correction of ventricular septal defect with improved cosmetic results in patients greater than 7.5 kg. This aprroach can be used in either the transatrial or transarterial approach, and in smaller weight infants.

Minimally invasive pediatric surgery in uncomplicated congenital heart disease

BACKGROUND

We aimed to highlight the use of a minimally invasive approach in uncomplicated congenital heart surgery.

PATIENTS AND METHODS

We investigated retrospectively 32 children below 10 years of age who underwent elective closure of ostium secundum type (n = 27), sinus venosus type (n = 4) and ostium primum type (n = 1) atrial septal defects through a limited skin incision and partial lower sternotomy between August 2001 and December 2008. All patients had cannulation through the same incision for cardiopulmonary bypass.

RESULTS

A pericardial patch was used to close the defect in 8 patients and direct suturing in 24. The mean time from the skin incision to cannulation was 56 ± 23 min. Total bypass time was 27 ± 12 min, and crossclamp time was 15 ± 8 min. Mean length of hospital stay was 4 ± 2 days. We did not encounter any complications or mortality.

CONCLUSIONS

A minimally invasive approach, consisting of a limited skin incision and partial lower sternotomy, is a safe, reliable, and cosmetically advantageous method in uncomplicated congenital heart disease surgery, which can be performed widely, and may replace the standard approach without increasing mortality and morbidity.

Safety advantage of modified minimally invasive cardiac surgery for pediatric patients

Minimally invasive cardiac surgery (MICS) using a small surgical incision in children provides less physical stress. However, concern about safety due to the small surgical field has been noted. Recently, the authors developed a modified MICS procedure to extend the surgical field. This report assesses the safety and benefit of this modified procedure by comparing three procedures: the modified MICS (group A), conventional MICS (group B), and traditional open heart surgery (group C). A retrospective analysis was performed with 111 pediatric patients (age, 0-9 years; weight, 5-30 kg) who underwent cardiac surgery for simple cardiac anomaly during the period 1996-2010 at Juntendo University Hospital. The modified MICS method to extend the surgical view has been performed since 2004. A skin incision within 5 cm was made below the nipple line, and the surgical field was easily moved by pulling up or down using a suture or a hemostat. The results showed no differences in terms of gender, age, weight, or aortic cross-clamp time among the groups. Analysis of variance (ANOVA) indicated significant differences in mean time before cardiopulmonary bypass (CPB), CPB time, operation time, and bleeding. According to the indices, modified MICS was similar to traditional open surgery and shorter time or lower bleeding volume than conventional MICS. No major mortality or morbidity occurred. In conclusion, the modified MICS procedure, which requires no special techniques, was as safe as conventional open heart surgery and even reduced perioperative morbidity.

Right posterior-lateral minithoracotomy access for treating congenital heart disease

A modified right posterior-lateral minithoracotomy with the aid of peripheral cardiopulmonary bypass is a surgical option that has been adopted in our institution in selected patients with simple congenital heart disease. We present our selection criteria, describe our technique, and analyze our results with this modified technique.

Lower ministernotomy and fast tracking for atrial septal defect

We report our experience with a 3-5-cm lower ministernotomy incision for closure of atrial septal defect in 53 patients. Fibrillatory arrest was used in 19 patients, and crossclamping with cardioplegia in 33. One patient had to be converted from fibrillatory arrest to crossclamping with cardioplegic arrest. The mean bypass time was 39.6 +/- 13.1 min, arrest time was 9.9 +/- 4.5 min, and crossclamp time was 20.7 +/- 8.69 min. All patients recovered without adverse events. They were fast tracked to recovery and extubated after 63.4 +/- 9.2 min. The mean intensive care unit stay was 1.07 +/- 0.33 days, and hospital stay was 3.07 +/- 0.38 days. The ministernotomy approach was used successfully in 51 patients; in the other 2, it had to be converted to a full sternotomy because of technical difficulties. Our experience confirms that this technique offers satisfactory cosmetic results, stable sternal reconstruction, good surgical exposure, minimal interference with respiratory mechanics, and minimal pain, allowing extubation in the operating room and a speedy recovery.

Treatment of ascending aorta disease with Bentall-De Bono operation using a mini-invasive approach

BACKGROUND

Use of minimally invasive approaches in cardiac surgery is increasing, obtaining a wide consensus and representing a challenging alternative technique for many surgeons. We report our experience of the treatment of ascending aorta disease using the Bentall-De Bono procedure through a minimally invasive approach.

METHODS

Between September 1997 and June 2005 at 'Policlinico San Matteo', Pavia, we treated 40 patients affected by ascending aorta disease and aortic valve regurgitation using a Bentall-De Bono procedure through a minimally invasive approach, by means of a reversed T or J ministernotomy. Data were analyzed retrospectively. Thirty patients were men. Short-term and mid-term mortality and peroperative complications were analyzed.

