Limited Thoracotomy Research Articles

Esophageal-pericardial fistula with purulent pericarditis secondary to esophageal carcinoma presenting with tamponade

A case of esophago-pericardial fistula secondary to esophageal carcinoma causing pericardial effusion and tamponade is presented. Palliation can be achieved effectively by limited thoracotomy, pericardial resection and drainage, and in selected cases esophageal stenting.

Diagnostic thoracoscopic lung biopsy: an outpatient experience

Background Tissue diagnosis of either interstitial lung disease or indeterminate pulmonary nodules can be obtained by either limited thoracotomy or thoracoscopic lung biopsy. Both procedures traditionally have required hospital admission. We report a series of patients undergoing outpatient thoracoscopic lung biopsy to demonstrate the safety and efficacy of this practice. Methods Sixty-two ambulatory patients with a clinical diagnosis of either interstitial lung disease or indeterminate pulmonary nodule(s) underwent thoracoscopic lung biopsy between June 2000 and June 2001. All procedures were performed with double-lumen endotracheal anesthesia and stapled wedge resection. Chest tubes were removed if no air leak was present and if chest radiograph demonstrated no residual pneumothorax. Results Of 62 patients undergoing thoracoscopic lung biopsy, 45 (72.5%) were discharged home within 8 hours of observation on the day of operation. Fourteen (22.5%) were discharged within 23 hours of their operation. Reasons for 23-hour observation included significant comorbidity (8), pain management (4), postoperative air leak (1), and conversion to muscle-sparing thoracotomy (1). Three (5%) required admission for prolonged air leak (2) or conversion to muscle-sparing thoracotomy (1). Diagnoses were obtained in 61 patients, including neoplasm (25), interstitial lung disease (18), granulomatous disease (7), and other (11). One patient was readmitted for pneumothorax. Patients diagnosed with nonbronchogenic pulmonary metastases were more likely to be discharged on the day of operation. No differences in age, smoking status, or preoperative pulmonary function testing were observed between patients requiring short-stay observation and those discharged immediately after operation. Conclusions Outpatient thoracoscopic lung biopsy is safe and effective, and has become our procedure of choice for diagnosis of either interstitial or focal lung disease.

Minimally Invasive Surgery for Congenital Heart Defects in Paediatric Patients

In selected cases, minimally-invasive approaches are favoured for the correction of congenital heart defects with regard to better cosmetic results. Between July 1999 and April 2001, 25 children (9 male; mean age 5.8 +/- 4.1 years; mean weight 19.6 +/- 12.6 kg) were operated on using minimally invasive approaches. Diagnoses were: ASD (n = 19), VSD (n = 2), ostium primum defect (n = 3) and Tetralogy of Fallot (n = 1). Female patients with ASD underwent a limited right anterolateral thoracotomy. A ministernotomy was chosen in male patients, in patients under 6 months of age, and in patients with malformations other than ASD. Cannulation was always performed via the chest incision. There were no perioperative complications. Mean operation time was 3.23 +/- 0.89 h. Twelve patients were extubated immediately after surgery, mean ventilation time in the others was 12.1 +/- 11.7 h. Mean ICU stay and hospital stay were 1.5 +/- 0.75 days and 8.3 +/- 2.2 days, respectively. Follow-up (mean 4.8 +/- 4.6 months) was uneventful. Intracardiac repair of some congenital heart defects can be performed safely and effectively via minimally-invasive approaches. Indications are expanding towards more complex defects. Exposure for precise repair is good, additional incisions can be avoided, and cosmetic results have been excellent.

Limited right posterior thoracotomy approach to atrial septal defect.

