Eur J Cardiothorac Surg 1998;13:551-554
© 1998 Elsevier Science NL
Cardiac surgery by transxiphoid approach without sternotomy1
Henry J.C.M. van de Wala,
Miguel Barbero-Marcialb,
Sylvie Hulina,
Yves Lecomptea
a Institut Cardiovasculaire Paris Sud, Institut Hospitalier Jacques Cartier, Massy, France
b Heart Institute, University of São Paulo Medical School, Hospital Sirio Libanês, São Paulo, Brazil
Received 29 September 1997;
received in revised form 23 February 1998;
accepted 2 March 1998.
Corresponding author. Donksestraat 23, NL-5271 TN Sint Michielsgestel, The Netherlands. Tel./fax: +31 73 5943306; e-mail: vandewal@worldaccess.nl
 |
Abstract
|
|---|
Objective: In a attempt to avoid the potential drawbacks associated with sternotomy coupled with a desire for a smaller scar led us to investigate the transxiphoid approach without sternotomy. We present our preliminary experience and a comparison between the sternal and thoracic approaches. Methods: From June 1996, at the Institut Cardiovasculaire Paris Sud, Massy, France (ICPS) and the Heart Institute, São Paulo, Brazil (HI) the transxiphoid approach was adopted for the correction of selected congenital cardiac defects. The xiphoid was resected through a 6 cm long vertical skin incision. With a special retractor the sternum was elevated cephalad and anteriorly. Closure of the defect was performed in the conventional manner. Twenty-six patients; 17 boys and 9 girls were entered into the study from representing 19 atrial septal defects (ASDs), 4 ventricular septal defects (VSD) and 3 partial atrio ventricular septal defects (AVSD). In addition at ICPS the transxiphoid approach for correction of ASD was compared to the thoracic and sternal approaches performed in the same period. Results: Both the aortic cross clamp time as well as the duration of extracorporeal circulation were increased when compared to either standard sternotomy or thoracotomy approaches. There were no differences within the groups when comparing body surface area, amount of chest drainage or length of either ICU or hospital stay. However the patients in the transxiphoid group showed less pain and respiratory discomfort. Conclusion: Our initial experience with the transxiphoid approach without sternotomy confirms that it is a promising technique that can be considered an alternative to conventional sternotomy. The access is adequate for surgical procedures performed through a right atriotomy. The advantages include a better cosmetic scar, less surgical trauma, minimal respiratory discomfort and a potentially lower risk of infection. However cardiopulmonary bypass and cross clamp times are increased. There were no complications, and patient satisfaction was high.
Key Words: Atrial septal defect • Transxiphoid approach • Minimal invasive surgery
|
Introduction
|
|---|
The surgeons interest in minimal invasive procedures has been increasing. The potential of less surgical trauma, greater patient comfort, shorter hospital stay, lower chance of postoperative complications, reduced costs and a better cosmetic appearance, are used to justify this current tendency.
Additionally the patient or the parents are increasingly asking for the least possible invasive technique. Although cardiologists have reported successful closure of atrial septal defects (ASD) using catheter techniques
[1], there remain limitations in relation to the type and size of the defect as well as the age of the patient and vascular access. For surgical correction of congenital heart defects adequate exposure is crucial. Various surgical incisions have been advocated to address cosmetic aspects, i.e. lateral thoracotomy, or submammary skin incisions. To combine adequate access with a smaller scar, less pain and reduced respiratory discomfort as well as shorter hospital stay `the transxiphoid approach without sternotomy' has been proposed.
The aim of the present study is to present our preliminary experience with the transxiphoid window approach and a comparison between sternal and thoracic approach.
|
Patients and methods
|
|---|
From June 1996 until April 1997, at the Institut Cardiovasculaire Paris Sud (ICPS), Massy, France and the Heart Institute (HI), São Paulo, Brazil, 26 children (17 boys, 9 girls), underwent open heart surgery for correction of congenital heart disease using the transxiphoid window approach. The 14 children from ICPS (8 boys and 6 girls) had a mean age of 3 years (range 6 months to 8 years) while the 12 patients (9 boys and 3 girls) from HI had a mean age of 5 years (range 6 months to 14 years) with no significant differences between the two institutes. The diagnoses were ASD in 19 (ICPS, 7; HI, 12), perimembranous ventricular septal defect (VSD) in 4 (ICPS) and partial atrio ventricular septal defect (AVSD) in 3 (ICPS).