RESULTS

None of the patients died during the 30-day postoperative period. The mean ICU and length of stay times were 3.3 +/- 8.2 and 9.3 +/- 7.2 days, respectively. Six patients (15%) had one or more postoperative complications. One patient (2.5%) underwent early reoperation for bleeding. None underwent a procedure-related reoperation. Mechanical ventilation was longer than 48 h in five patients (12.5%). The mean follow-up was 38.4 +/- 31 months. Survival at 1, 3 and 5 years was, respectively, 94.1, 90.6 and 90.6%. At the end of the follow-up, there were 37 survivors. Twenty-seven (73%) patients were in New York Heart Association I, six (16%) were in New York Heart Association II and four (11%) were in New York Heart Association III.

CONCLUSION

Reversed T or J ministernotomy is a feasible and secure alternative to complete sternotomy. The short incision may enhance the outcome and does not affect the survival, offering proper access to the anatomic structures.

Adaptation of Median Partial Sternotomy in Head and Neck Surgery

Upper mediastinum involvement in diseases of the head and neck may require a sternal split. This study describes our adaptation of the upper median or “minimal” sternotomy technique for the treatment of head and neck pathologies. Between April 2002 and October 2005, 17 patients aged 4 to 82 years underwent minimal sternotomy in our institution for a variety of head and neck pathologies. The 17 patients included 11 adults with metastatic thyroid disease (six metastatic papillary thyroid carcinoma, two medullary carcinoma, and one Hürthle cell carcinoma) and huge retrosternal goiter (n = 2), four adults with parathyroid disease (two primary parathyroid adenoma, one secondary hyperplasia, and one parathyroid carcinoma), and two children with lymphangioma and huge thymic cyst (one each). Average hospitalization was 8 days. Four patients needed a thoracic drain for 2 days, one had recurrent laryngeal nerve palsy, and one had phrenic nerve paresis. There were no postoperative deaths. Minimal sternotomy appears to be an excellent alternative for surgical exploration of the mediastinum and may be used in head and neck surgery for a range of indications.

Short Operation Time: An Important Element to Reduce Operative Invasiveness in Pediatric Cardiac Surgery

BACKGROUND

The mini skin incision procedure is considered an important element of minimally invasive cardiac surgery because of its definitive cosmetic advantage. However, the operative hazard of limited exposure may be associated with prolonged operation time and increased surgical insult.

METHODS

A total of 357 consecutive patients undergoing repair of an isolated atrial or ventricular septal defect, in whom the mini skin procedure was applied, were investigated. Patients were grouped by diagnosis and body weight. Univariate and multivariate risk analyses were conducted in the specific patient group undergoing ventricular septal defect repair weighing less than 5 kg.

RESULTS

The operation time was reduced by 21.0% (93.4 to 73.8 minutes) during this time period. Univariate risk analysis revealed that the operation time had a significant correlation with time to extubation (p < 0.0001), catecholamine duration (p = 0.0003), intensive care unit stay (p < 0.0001), hospital stay (p = 0.016), arterio-alveolar oxygen tension difference at the time of extubation (p = 0.0253), and furosemide dose required in the first 24 hours (p = 0.0332). Multiple linear regression analysis revealed that the operation time had an impact on time to extubation, arterio-alveolar oxygen tension difference at the time of extubation, and intensive care unit stay. The length of skin incision was not correlated with any outcome measure.

CONCLUSIONS

The mini skin incision, if associated with prolonged operation time, may increase the overall insult in pediatric cardiac surgery. In order to reduce operative invasiveness, simultaneous effort to reduce, or at least not to increase, the operation time are mandatory.

Minimal access via lower partial sternotomy for congenital heart defects

To evaluate the invasiveness of a minimal access approach for simple congenital heart defects, and determine whether it can be regarded as a standard operation, 83 patients with an atrial septal defect and 73 with a ventricular septal defect underwent repair through a minimal skin incision and lower partial median sternotomy. There were no operative deaths, severe intraoperative complications, or conversion to full sternotomy. The clinical course of 106 patients was compared with that of 21 treated using a full sternotomy by the same surgeon; there were no significant differences, except in the operative time for ASD patients. The clinical courses of 2 minimal access subgroups (50 patients operated on by residents and 106 treated by the staff surgeon were compared; operative time, bypass time, ventricular fibrillation time (ASD repair), and cardiac arrest time (VSD repair) were significantly shorter in those operated on by the staff surgeon, but there was no difference in clinical course. The minimal access approach produced good cosmetic results, its invasiveness was similar to that of a full sternotomy, and it may be considered a standard operation for pediatric patients with septal defects.