Experience of atrial septal defect closure via a limited posterior thoracotomy is described. From July 1999 to May 2001, 75 prepubertal girls with a median age of 7 years (range, 3 to 13 years) and a median weight of 18 kg (range, 10 to 46 kg) underwent atrial septal defect closure through a limited right posterior thoracotomy. All but 2 patients had an uneventful postoperative recovery. The median duration of ventilation was 13.3 hours (range, 4 to 24 hours). Median hospital stay was 6 days (range, 6 to 8 days). All patients were followed up for 7 to 32 months (mean, 15 months). The wounds healed well without any restriction of limb movement. The limited posterior thoracotomy gave excellent cosmetic results and can be used as a safe alternative approach for atrial septal defect closure in prepubertal females.

Initial prospective multicenter clinical trial of robotically-assisted coronary artery bypass grafting

Background. This multicenter prospective trial was designed to assess the safety and efficacy of using a robotically-assisted microsurgical system to create endoscopic coronary anastomoses. Methods. Thirty-two patients scheduled for elective primary coronary surgery underwent endoscopic anastomosis of the left internal thoracic artery (LITA) to the left anterior descending (LAD) artery. Three thoracic ports (two for instruments and one for a camera) were placed, and a robotic system was used to perform the LITA–LAD graft. Conventional techniques were used to perform the other grafts. Thirty-one patients underwent median sternotomy and 1 patient underwent a limited anterior thoracotomy. Results. Graft flow was measured in the operating room and averaged 37 ± 19 mL/min. Mean anastomosis time was 24 ± 9 minutes. There were three intraoperative revisions (9%). Two were for inadequate flow and one for an inadvertent injury. Each of these grafts was successfully revised by hand. There were no technical failures of the robotic system. Average postoperative length of stay was 5.5 ± 2.7 days. There were three reoperations for bleeding, but none of these were related to the LAD anastomosis. Two months following the operation, selective angiography revealed a graft patency of 93%. The patients have been followed for 16 ± 4 months. Conclusions. This initial prospective multicenter trial documents the feasibility of robotically-assisted coronary bypass grafting. Further trials are warranted to establish the safety and efficacy of this new technology.

What is the advantage of a thoracoscopic lobectomy over a limited thoracotomy procedure for lung cancer surgery?

Background. To clarify any advantages of video-assisted thoracoscopic surgery (VATS) over anterior limited thoracotomy (ALT) for lobectomy in lung cancer, we compared the two procedures in a retrospective analysis. Methods. Sex- and age-matched (± 5 years) lung cancer patients in clinical stage I who underwent lobectomy by means of VATS (n = 33) or ALT (n = 33) were compared in terms of the number of resected lymph nodes, operating time, intraoperative blood loss, duration of postoperative chest tube drainage, and chest pain. Pain was evaluated using a visual analog scale and analgesic requirements. Vital capacity (VC), respiratory muscle strength, and results of a 6-minute walking (6 MW) test were also compared preoperatively and 1 and 2 weeks postoperatively. Results. Compared with the ALT group, the VATS group experienced less pain between postoperative day (POD) 1 and POD 7 ( p < 0.05 to 0.001) and had lower analgesic requirements up to POD 7 ( p < 0.001). However, there were no significant differences in pain on POD 14. There were also no significant differences in intraoperative factors or in the postoperative impairment of VC, respiratory muscle strength, and 6 MW test results. Conclusions. Although VATS lobectomy reduces chest pain during the first week after surgery compared with ALT, this advantage is lost within 2 weeks. Both techniques result in similar impairments of pulmonary function, respiratory muscle strength and walking capacity. Therefore, if curative resection of lung cancer by VATS would be technically difficult for any reason, including the surgeon’s skill and experience, a limited open thoracotomy would be preferable from the standpoints of safety and the patient’s prognosis.

