APPLICATION OF DIFFERENT MINI-INVASIVE TECHNOLOGY IN CARDIAC SURGERY

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PUBLISHED DATE: - 31-07-2024

DOI: -

https://doi.org/10.37547/TAJMSPR/Volume06Issue07-09

PAGE NO.: - 68-74

APPLICATION OF DIFFERENT MINI-
INVASIVE TECHNOLOGY IN CARDIAC
SURGERY

Yarbekov R.R.

State Institution "Republican Specialized Scientific and Practical Medical Center of Surgery
named after academician V.Vakhidov", Uzbekistan

Ilkhomov O.E.

State Institution "Republican Specialized Scientific and Practical Medical Center of Surgery

named after academician V.Vakhidov", Uzbekistan

INTRODUCTION

Along with the broader surgical community,

cardiovascular surgery is in the process of constant
evolution of techniques in the 1990s the world first

became aware of minimally invasive valve surgery,
which has influenced virtually all types of cardiac

surgery performed today,which has been an
evolution for cardiologists[1]. With the increasing

patient interest in minimally invasive procedures,
it is more important than ever for surgeons to keep

abreast of the most common minimally invasive
techniques in cardiac surgery.
In this article, we will review the most commonly

used incisions and approaches, focusing on aortic

valve, mitral valve, and aortocoronary bypass

procedures[3].
Hemisternotomy
Minimally invasive accesses to the aortic valve can

be performed using a wide range of incisions, with
the most commonly used access being the

hemisternotomy, usually J-shaped to the right

fourth intercostal space. In this method, a midline
incision is made at the sterno-manubrial junction

and extended 4-5 cm downward [2]. The necessary
exposure of the sternum can be achieved without

enlarging the skin incision by undermining the soft
tissues both above and below. A standard sternal

RESEARCH ARTICLE

Open Access

Abstract

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saw is then used to divide the sternum along the
midline to its smooth curve and entrance into the

fourth intercostal space. Although extending the

incision to the fourth intercostal space is the most
common approach, the specific intercostal space

used can and should be customized to the
patient[4]. For example, suitable exposure may be

possible using the third intercostal space in a lean
patient, whereas the fifth space may be required in

an obese patient. Aortic root exposure is also
possible with a sternotomy in the fifth intercostal

space, making this access useful in a wide range of
aortic valve and aortic root surgeries. After

crossing the sternum and dissecting the
mediastinal tissues, a vertical pericardiotomy is

performed and the edges of the pericardium are
sutured to the skin. This allows complete anterior

retraction of the mediastinum and maximizes

exposure of the aorta[5].
One advantage of the hemisternotomy is that it

allows a variety of cannulation strategies, from

fully central to purely peripheral. Columbia
University uses standard centrally placed cannulas

for the ascending aorta and right atrium, as well as
drainage of the right superior pulmonary vein and,

if

desired,

a

retrograde

catheter

for

cardioplegia[7]. This method is the same as that

used in total sternotomy surgery; it minimizes the

number of new techniques that must be learned to
perform the procedure successfully. Exposure and

visualization can be maximized by withdrawing the
venous cannula inferolaterally, suturing through

the chest wall with a needle hook, using low-profile
aortic cross-clamps, and placing the patient in a

steep reverse Trendelenburg position. Despite this,
cannulation can also be performed through the

femoral artery and vein by placing a pulmonary
artery vent or retrograde cardioplegia catheter

peripherally from the neck. Completely peripheral
cannulation minimizes potential obstructions in

the operative field, but requires considerable
experience on the part of the anesthesia and

perfusion teams[9].
Some reports suggest that taking cannulation to the

periphery of the field provides adequate
visualization and workspace without the additional

technical challenges associated with peripheral
cannulation. Once cannulation is achieved, the

remainder of the operation is performed in a

standardized manner[10].
Right anterior thoracotomy
Another minimally invasive access to the aortic

valve is the right anterior thoracotomy. This

operation is more commonly used in mitral valve

surgery, in addition it can also be used in aortic
valve surgery, which avoids sternotomy, and

provides less exposure as the aortic root and valve
are more difficult to see and reach from this angle.

Right anterior thoracotomy usually requires more
sophisticated and active monitoring via esophageal

echocardiography at least for peripheral
cannulation and in some cases for peripheral

insertion of retrograde cardioplegia catheters or
pulmonary vein ventilation[11].
The technique of right anterior thoracotomy is

performed using a 4-6 cm long incision is made

along the medial surface of the right third
intercostal space, dissecting the underlying tissue

and entering the pleural cavity[12]. Because of the
medial incision, ligation of the right internal

mammary vessels is usually required at this stage,
and separation of the third or fourth rib from the

sternum may be necessary to ensure adequate
exposure. The pericardium is then opened

anteriorly from the diaphragmatic nerve and a
pericardiotomy is performed to the diaphragm

below and to the pericardium above. A cannula for
antegrade cardioplegia is inserted directly through

the primary incision, and a transthoracic aortic

transverse clamp is inserted through the stab
incision, after which the disconnected rib is