The case against minimally invasive cardiac surgery

Stellar outcomes have been achieved for patent ductus arteriosus (PDA), atrial septal defect (ASD), and ventricular septal defect (VSD) repairs by using the traditional surgical methods. Over the last decade, minimally invasive procedures have been introduced that promise excellent results with an improved cosmetic appearance, shorter rehabilitation period, less pain, and decreased hospital cost. We reviewed various minimally invasive procedures that are used in PDA, ASD, and VSD to assess their safety and efficacy. These techniques use limited approaches to the heart (partial sternotomies, transxiphoid, anterolateral thoracotomy, and mini-thoracotomy) that reduce the surgeons access and control of the cardiac structures. Cannulation sites for the establishment of cardiopulmonary bypass have been altered. Minimally invasive therapies for congenital heart surgery cannot be adopted until evidence-based data has proven them to be equal or better than the traditional procedure.

Inferior Partial Sternotomy for Surgical Closure of Isolated Ventricular Septal Defects in Children

BACKGROUND

Surgical closure of isolated ventricular septal defect (VSD) through partial inferior sternotomy offers the advantages of a much shorter, cosmetically superior skin incision, potentially improved sternal stability, a lower rate of infection, and less postoperative pain. We report our technique and results of use of inferior partial sternotomy for closure of isolated VSD in children.

PATIENTS AND METHODS

From July 2002 to July 2003, 24 consecutive patients with a median age of 4.5 months (range, 1 month-4.5 years) underwent partial inferior sternotomy for isolated VSD closure. The length of the incision ranged from 4 to 6 cm. Special features of the approach included T incision of the lower sternum (from the fourth intercostal space to the xiphoid), establishment of cardiopulmonary bypass with central cannulation, aortic cross-clamping, and cardioplegic arrest. All VSDs were approached through right atriotomy. Perimembranous VSDs were exposed after detachment of the anterior leaflet of the tricuspid valve and were closed with a continuous suture. Muscular VSDs were approached directly. Perioperative and postoperative echocardiographic findings were available for all patients. Follow-up was complete.

RESULTS

There was no mortality or significant surgical morbidity. Median cross-clamping and cardiopulmonary bypass times were 43 and 103 minutes, respectively. All patients were in sinus rhythm. Perioperative and postoperative echocardiography confirmed the absence of any residual defects in perimembranous VSDs and the presence of a trace residual VSD in 4 patients with muscular VSDs. Optimal healing of the partial sternotomy was obtained in all patients.

CONCLUSIONS

Inferior partial sternotomy is less invasive than and cosmetically superior to full sternotomy. It provides excellent results when applied to isolated VSD with standard surgical techniques.

Minimally invasive valve surgery: different techniques and approaches

Less invasive approaches to cardiac surgical procedures are being developed in an effort to decrease patient morbidity and enhance postoperative recovery in comparison with conventional methods. Although full median sternotomy has been the standard surgical approach to the heart for more than 30 years, minimally invasive techniques using limited incisions are rapidly gaining acceptance. Potential advantages of a small skin incision include less trauma and tissue injury, leading to a less painful and quicker overall recovery, as well as shorter hospital stays for patients. Decreasing the size of the skin incision for minimally invasive valve surgery to significantly less than the cardiac size requires specific access to the valve to be repaired or replaced. Thus, various minimally invasive techniques and approaches have been described for aortic and mitral valve surgery. This article will review the different minimally invasive techniques and approaches, as well as early results and outcomes for aortic and mitral valve surgery.

Comparison of different approaches for pediatric congenital heart diseases

To compare the clinical results of different surgical approaches for congenital heart disease in pediatric patients, 1669 cases of atrial septal defect, ventricular septal defect, or tetralogy of Fallot, which were corrected from January 1999 to December 2001, were classified according to approach (sternotomy, ministernotomy, or minithoracotomy). In cases of ventricular septal defect, the incidence of pulmonary complications was significantly higher in the minithoracotomy group than in the full sternotomy or ministernotomy groups. In patients with tetralogy of Fallot, hemoglobin concentration was higher, oxygen saturation was lower, and more patients required a transanular patch in the sternotomy group than in the other groups, but the clinical results were similar. Patients with complex defects or severe pulmonary hypertension should undergo a full sternotomy.

Avoidance of full-sternotomy: effect on inflammatory cytokine production during cardiopulmonary bypass in rats

BACKGROUND AND AIM OF THE STUDY

Although open heart operations via a mini-sternotomy or mini-thoracotomy are considered "less invasive" cosmetically and are hopeful for early social recovery, clinical experiences have not shown less invasiveness toward systemic inflammatory response, because of the wide variety of patients and operative procedures encountered. We examined the effect of a mini-sternotomy on an inflammatory response during a cardiopulmonary bypass (CPB) procedure performed in rats.