The Effects of FK506 on Neurologic and Histopathologic Outcome After Transient Spinal Cord Ischemia Induced by Aortic Cross-Clamping in Rats

Spinal cord injury is a devastating complication of thoracoabdominal aortic surgery. We investigated the effect of the immunosuppressant FK506, a macrolide antibiotic demonstrated to have neuroprotective effects in cerebral ischemia models, in a rat model of transient spinal cord ischemia. Spinal cord ischemia was induced in anesthetized rats by using direct aortic arch plus left subclavian artery cross-clamping through a limited thoracotomy. Experimental groups were as follows: sham-operation; control, receiving only vehicle; FK506 A, receiving FK506 (1 mg/kg IV) before clamping; and FK506 B, receiving FK506 (1 mg/kg IV) at the onset of reperfusion. Neurologic status was assessed at 24 h and then daily up to 96 h with a 0 to 6 scale (0, normal function; 6, severe paraplegia). Rats were randomly killed at 24, 48, or 96 h, and spinal cords were harvested for histopathology. Physiologic variables did not differ significantly among experimental groups. All control rats suffered severe and definitive paraplegia. FK506-treated rats had significantly better neurologic outcome compared with control. Histopathologic analysis disclosed severe injury in the lumbar gray matter of all control rats, whereas most FK506-treated rats had less injury. These data suggest that FK506 can improve neurologic recovery and attenuate spinal cord injury induced by transient thoracic aortic cross-clamping. A single dose-injection of the immunosuppressant FK506 significantly improved neurologic outcome and attenuated spinal cord injury induced by transient thoracic aortic cross-clamping in the rat.

SCVIR Annual Meeting Film Panel Session: Diagnosis and Discussion of Case 1

A previously healthy 22-year-old Colombian man presented with recurrent fevers, cough, hemoptysis, and weight loss. He was treated with various antibiotics for presumed pneumonia without clinical response. Noncontrast high-resolution CT of the chest was performed (Fig 1.1). An empiric course of steroids produced only transient improvement. Multiple HIV tests and blood cultures were negative, as were bronchoscopy and bone marrow biopsy. Blood work demonstrated an elevated erythrocyte sedimentation rate (.90 mm/h). Lower extremity Doppler sonography revealed no evidence of deep venous thrombosis. Transesophageal echocardiography identified an 8 mm right atrial mass. Contrast-enhanced CT (Fig 1.2) was performed. The patient then underwent limited right thoracotomy with resection of the posterior segment of the right lower lobe. Pathologic examination revealed chronic pleuritis, hemorrhagic infarct, and organizing thrombus within the small pulmonary arteries. The right atrial mass was resected. Pathologic examination showed it to be composed entirely of thrombus. No organisms were seen and all cultures were negative. Postoperatively, the patient continued to experience fevers to 105°F that did not resolve with parenteral antibiotics. After receiving cyclosporine, his fever decreased and he experienced no further hemoptysis. Repeat CT showed no change in the size of the left pulmonary artery aneurysm, but the thickness of the wall diminished, and there was apparent improvement in the right pulmonary artery aneurysm, with a decrease in size and thickness of the aneurysm wall. He remained symptom-free for 3 months while undergoing empiric immunosuppression; however, he developed recurrent fevers and blood-tinged sputum, which progressed to frank hemoptysis, requiring hospitalization. Corticosteroid therapy was initiated and CT demonstrated an increase in the size of the left lower lobe pulmonary artery aneurysm with interim aneurysmal dilation of several sub-

Open lung biopsy as an outpatient procedure

Background. Lung biopsies are frequently needed to diagnose diffuse interstitial lung diseases. Both limited thoracotomy (open lung biopsy) and thoracoscopy can be used for lung biopsies, but both procedures have traditionally required hospital admission. We report a series of patients that underwent outpatient open lung biopsy to show the safety and effectiveness of this practice. Methods. We reviewed records of ambulatory, nonoxygen dependent patients with a clinical diagnosis of diffuse interstitial lung disease that underwent outpatient open lung biopsy between January 1997 and December 1999. All procedures were done by a senior surgeon using single lumen endotracheal anesthesia, a small anterolateral thoracotomy without rib spreading, stapled wedge resection, and no chest tube. Patients were discharged the same day. Results. Thirty-two patients with a clinical diagnosis of diffuse interstitial lung disease underwent outpatient open lung biopsy. Mean age was 58 years (range, 21 to 74 years). Preoperative forced expiratory volume in 1 second was 74.3% ± 7.0% of predicted. A pathologic diagnosis was established in all patients: usual interstitial pneumonia, 26 patients; sarcoidosis, 2; metastatic carcinoma, 2; desquamative interstitial pneumonia, 1; and mixed dust pneumoconiosis, 1 patient. No patient required a chest tube, overnight observation, or hospital admission. No complications occurred. Conclusions. Selected patients with a clinical diagnosis of diffuse interstitial lung disease can safely and effectively undergo diagnostic outpatient open lung biopsy. However, careful patient selection and attention to operative detail are essential.

