Operative Incisions for Minimally Invasive Cardiac Surgery

Abstract

l-n a previous article in tiffs publication, 1 we discussed _our first approach to minimally invasive aortic valve surgery, the parasternal approach. Be~nning in July 1996, our first 35 patients underwent aortic through a right parasternal approach. We took this approach because we reasoned that this nfight enable easier isolation of the aorta, as the aorta lies under the second intercoastal space. Through this incision, we did, in fact, gain adequate exposure for the conventional aortic valve replacement and homograft root replacement. As we gained more experience, however, we learned that in certain situations more flexibility in the incision is required. Also, as we decreased our dependence on femoral artery/femoral vein cannulation, we wanted to cannulate for cardiopuhnonary bypass in the chest using either the innominate vein or the right atrium. Therefore, after January 1997, we began to use the upper nfini-sternotomy, our current incision, which was popularized initially by Gundry. 2 In a presentation at the American Association for Thoracic Surgery in 1998, we presented our experience with the lower right parasternal approach to the mitral valve. 6 This is the approach that we used in our first 150 cases. Although this approach provides adequate exposure of the mitral valve, it became evident that only one operator could see well even with the use of a head video camera; thus, it was difficult for assistants to help, and, moreover, in a residency teaching program it was hard to instruct residents how to do these procedures via this incision. In addition, there was too much reliance on the femoral artery/femoral vein cannulation technique. On January 1, 1999, we began using our current incision, a lower mini-sternotomy as suggested by Doty. 7 We have also used a lower mini-sternotomy incision for correcting congenital heart disease lesions in adults. Currently, the primary incision for so-called minireally invasive coronary bypass surgery is basically a complete sternotomy for the performance of offpump coronary artery bypass grafting, needing no description.