|
Operative technique
|
|---|
A longitudinal skin incision commencing 1 cm above the base of the xiphoid is extended distally 1 cm below the tip, through the linea alba, giving a total length of approximately 6 cm (
Fig. 1
). Using electrocautery the xiphoid process is resected and the incision extended cephalad into the cartilagenous base of the supraxiphoid portion of the sternum. Antero-superior traction is applied with the aid of a specially made deep profile retractor. The pleura is carefully pushed back to avoid entering it. The pericardium is opened vertically in the midline and its diaphragmatic attachment laterally. Traction sutures are applied to the edges of the pericardium. The `transxiphoid window' gives access to the front of the right atrium.
View larger version (44K):
[in this window]
[in a new window]
|
Fig. 1. Schematic drawing of transxiphoid window approach without sternotomy. (A) skin incision, (B) xiphoid resection. Anterio-superior traction of woundretractor fixed to the anaesthetic arch. C, frontal view; D, lateral view.
|
|
The arterial cannula is inserted either in the ascending aorta or in the left femoral artery. The inferior vena cava is cannulated directly using a right angled short tip cannula. The superior vena cava is cannulated through the right atrium. Caval snares are applied.
The aorta is exposed to allow infusion of cardioplegia as well as for deairing. Following institution of extracorporeal circulation, the aorta is cross-clamped. Due to the limited incision, the aortic clamp is positioned from the right side of the aorta. In the majority of the cases the pulmonary trunk is also included.
The caval tapes are snugged, the right atrium is opened vertically and retracted with stay sutures exposing the atrial septum. The intracardiac repair is performed in standard fashion.
Deairing of the left cardiac cavities is performed in routine manner. After which, the right atrium is closed and the remainder of the operation is completed as usual.
Video-thorascopy although not essential to the procedure can be used to improve the surgical assistants view. A 30° STORZ ENDOSCOPE SN 10/30/1419 was utilized for this purpose.
|
Statistical methods
|
|---|
The analysis of variance (ANOVA) test
[3] was used to compare the value of a variable in the two groups. A value of P<0.05 was considered to be statistically significant. Values are expressed as mean±standard error of the mean (SEM).
|
Results
|
|---|
The transxiphoid approach was adequate and successful repair was achieved in all patients. Arterial cannulation was routinely performed in the femoral artery at HI. At ICPS cannulation was initially via the ascending aorta but subsequently routinely in the femoral artery (7 patients in both sites). In São Paulo all patients were routinely extubated in the operation room. In Massy it was the policy to extubate the child in the ICU (mean 9±2 h). There was no mortality in either group and no complications such as bleeding, sternal dehiscence and no subdermal hematoma. Postoperative transthoracic echocardiography confirmed correction of all defects. Cannulation of the femoral artery did not result in any alteration in flow or pulse of the lower limbs. Hospital stay in HI was significantly shorter, the children were discharged between the 3rd and 5th postoperative day (mean 4±0.2, P=0.0001). In ICPS in accordance with both the hospital and social custom discharge occurred between the 8th and 10th day (mean 9±0.2).
Additionally in ICPS the transxiphoid approach for correction of ASD was compared to the other approaches performed in the same time period. Mean cross-clamp time of 18±2 min for the transxiphoid approach was significantly longer compared to 12±2 min for the sternotomy group. Comparison to 14±1 min for the thoracotomy patients was not significant. Likewise duration of extracorporeal bypass time was significantly longer for the transxiphoid group compared to sternotomy (41±4 vs. 25±3 min). The comparison with the thoracic group (31±3 min) was not significant. Chest drainage, ICU and hospital stay did not differ between the groups. Although not having a sternotomy has shown its value to the patient in terms of less pain and respiratory discomfort.
|
Discussion
|
|---|
Currently closure of both ASD and selected VSD lesions can currently be performed by catheter intervention techniques as an alternative to surgical closure
[1]
[2]
[4]. However, immediate and late complications have led to the reassessment of the procedure, limiting factors being size and type of ASD and the complications of venous or arterial access in low-weight children.
