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Modified Button-Bentall Operation: The Miniskirt Technique

Monday, March 9, 2020

Venturini A, Gallingani A, Mangino D. Modified Button-Bentall Operation: The Miniskirt Technique. March 2020. doi:10.25373/ctsnet.11927619

The aim of this video is to highlight the surgical details of a modified button-Bentall operation specifically designed to incorporate any type of prosthetic valve in composite conduit aortic root replacement. The authors’ technical modification allows composite conduit creation and proximal suture line construction as a single-step maneuver. Moreover, the proximal suture line is reinforced with a running monofilament suture incorporating aortic wall remnants and graft edge, therefore improving proximal hemostasis. In the strategy presented, the fundamental principles of a traditional aortic root replacement are respected, and meticulous surgical technique to ensure absolute hemostasis is of the utmost importance in aortic root surgery.

One of the key points in the authors’ technique for aortic root replacement is the miniskirt technique. The authors don’t use routinely valved conduits for aortic root replacement, preferring to prepare the conduit during the operation so that they can choose separately the prosthetic valve and the vascular graft.

After the implantation of the valved graft, the authors perform a continuous 4/0 polypropylene suture between the proximal part of the vascular graft and the remnant of the aortic sinuses above the annulus. This hemostatic suture has been named Miniskirt.

The patient was a 48-year-old man with a 55 mm aortic root aneurysm and a moderate to severe aortic regurgitation due to a calcified bicuspid aortic valve. After a longitudinal aortotomy, the ascending aorta was resected, the aortic valve was excised, and the coronary artery buttons were carefully prepared.  Special attention has to be made in resecting and preparing the aortic root. If possible, at least 10 mm of native aortic wall has to be left in place. Subsequently, a deep root dissection was carried out, similar to what the authors do for a David procedure. This deep dissection is crucial to expose at least 8 to 10 mm of the aortic wall, which is necessary to perform the miniskirt. The authors then started placing 2/0 pledgeted interrupted stitches all around the aortic annulus. Teflon felts were left outside the aorta. Then all the 2/0 stitches are passed first in the valve and then in the Valsalva graft. In order not to lose any additional ischemic time, if they make a comparison with the use of a commercially available readymade valved graft, they try to pass all the stitches in the valve and in the tube altogether. They have approximately 8 mm of aortic wall and the basal collar of the Valsalva graft.

The authors start the miniskirt suture. A 4/0 polipropilene with a 17 mm needle is used. Usually, they start forehand from the left-right commissure and proceed first counterclockwise. Therefore, they suture the remnant of the left sinus first. If needed, excessive aortic tissue from the top of the commissures can be removed. Then they proceed clockwise in order to finish the miniskirt.

The authors believe this technique is very important in order to obtain a safe hemostasis and to prevent the growth of late pseudoaneurysms. Coronary ostia reimplantation is the next step of the operation. A thin strip of teflon felt is used to reinforce both coronary ostia. Distal anastomosis was performed after reinforcement of the fragile aortic wall with two strips of teflon. After careful deairing, cross clamp was removed and spontaneous sinus rhythm was observed. The patient was then easily weaned off CPB. Transesophageal echocardiography confirmed a well-functioning aortic valve and a normally contracting left ventricle.


  1. Copeland JG 3rd, Rosado LJ, Snyder SL. New technique for improving hemostasis in aortic root replacement with composite graft. Ann Thorac Surg. 1993; 55:1207-1209.
  2. Michielon G, Salvador L, Da Col U, Valfrè C. Modified button-Bentall operation for aortic root replacement: the miniskirt technique. Ann Thorac Surg. 2001; 72:S1059-1064.
  3. Yan TD. Mini-Bentall procedure: the “French Cuff” technique. Ann Thorac Surg. 2016; 101:780-782.


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I wish to congratulate our collegues for presenting their technique . The on site development of a composite graft has of course the potential for bleeding due to a small mismatch between the aortic valve and the valsalva graft. This potential is minimized by the second suture line of the mini skirt. Of course is not needed if the composite graft is already fixed. I find extremely usefull the mini skirt technique in redo root cases when an already aortic valve implant should be kept in place. Again thank you for presenting to us your technique.
Nice video of this technique. Having said that, sewing the valve on the graft with a running 4-0 Prolene takes not more than 4-5 minutes without rushing. It then makes it much quicker to pass the valve sutures through the newly made conduit, so your point about this technique expediting the procedure is a bit shaky. In addition, if you put your pledgets on the ventricular side (supra-annular implantation) rather than outside the aorta (like you would do in a plain AVR), then you do not need to dissect the aorta off the surrounding muscle in order to wrap the aortic remnant onto your conduit. Still, a very nice video.
Dear Dr Tolis, your opinion is very important for us. You are suggesting some possible modifications of the technique I presented. They are very interesting, however I try, whenever possible, to repeat our standard technique that always gave us excellent results
I have seen Dr. David put sutures from the outside in as you did, it seems very hemostatic and the miniskirt only reinforces that. What type of valve and size of valve do you use in relationship to the graft? In other words valve size to graft size. It seemed like thee wasn't much difficulty fitting the graft into the conduit. Do you think one of the downsides of not sewing the graft in separately would be that in the event of a re-op for degeneration of the valve, the whole entire root needs to be done rather than just cutting out the valve and replacing it from the inside?
Thank you Dr Rubelowsky for your comment. I really appreciated. I always use the valve sizers as in a normal AVR, secondly i choose the size of the Valsalva graft according to the distal aorta, so that your custom made valved conduit really perfectly adapts to each different patient. You will never have difficulty in fitting the graft into the conduit with this technique. If you are in doubt about the tube size, just take the large one, it will make your life easier.
I will also make a comment about this technique in cases of REDO for degeneration of the valve. If you only need to replace the valve you don't have to redo the entire root: the only thing to do is to remove the valve leaving in place the external part of its sewing ring. In addition, when you pass all the stitches for the new valve you reinforce the proximal suture line again. Therefore it's pretty much easier than a standard AVR. Your redo will also be easy if at the first operation your choice was for a quite large graft (if you have a 30mm tube you can fit nearly any kind of valve in it).

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