sutured to the sternum. The surgeon should
consider the frequent need for rib-cartilage

disarticulation and rib fractures that are associated
with this access[13].
Operations performed on the mitral valve
Right parasternal access for minimally invasive

mitral valve surgery has been used by some

authors. A few years later, other cardiac surgeons
performed via right-sided thoracotomy, where

alternative approaches such as hemisternotomy,

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left thoracotomy and right minithoracotomy were
developed; of these, right-sided minithoracotomy

is the most widely used in current clinical

practice[14].
Right minithoracotomy
Right minithoracotomy is recognized as the most

commonly used incision in minimally invasive

mitral valve surgery and is now the standard

minimally invasive access in most centers. Several
retrospective studies have evaluated outcomes

after

mitral

valve

surgery

via

right

minithoracotomy[15]. Benefits including a better

view of the valve, reduced risk of infection due to
the well-vascularized superior pectoralis muscle

and lack of sternal separation, shorter
hospitalization. stay, less postoperative bleeding,

and less postoperative pain[16].
To access the mitral valve through right-sided

minithoracotomy, an inframammary incision of 4-
6 cm in length along the mid axillary line is made

for primary access and supplemented with stab
incisions if necessary [17]. This primary incision is

made 1-2 cm below the nipple in men and
approximately 1 cm above the breast crease in

women, followed by soft tissue dissection directed
cranially to the chest wall to allow access to the

chest cavity through the fourth intercostal space.
The incision is usually made medially to minimize

the working distance to the valve, but not as
medially as in aortic valve surgery, shifting the

incision slightly laterally results in a wider view of
the valve but at the expense of greater surface

distance. The ideal location to maximize working

distance and visualization of the valve can be
altered according to the surgeon's preference. Once

the primary incision is made, stab incisions are
used to introduce accessory instruments[18].
In our practice, two small puncture incisions are

made a few intercostal spaces below the main
incision to guide the carbon dioxide insufflator and

suction pump during the procedure and the pleural
drainage tube afterward. If desired, a 5 or 8 mm

videoscope can be introduced through one or more

incisions, both of which are located along the
anterior axillary line. To improve exposure of the

heart, the right hemisphere of the diaphragm is
withdrawn downward by suturing its tendinous

dome and bringing it to the skin through the

seventh to eighth interval with a needle-hook
apparatus[19].
The pericardium is then opened, starting a few

centimeters

anteriorly

from

the

right

diaphragmatic nerve, and the pericardiotomy is

continued down to the diaphragm and up to the
ascending aorta. The anterior edge of the

pericardium is withdrawn with sutures to the
medial aspect of the skin incision, and the posterior

edge is withdrawn with sutures brought to the skin

with a needle hook. A transthoracic Chitwood
clamp is then inserted through the stab wound in

the third interval along the right medial axillary
line and prepared for possible atrial retraction by

inserting a retractor through the chest wall medial
to the primary incision. This retractor may be self-

retaining, as in devices that attach directly to the
chest wall with screw clamps, or may be held in

place with table clamps [20]. Although cannulation
during artificial circulation can be performed in a

completely peripheral fashion. Similar to
minimally invasive aortic surgery, the use of

central cannulation minimizes both the amount of
new techniques required to adopt the entire

procedure and the expertise required of other

members of the surgical team, such as anesthesia
and perfusion. In particular, the avoidance of

peripheral arterial cannulation and endoaortic
balloon occlusion not only simplifies and shortens

the procedure, but also eliminates the risk of
complications such as retrograde aortic dissection,

retroperitoneal hemorrhage, and lower extremity
ischemia[21].
In minithoracotomy, cannulas for aortic, superior

vena cava, antegrade cardioplegia, and retrograde

cardioplegia can be placed centrally through the
primary incision, leaving only the inferior vena

cava cannula to be placed peripherally. Some
surgeons perform a multistage venous cannula

through the femoral vein using the Seldinger
technique under PEE control, supplementing if

necessary with a standard rectangular cannula
inserted through the primary incision into the

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superior vena cava. In reviewing the various
literature, we believe that although this degree of

central cannulation reduces the technical

complexity and simplifies the entire process, it still
creates the potential for difficulty in visualization

or movement during the procedure. Other authors
believe that cannulation involves a fully peripheral

and hybrid design, with the aortic and venous
cannulas placed in the periphery and the cannulas

for antegrade and retrograde cardioplegia
remaining in the center[22].
After cannulation of the patient and initiation of

artificial circulation, mitral valve exposure can be

started with dissection of Sondergaard's sulcus.
Once the aorta is clamped, the left atrium is opened

and the anterior left atrium and septum are
retracted forward using one of the types of

retractors described above. One technique that
helps to maximize visualization is to place a

retraction suture mainly using 3-0 monofilament,
approximately one centimeter from the P3 portion

of the mitral annulus in the inferior wall of the left
atrium[23]. This suture is then led out of the left

atrium, behind the inferior vena cava (through the
oblique sinus) and out of the thorax laterally. This