Although median sternotomy remains the most reliable approach to the heart, for cosmetic reasons a Y incision in the neck was introduced
[5]. Alternatively in girls and young women a bilateral submammary skin incision
[6]
[7] is made. However, the extensive subcutaneous detachment to expose the sternum and the potential risks of both infection and sensory changes in the breast have led to its virtual abandonment. The complications of sternotomy are well known
[8].
Antero-lateral thoracotomy through the fourth intercostal space is an adequate approach for procedures performed through a right atriotomy. This approach however, presents some potential disadvantages such as the opening of the pleural space, which could provoke greater incidence of atelectasia and other pulmonary complications, as well as greater postoperative pain due to trauma to the intercostal nerves
[9]. Most importantly, it can be difficult to determine the exact position of the inframammary groove in young girls.
To avoid the potential drawbacks associated with sternotomy, interest in minimally invasive surgery in cardiac surgery started as evidenced in myocardial revascularization, with or without the use of extracorporeal circulation
[10] and for aortic and mitral valve replacement
[11]. Video-endoscopic operations have been used for biopsy and pericardium drainage, closure of the patent ductus arteriosus
[12] in addition to division and suture of the pulmonary vascular ring
[13]
[14].
Both Gundry
[15] and Cosgrove
[16] have advocated the use of limited exposure incisions for the correction of cardiac anomalies. In general in paediatric cardiac surgery, minimally invasive procedures are uncommon due to the complexity of the anomalies, low body-weight and the manipulation of delicate anatomic structures. Chang et al.
[17] recently published data of ASD closure using video-assisted right antero-lateral minithoracotomy. They used deep hypothermia and report long periods of extracorporeal circulation (47–126 min). Despite the favourable outcome, their technique, adds a significant complexity to an otherwise potentially simple and safe operation. Other approaches have been developed for the minimally invasive surgery for intracardiac defects such as reduced sternotomy, with partial opening of the sternum
[18]
[19]
[20], yet none without opening the sternum.
The transxiphoid window is adequate for surgical procedures performed through a right atriotomy. The malleability of the cartilaginous sternum in the younger infants contributed to the possibility of aortic cannulation. In the older patients no sternotomy was performed to cannulate the aorta. The advantage of not opening the sternum is seen in the postoperative period. The patients have a much more rapid recovery, because there is less postoperative pain and discomfort. Discharge from the hospital can occur on the 3rd postoperative day, with almost immediate return to normal physical activities. During this initial period at Massy one opted to adhere to the normal discharge policy, although earlier discharge would have been possible. The cosmetic aspect is another beneficial factor.
It is valid to point out that the limited exposure of the heart through this incision makes technical demands on the surgeon. Moreover, anatomic variations might result in the necessity for extending the incision into a classical or partial sternotomy. In addition, in the presence of haemorrhage the conventional sternotomy should immediately be performed.
|
Conclusion
|
|---|
Our initial experience with the transxiphoid approach without sternotomy confirms that it is a promising technique that can be considered an alternative to conventional sternotomy. The access is adequate for surgical procedures performed through a right atriotomy. The advantages include a better cosmetic scar, less surgical trauma, minimal respiratory discomfort. It is expected that this will represent in a lower risk of infection. Despite cardiopulmonary bypass and cross-clamp times being increased.
|
Acknowledgments
|
|---|
We express our thanks to S.R. Woolley, FRCS for his help in preparing this manuscript.
|
Footnotes
|
|---|
Presented at the 11th Annual Meeting of the European Association for Cardio-thoracic Surgery, Copenhagen, Denmark, September 28 – October 1, 1997. 
