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Right lateral mini-thoracotomy for mitral valve surgery

Tuesday, November 3, 2015

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Diana Reser, Tomas Holubec, Murat Yilmaz, Andrea Guidotti and Francesco Maisano

Since the 1990s, minimally invasive cardiac surgery has gained wide acceptance due to patient and economic demand. The advantages are less trauma, less bleeding, less wound infections, less pain and faster recovery. Many studies showed that the outcomes are comparable with those of conventional sternotomy. Right lateral mini-thoracotomy evolved into a routine and safe access in specialized centres for minimally invasive mitral valve surgery. The 6-cm incision is performed over the fifth intercostal space in the inframammary groove. With a double-lumen tube, the right lung is deflated before entering the pleural cavity. A soft tissue retractor is used to minimize rib spreading. The stab incisions for the endoscopic camera and the transthoracic clamp are performed in the right anterior and posterior axillary line in the third intercostal space. Surgery on the mitral valve is performed in a standard fashion under a direct vision with video assistance. One chest tube is inserted. The intercostal space is adapted with braided sutures to prevent lung herniation. Ropivacaine is used for local infiltration. The pectoral muscle, subcutaneous tissue and skin are adapted with running sutures. Complications of a right lateral mini-thoracotomy are rare (conversion to sternotomy, rethoracotomy, phrenic nerve palsy, wound infection and thoracic wall hernia) and well manageable.


I have used a 10 cm submammary incision since 1993, with both lung anaesthesia,without any other incision for clamping,cannulation or vision. Aortic Cannulation and clamping is done through this incision. The video of this surgery was published in CTSnet in 2002 and the technique was published in THI journal 1993,Asian annals and Annals of thoracic surgery in 1995.I have performed Mitral, Aortic and Tricuspid repair and replacement, ASD/VSD closure and repair of TAPVC through this incision. No new instruments or equipment is required and there is no femoral cannulation.The cosmetic result is very satisfactory for the patients.Over the years and with experience this incision has now shortened to 8 cms especially in children and adolescents. There were NO conversions. Periodically I see such publication that do not refer to our work from India!!.
This is for tech savy surgeons . The cost and cosmetic consideration can't match Dr Sampath Kumar's way where cosmesis is good . Second issue is analgesia for various holes - epidural as routine can solve that but I doubt how many do that.

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