serves both to drain the excess inferior wall of the
left atrium away from the valve and to improve the

view of the inferior valve. Other work by cardiac

surgeons where used a similar technique placing
the transthoracic retractor as close to the sternum

as possible to prevent the left atrium from sliding
off the retractor and away from the surgeon. Paying

special attention to the left internal mammary
artery, which may be injured by this maneuver, the

valve is approximated a few centimeters by placing
several thick sutures on the posterior aspect of the

mitral annulus, as is done during annuloplasty, and
attaching them to the surgical band. After

detection, valve repair or replacement is
performed in the standard way of valve

replacement, the atriotomy is closed in the
standard way and cardiac dehiscence is performed

under ChEE monitoring[24].
There is much debate about de-aeration in

minimally invasive surgery, which consists of using
carbon dioxide insufflation in each case followed by

an extensive de-aeration protocol performed
under the supervision of a PEE that involves

positioning the patient in deep Trendelenburg

during aortic unclamping, aggressive cardiac
volume loading, positive pressure ventilation to

clear pulmonary venous air, and alternating left
and right table positions to remove air trapped

beneath the interventricular septum. After de-
aeration, electrodes for cardiac pacing are placed,

local nerve blockade is applied, and the chest is
closed[25].
Robot-assisted mitral valve surgery
The history of foreign colleagues in the

development of telemanipulation technology in the

1990s paved the way for robotic valve surgery, and
in 1998 Karpente i Mor independently reported the

first cases of robotic mitral valve plasty. The
technique evolved rapidly, and over the next 2

years Mexmnesh and colleagues performed the
first closed endoscopic mitral valve plasty, Grossi

and colleagues performed posterior leaflet repair,
and Chitvud and colleagues performed posterior

leaflet resection followed by reconstruction. and

colceal annuloplasty[26]. In addition to the
potential benefits of minimally invasive surgery,

numerous groups have reported additional
benefits of robotic surgery, including three-

dimensional visualization, ambidextrous, tremor
filtration, motion scaling, and even smaller

incisions. Results after robotic mitral valve surgery
in a prospective multicenter phase II trial involving

112 patients showed an 8% incidence of
postoperative grade 2 mitral regurgitation and a

5.4% reoperation rate. Columbia University
Medical Center used in the first US trial of robotic-

assisted mitral valve surgery and is currently
performing the procedure developed by Professor

Chitwood via a 5-6 cm right submammary

minithoracotomy that enters the chest through the
fourth intercostal space[27]. This incision is similar

to that used in the previously described
minithoracotomy, and intrathoracic preparation in

our center is performed in the same manner. As
discussed previously, cannulation for artificial

circulation can be peripheral or central. Aortic
occlusion can be performed either by transthoracic

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aortic clamping or by endo-aortic balloon with
continuous carbon dioxide insufflation in the

operating field. Usually, two robotic arms are

inserted into the chest through 10-mm trocar
incisions[13]. The right instrument is inserted 4-6

cm lateral to the thoracotomy site in the fourth or
fifth intercostal space, and the left instrument is

placed medial and cranial to the right instrument in
the second or third intercostal space. A distance of

6 cm is maintained between the levers, and the
alignment of the levers with the valve plane is

optimized to allow unrestricted movement of the
instruments[17].
A stereoscopic endoscope with a 30 degree angle of

view is inserted through the medial part of the

thoracotomy, leaving the remaining part of the
incision as a working port for the assistant on the

patient's side. If desired, the third arm can also be
used as a dynamic retractor. When the patient is on

artificial circulation, the left atrium is accessed by a
left atriotomy through the interatrial sulcus and

the valve is exposed using a transthoracic
intraatrial retractor. Valve repair, atriotomy

closure, disconnection from artificial circulation,
de-aeration and closure can then be performed in

the usual way[23].
Aortocoronary bypass
Aortocoronary bypass remains the gold standard

for coronary revascularization and is still
predominantly performed via median sternotomy

with little change in the overall invasiveness of the
procedure[11].This is due to several factors that

complicate this procedure when performed

through small incisions, including the technical
requirements of delicate vessel dissection and

suturing, the difficulty of exposing multiple regions
of the heart, internal thoracic arteries, and aorta,

and the long operative time. Despite these
problems, experience with minimally invasive

aortocoronary bypass surgery is growing[17].

CONCLUSIONS

In summary, since the 1990s, minimally invasive

techniques have been used for a wide range of
cardiac surgeries. Over the past two decades,

numerous sources have demonstrated the

feasibility, safety and efficacy of minimally invasive
cardiac surgery and supported its integration into

clinical practice. The Vakhidov Republican

Specialized Scientific and Practical Medical Center
for Surgery is one of the leading centers for the

treatment of congenital and acquired heart defects,
where all methods of operative cardiac surgical

treatment available to modern medicine are
offered. Excellent technical equipment, as well as

highly qualified specialists provide the best
conditions that guarantee an individual and

optimal approach to the treatment of each patient.

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