METHODS

Thirty-two adult Sprague-Dawley (SD) rats, each of which underwent a 120-minute CPB, were randomly divided into four groups according to the method of exposing the pericardial cavity; no sternotomy (Group N [0 cm], n = 8), right para-sternal thoracotomy (Group P [2 cm], n = 8), lower mini-sternotomy (Group M [2 cm], n = 8), and full-sternotomy (Group F [4 cm], n = 8). Blood samples were obtained (1) just prior to the initiation of CPB, and then (2) 30, (3) 60, and (4) 120 minutes after the initiation of CPB.

RESULTS

Thirty minutes after the initiation of CPB, there were significant differences in plasma interleukin [IL]-6 levels between groups, except for Groups P and M; whereas at 60 minutes the only significant difference occurred between Groups N and F, and at 120 minutes there were no significant differences between any of the groups. Further, plasma IL-8 levels were not significantly different at each sampling point between all of the groups.

CONCLUSIONS

These results first demonstrate experimentally that the avoidance of a full-sternotomy can be considered a less invasive strategy in terms of reducing the systemic inflammatory response that accompanies a shorter CPB duration.

Minimally invasive or interventional repair of atrial septal defects in children: experience in 171 cases and comparison with conventional strategies

OBJECTIVES

The goal of this study was to evaluate percutaneous interventional and minimally invasive surgical closure of secundum atrial septal defect (ASD) in children.

BACKGROUND

Concern has surrounded abandoning conventional midline sternotomy in favor of the less invasive approaches pursuing a better cosmetic result and a more rational resource utilization.

METHODS

A retrospective analysis was performed on the patients treated from June 1996 to December 1998.

RESULTS

One hundred seventy-one children (median age 5.8 years, median weight 22.1 kg) underwent 52 device implants, 72 minimally invasive surgical operations and 50 conventional sternotomy operations. There were no deaths and no residual left to right shunt in any of the groups. The overall complication rate causing delayed discharge was 12.6% for minimally invasive surgery, 12.0% for midline sternotomy and 3.8% for transcatheter device closure (p < 0.01). The mean hospital stay was 2.8 +/- 1.0 days, 6.5 +/- 2.1 days and 2.1 +/- 0.5 days (p < 0.01); the skin-to-skin time was 196 +/- 43 min, 163 +/- 46 min and 118 +/- 58 min, respectively (p < 0.001). Extracorporeal circulation time was 49.9 +/- 10.1 min in the minithoracotomy group versus 37.2 +/- 13.8 min in the sternotomy group (p < 0.01) but without differences in aortic cross-clamping time. Sternotomy was the most expensive procedure (15,000 EUR +/- 1,050 EUR vs. 12,250 EUR +/- 472 EUR for minithoracotomy and 13,000 EUR +/- 300 EUR for percutaneous devices).

CONCLUSIONS

While equally effective compared with sternotomy, the cosmetic and financial appeal of the percutaneous and minimally invasive approaches must be weighed against their greater exposure to technical pitfalls. Adequate training is needed if a strategy of surgical or percutaneous minimally invasive closure of ASD in children is planned in place of conventional surgery.

Evaluation of different minimally invasive techniques in pediatric cardiac surgery: is a full sternotomy always a necessity?

STUDY OBJECTIVES

A variety of minimally invasive techniques have been recently introduced in adult cardiac surgery. Experiences with children and newborns are, however, limited. In this report, we present our first experiences with different methods of ministernotomies for closure of atrial septum defect (ASD) and ventricular septum defect (VSD) in pediatric cardiac patients. Also, the current literature for different surgical approaches is reviewed.

PATIENTS AND METHODS

Twenty-five pediatric patients (range, 4 months to 12 years old) underwent elective ASD or VSD closure. Surgical access was either without division of the sternum (group A, n = 5), with partial inferior sternotomy (group B, n = 5), total sternotomy with limited skin incision (group C, n = 5), or total sternotomy with full skin incision (group D, n = 10).

RESULTS

There were no severe intraoperative complications regarding exposure, cannulation, or bleeding. Conversion to full sternotomy was not necessary in any patient. Bypass time and cross-clamp time in groups A, B, and C were comparable to the standard operation (group D). However, preparation time was significantly increased in one minimally invasive group (group A vs group D, p<0.05). Despite general feasibility, the transxiphoidal access without sternotomy compromises exposure of the ascending aorta, resulting in impaired administration of cross-clamping, cardioplegia, and especially de-airing.

CONCLUSIONS

Transatrial pediatric cardiac operations can be performed without or with limited sternotomy. The partial sternotomy allows uncompromised exposure of the great vessels and should be favored over the transxiphoidal approach. The operative access and perioperative risk is comparable to a classical standard surgical approach. Advantages include improved cosmetic results in combination with a high degree of safety.