Comparison of Short-Term Versus Long-Term Epidural Analgesia After Limited Thoracotomy with Special Reference to Pain Score, Pulmonary Function, and Respiratory Muscle Strength

To determine the optimal duration of epidural analgesia (EA) after lung cancer surgery, a retrospective analysis was conducted to compare chest pain, pulmonary function, and respiratory muscle strength between patients given EA until postoperative day (POD) 3 and those given EA until POD 8. Each group comprised 25 lung cancer patients who underwent a lobectomy under anterior limited thoracotomy and given continuous thoracic EA using morphine until POD 3 (POD3-EA group) or POD 8 (POD8-EA group). The two groups were matched by sex and age. Postoperative pain from PODs 1 to 12 was evaluated by the pain score and analgesic requirements. The pulmonary function and respiratory muscle strength were measured on POD 7. The POD3-EA group did not experience any increase in pain after withdrawal, but the POD8-EA group did show a significant increase in pain the day after withdrawal (P < 0.05). The pain scores on PODs 8 and 9 in the POD8-EA group were significantly higher than those in the POD3-EA group (P < 0.05). There was no significant difference in pulmonary function and respiratory muscle strength on POD 7 between the two groups. Although the postoperative thoracic EA did not affect pulmonary function and respiratory muscle strength, prolonged thoracic EA after a limited thoracotomy significantly increased the pain after withdrawal, thus negatively affecting postoperative pain control.

Late Mediastinal Shift After Repeated Aspiration of Postpneumonectomy Seroma

Development of a postoperative seroma is a frequent complication after muscle-sparing thoracotomy. We describe an unusual case of late mediastinal shift in a patient in whom our original plan to perform a limited muscle-sparing thoracotomy was abandoned. The procedure was converted to a standard posterolateral incision to perform a pneumonectomy for a large central carcinoid tumor with extrabronchial extension. Fluid that accumulated in her pneumonectomy space presumably shifted into the dissected tissues of her chest wall, and was then drained repeatedly by her local physician in the time interval between 2 weeks and 3 months after surgery.

VENTRICULAR WALL DYNAMICS

The Heart Patch ventricular assist device leads to distortion of ventricular chamber shape preventing use of traditional geometry-based volume measurements. Also, tracking of realtime wall dynamics would allow fine-tuning of compression efficacy and possible feedback control of the controller/ driver. We therefore studied ventricular chamber geometry and wall dynamics in response to Heart Patch compression using implanted sonomicrometer sensors. The Heart Patch, sonomicrometer crystals (Sonometrics Corp, Ontario) and flow probes were implanted in three sheep through a limited 4th LICS thoracotomy under general anesthesia. The crystals were placed to record short and long axis information in both ventricles. Studies were performed after seven days when ultrasound signals indicated good acoustic coupling of crystals. The ventricular chambers were divided into two segments each and the distances between crystals determined the shape of each segment. The derived shape determined the optimal algorithm for calculation of ventricular volumes. Typically, 8 crystals provided information on 28 dimensions while filling volumes and pressures were varied in the pneumatically activated Heart Patches. Hemodynamic measurements included ascending aortic blood flow and blood pressure. We conclude that wall dynamics and ventricular volumes in response to an implanted Heart Patch DCC device can be successfully analyzed using a new algorithm based on multiple dimensions obtained from sonomicrometer crystals.

