APPLICATION OF DIFFERENT MINI-INVASIVE TECHNOLOGY IN CARDIAC SURGERY

Аннотация

INTRODUCTION valve, mitral valve, and aortocoronary bypass Along with the broader surgical community, procedures[3]. cardiovascular surgery is in the process of constant evolution of techniques in the 1990s the world first Hemisternotomy became aware of minimally invasive valve surgery, Minimally invasive accesses to the aortic valve can which has influenced virtually all types of cardiac be performed using a wide range of incisions, with surgery performed today,which has been an the most commonly used access being the evolution for cardiologists[1]. With the increasing hemisternotomy, usually J-shaped to the right patient interest in minimally invasive procedures, fourth intercostal space. In this method, a midline it is more important than ever for surgeons to keep incision is made at the sterno-manubrial junction abreast of the most common minimally invasive and extended 4-5 cm downward [2]. The necessary techniques in cardiac surgery. exposure of the sternum can be achieved without In this article, we will review the most commonly enlarging the skin incision by undermining the soft used incisions and approaches, focusing on aortic tissues both above and below. A standard sternal https://www.theamericanjournals.com/index.php/tajmspr 68 THE USA JOURNALS THE AMERICAN JOURNAL OF MEDICAL SCIENCES AND PHARMACEUTICAL RESEARCH (ISSN – 2689-1026) VOLUME 06 ISSUE07 saw is then used to divide the sternum along the technical challenges associated with peripheral midline to its smooth curve and entrance into the cannulation. Once cannulation is achieved, the fourth intercostal space. Although extending the remainder of the operation is performed in a incision to the fourth intercostal space is the most standardized manner[10]. common approach, the specific intercostal space Right anterior thoracotomy used can and should be customized to the patient[4]. For example, suitable exposure may be Another minimally invasive access to the aortic possible using the third intercostal space in a lean valve is the right anterior thoracotomy. This patient, whereas the fifth space may be required in operation is more commonly used in mitral valve an obese patient. Aortic root exposure is also surgery, in addition it can also be used in aortic possible with a sternotomy in the fifth intercostal valve surgery, which avoids sternotomy, and space, making this access useful in a wide range of provides less exposure as the aortic root and valve aortic valve and aortic root surgeries. After are more difficult to see and reach from this angle. crossing the sternum and dissecting the Right anterior thoracotomy usually requires more mediastinal tissues, a vertical pericardiotomy is sophisticated and active monitoring via esophageal performed and the edges of the pericardium are echocardiography at least for peripheral sutured to the skin. This allows complete anterior cannulation and in some cases for peripheral retraction of the mediastinum and maximizes insertion of retrograde cardioplegia catheters or exposure of the aorta[5]. pulmonary vein ventilation[11]. One advantage of the hemisternotomy is that it The technique of right anterior thoracotomy is allows a variety of cannulation strategies, from performed using a 4-6 cm long incision is made fully central to purely peripheral. Columbia along the medial surface of the right third University uses standard centrally placed cannulas intercostal space, dissecting the underlying tissue for the ascending aorta and right atrium, as well as and entering the pleural cavity[12]. Because of the drainage of the right superior pulmonary vein and, medial incision, ligation of the right internal if desired, a retrograde catheter for mammary vessels is usually required at this stage, cardioplegia[7]. This method is the same as that and separation of the third or fourth rib from the used in total sternotomy surgery; it minimizes the sternum may be necessary to ensure adequate number of new techniques that must be learned to exposure. The pericardium is then opened perform the procedure successfully. Exposure and anteriorly from the diaphragmatic nerve and a visualization can be maximized by withdrawing the pericardiotomy is performed to the diaphragm venous cannula inferolaterally, suturing through below and to the pericardium above. A cannula for the chest wall with a needle hook, using low-profile antegrade cardioplegia is inserted directly through aortic cross-clamps, and placing the patient in a the primary incision, and a transthoracic aortic steep reverse Trendelenburg position. Despite this, transverse clamp is inserted through the stab cannulation can also be performed through the incision, after which the disconnected rib is femoral artery and vein by placing a pulmonary sutured to the sternum. The surgeon should artery vent or retrograde cardioplegia catheter consider the frequent need for rib-cartilage peripherally from the neck. Completely peripheral disarticulation and rib fractures that a