|
References
|
|---|
- Rome J.J., Keane J.F., Perry S.B., Spevak P.J., Lock J.E. Double-umbrella closure of atrial septal defects. Initial clinical applications. Circulation 1990;82:751.[Abstract/Free Full Text]
- Reddy S.C., Rao P.S., Ewenko J., Koscik R., Wilson A.D. Echocardiographic predictors of success of catheter closure of atrial septal defect with the buttoned device. Am Heart J 1995;129:76-82.[Medline]
- Dexter F., Chestnut D.H. Analysis of statistical tests to compare visual analog scale measurements among groups. Anesthesiology 1995;82:896-902.[Medline]
- Latson L.A. Residual shunts after transcatheter closure of patent ductus arteriosus. A major concern of benign `techno-malady'?. Circulation 1991;84:2591-2593.[Free Full Text]
- Nandi P., Mok C.K., Ong G.B. Y incision for median sternotomy. Aust N Z J Surg 1979;49:489-491.[Medline]
- Brutel de la Riviere A., Brom G.H.M., Brom A.G. Horizontal submammary skin incision for median sternotomy. Ann Thorac Surg 1981;32:101-104.[Abstract]
- Baucia J.A., Sobrinho A.F., Marcial M.B. Incisão Submamária para Esternotomia Mediana. Arq Bras Cardiol 1993;60:335-338.[Medline]
- Sanfelippo P.M., Danileson G.K. Complications associated with median sternotomy. J Thorac Cardiovasc Surg 1972;63:419-423.[Medline]
- Rosengart T.K., Stark J.F. Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg 1993;55:1138-1140.[Abstract]
- Benetti F.J., Ballester C. Use of thoracoscopy and a minimal thoracotomy, in mammary-coronary bypass to left anterior descending artery, without extracorporeal circulation. Experience in 2 cases. J Cardiovasc Surg 1995;36:159-161.[Medline]
- Lin P.J., Chang C.H., Chu J.J., Liu H.P., Tsai F.C., Lin F.C., Chiang C.W., Yang M.W., Tan P.P. Video-assisted mitral valve operations. Ann Thorac Surg 1996;61:1781-1787.[Abstract/Free Full Text]
- Fortser R. Thoracoscopic clipping of patent ductus arteriosus in premature infants. Ann Thorac Surg 1993;56:1418-1420.[Abstract]
- Burke R.P., Wernovsky G., van der Velde M., Hansen D., Castaneda A.R. Video-assisted thoracoscopy surgery for congenital heart disease. J Thorac Cardiovasc Surg 1995;109:499-508.[Abstract/Free Full Text]
- Burke R.P., Chang A.C. Video-assisted thoracoscopic division of a vascular ring in an infant: a new operative technique. J Thorac Cardiovasc Surg 1993;8:537-540.
- Gundry SR. Mini sternotomy approach to aortic valve repair/replacement. Presented at the 77th Annual AATS Meeting, Washington 1997.
- Cosgrove DM. Minithoracotomy. Presented at the 77th Annual AATS Meeting, Washington 1997.
- Chang C.-H., Lin P.J., Chu J.-J., Liu H.-P., Lin F.-C., Chiang C.-W., Su W.-J., Yang M.-W., Tan P.P.C. Video-assisted cardiac surgery in closure of atrial septal defect. Ann Thorac Surg 1996;62:697-701.[Abstract/Free Full Text]
- Tatebe S., Eguchi S., Miyamura H., Nakazawa S., Watanabe H., Sugawara M., Hayashi J., Date K., Nakagawa S. Limited vertical skin incision for median sternotomy. Ann Thorac Surg 1992;54:787-788.[Abstract]
- Wilson W.R., Jr., Ibawi M.N., DeLeon S.Y., Piccioni W., Jr., Tubeszewski K., Cutilletta A.F. Partial median sternotomy for repair of heart defects: a cosmetic approach. Ann Thorac Surg 1992;54:892-893.[Abstract]
- Komai H., Naito Y., Fujiwara K., Takagaki Y., Nishimura Y., Kawasaki S., Nakamura T. Lower mid-line skin incision and minimal sternotomy – a more cosmetic challenge for pediatric cardiac surgery. Cardiol Young 1996;6:76-79.
This article has been cited by other articles:
|
|
|
|
 
C. Hagl, U. Stock, A. Haverich, and G. Steinhoff
Evaluation of Different Minimally Invasive Techniques in Pediatric Cardiac Surgery : Is a Full Sternotomy Always a Necessity?
Chest,
February 1, 2001;
119(2):
622 - 627.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. T. Cremer, A. Boening, and J. K.W. Scheewe
Reply
Ann. Thorac. Surg.,
March 1, 2000;
69(3):
982 - 982.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