Humoral Immune Response During Coronary Artery Bypass Grafting

Background —The introduction of limited approaches to the heart and the avoidance of cardiopulmonary bypass (CPB) aim to reduce the invasiveness of CABG by decreasing the systemic release of inflammatory cytokines, such as tumor necrosis factor (TNF)-α, interleukin (IL)-6, and IL-8, as well as the anti-inflammatory agent IL-10. This study compares the humoral immune response in patients undergoing CABG with standard, minimally invasive, and “off-pump” techniques. Methods and Results —Thirty patients were divided into 3 operative groups: full sternotomy approach plus CPB (group A); full sternotomy approach, off pump (group B); and limited left anterior thoracotomy, off pump (group C). Plasma levels of TNF-α receptors p55 and p75, IL 6, IL-8, and IL-10 were taken at baseline, during CPB, and at 4, 24, and 48 hours and 6 days after surgery. A significant increased release of activated complement factors C5a and C3d, IL-8, and IL-10 was observed in patients subjected to CPB (group A) during the initial period and for a short time after perfusion ( P &lt;0.05). TNF-α receptors p55 and p75 showed a prolonged elevation (up to 48 hours) in the CPB group compared with the 2 off-pump groups. IL-6 showed no different release among the 3 surgical groups throughout the entire period. There was no significant difference in any parameter measured in relation to the type of operative approach. Conclusions —There is an inflammatory, as well as an anti-inflammatory, response during CABG that is related to the general surgical trauma. The release of immune mediators is enhanced by the use of CPB during various perioperative and postoperative phases. The type of operative approach did not influence this immune response.

A randomized, controlled trial comparing thoracoscopy and limited thoracotomy for lung biopsy in interstitial lung disease

Background. Lung biopsies are frequently needed to diagnose diffuse interstitial lung diseases. A prospective randomized, controlled trial comparing limited thoracotomy (open lung biopsy) and thoracoscopy for lung biopsy was done. Methods. Ambulatory patients with a clinical diagnosis of diffuse interstitial lung disease were randomized to thoracoscopy or limited thoracotomy. Data on postoperative pain, narcotic requirements, operating room time, adequacy of biopsy, duration of chest tube drainage, length of hospital stay, spirometry, and complications were collected. Results. A total of 42 randomized patients underwent lung biopsy (thoracoscopy 20, thoracotomy 22). The two study groups were comparable with respect to age, gender, corticosteroid use, and preoperative spirometry. Visual analog scale pain scores were nearly identical in the two groups ( p = 0.397). Total morphine dose was 50.8 ± 27.3 mg in the thoracoscopy group and 52.5 ± 25.6 mg in the thoracotomy group ( p = 0.86). Spirometry (FEV 1) values in the two groups were not significantly different on postoperative days 1, 2, 14, and 28 ( p = 0.665). Duration of operation was similar in both groups (thoracoscopy 40 ± 30 minutes, thoracotomy 37 ± 15 minutes; p = 0.67). The thoracoscopy and thoracotomy groups had equivalent duration of chest tube drainage (thoracoscopy 38 ± 28 hours, thoracotomy 31 ± 26 hours; p = 0.47) and length of hospital stay (thoracoscopy 77 ± 82 hours, thoracotomy 69 ± 55 hours; p = 0.72). Definitive pathologic diagnoses were made in all patients. Conclusions. There is no clinical or statistical difference in outcomes for thoracoscopic and thoracotomy approaches. Both thoracoscopy and thoracotomy are acceptable procedures for diagnostic lung biopsy in diffuse interstitial lung disease.

