Bentall Surgery via Right Anterior Minithoracotomy

Minimally invasive cardiac surgery is increasingly becoming a standard approach for the treatment of various cardiac pathologies such as aortic stenosis and mitral regurgitation. It is also gaining popularity in the context of coronary artery bypass grafting (CABG). 
In contrast, minimally invasive approaches for aortic aneurysm surgery remain rarely reported. Bentall procedures via right anterior minithoracotomy are still relatively uncommon. A few publications are available in the literature (1–6), all of which suggest potential patient benefits and good surgical safety. 

In this video, the authors present their technique for performing a Bentall procedure through a right anterior minithoracotomy. The patient had severe calcified aortic stenosis, and preoperative computed tomography (CT) imaging revealed a dilated aortic root measuring approximately 49 mm. The surgical indication for a Bentall procedure was clearly established. 

The patient was positioned supine with a lateral support pad under the right hemithorax. Intubation was performed using a single-lumen endotracheal tube. A 6–7 cm anterior minithoracotomy was performed in the third intercostal space. A thoracoscope was used for educational purposes, although the surgery itself was performed under direct vision. 

Cardiopulmonary bypass (CPB) was established via the right axillary artery because the iliac vessels were heavily calcified, and percutaneous femoral venous cannulation at the right groin. Cardiac arrest was achieved using antegrade cold blood cardioplegia through the coronary ostia.  
A standard bioprosthetic Bentall procedure was then performed with excellent surgical exposure.  

Closure and drainage of the pleural and pericardial spaces were carried out using conventional techniques. The drains were removed on postoperative day one, and the postoperative course was uneventful. 

The authors believe that the right anterior minithoracotomy approach is a feasible and safe option for selected patients requiring Bentall surgery. This technique broadens the spectrum of minimally invasive strategies available to cardiac surgeons. 

References

1. Johnson CA, Siordia JA, Wood KL, Robinson DA, Knight PA. Right Mini-thoracotomy Bentall Procedure. Innov 2018;13:32831.
2. Jawarkar M, Manek P, Wadhawa V, Doshi C. Mini-Bentall Surgery: The Right Thoracotomy Approach. J Chest Surg 2021;54:5547.
3. Karadzha A, Bogachev-Prokophiev A, Sharifulin R, Ovcharov M, Pivkin A, Afanasyev A. The Bio-Bentall procedure with concomitant hemiarch replacement through a right anterolateral minithoracotomy. Multimed Man Cardiothorac Surg MMCTS 2022;2022.
4. Hamiko M, Salamate S, Nassari MA, Spaeth A, Sirat S, Doss M, et al. Totally Endoscopic Replacement of the Ascending Aorta and the Aortic Root including the Aortic Valve via Right Mini-Thoracotomy: A Multicenter Study. J Clin Med 2024;13:2648.
5. He X, Guo F, Li J, Li Y, Yan Y. The safety and feasibility of mini-invasive Bentall surgery via right anterior mini-thoracotomy. J Thorac Dis 2024;16:291826.
6. Durdu MS, Gümüş F, Bolcal C. Comparison of different surgical approaches for ascending aortic surgery with or without aortic valve involvement: Right anterior minithoracotomy versus conventional median sternotomy. JTCVS Tech 2024;28:229.

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