Ischemic spinal cord injury induced by aortic cross-clamping: prevention by riluzole✩

Recent studies confirmed the deleterious role of glutamate in the pathophysiology of spinal cord ischemia induced by aortic cross-clamping. We investigated the effect of riluzole, an anti-glutamate drug, in a rat model of spinal cord ischemia. Spinal cord ischemia was induced in normothermia for 14 min in Sprague-Dawley rats using direct aortic arch plus left subclavian artery cross-clamping through a limited thoracotomy. Experimental groups were as follows: sham-operation (n=15), control (n=15) receiving only vehicle, riluzole (n=15) receiving riluzole (4 mg/kg) before clamping and at the onset of reperfusion. Separate animals were used for monitoring physiologic parameters in the sham-operation (n=3), control (n=5), and riluzole (n=5) groups. Neurologic status was assessed at 6, 24 h, and then daily up to 96 h. Rats were randomly killed at 24, 48, or 96 h (n=5 for each time). Spinal cords were harvested for histopathology, immunohistochemistry for microtubule-associated protein 2 (MAP-2), TUNEL staining, and analysis of DNA fragmentation by agarose gel electrophoresis. All sham-operated rats had a normal neurologic outcome, whereas all control rats suffered severe and definitive paraplegia. Riluzole-treated rats had significantly better neurologic function compared to the control. Histopathology disclosed severe neuronal necrosis in the lumbar gray matter of control rats, whereas riluzole-treated rats suffered usually mild to moderate injury. Riluzole particularly prevented motor neurons injury. MAP-2 immunoreactivity was completely lost in control rats, whereas it was preserved either completely or partly in riluzole-treated rats. TUNEL staining revealed numerous apoptotic neurons scattered within the whole gray matter of control rats. Riluzole prevented or dramatically attenuated apoptotic neuronal death in treated rats. DNA extracted from lumbar spinal cords of sham-operated and riluzole-treated rats exhibited no laddering, whereas spinal cords from control rats showed DNA laddering with fragmentation into approximately 180 multiples of base pairs. Riluzole may protect the spinal cord in a setting of severe ischemia by preventing neuronal necrosis and apoptosis. This drug may therefore be considered for clinical use during 'high risk' surgical procedures on the thoracoabdominal aorta.

Treatment of spontaneous pneumothorax.

Spontaneous pneumothorax (SP) continues to be a frequent management problem. The lack of universally accepted management guidelines and a myriad of treatment options contribute to the current heterogeneous approach to SP. Forthcoming guidelines may improve management. Meantime, simple observation in stable patients with a primary spontaneous pneumothorax (PSP) is reasonable, and encouraging smoking cessation is paramount. More aggressive management of a patient with a secondary spontaneous pneumothorax (SSP) is advisable and should include at least chest tube drainage with chest tube size selection key. Careful assessment of recurrence risk and early corrective intervention for patients with a persistent air leak will improve care of both PSP and SSP patients. If chest tube-directed pleurodesis is chosen for recurrence prevention, talc is the most successful agent available. However, no more than 5 g of talc should be utilized, given the potential increased risk for acute respiratory failure at higher doses, and patients should be advised of alternatives such as doxycycline. No overwhelming clinical outcome advantages for a thoracoscopic over a limited thoracotomy approach to SP management has been reported in any randomized controlled trial. Institutional experience with and the availability of thoracoscopy or limited thoracotomy should dictate the operative approach to SP recurrence prevention and air leak correction until further study clarifies the choice.

Long-term Effect of Bilateral Plication of the Diaphragm

To assess the feasibility and clinical outcome of bilateral plication of the diaphragm in patients with bilateral diaphragmatic paralysis (BDP) caused by neuralgic amyotrophy (NA), a mononeuritis of the phrenic nerves. Prospective, case-control study over a 1-year period. A university hospital in The Netherlands. Six patients who presented with BDP caused by NA. The diagnosis of BDP was based on the absence of muscle response after cervical magnetic stimulation of both phrenic nerves. Three patients did not undergo surgery but were observed for a period of 2 years, and the other three patients underwent a limited lateral thoracotomy at the eighth intercostal space. Plication was performed by U-stitches until the diaphragm was as tight as possible. Vital capacity (VC) and arterial blood gas was measured during follow-up. One month postoperatively, mean VC measured in the supine position was significantly improved by 17%, and this effect was sustained for 12 months. Arterial PO(2) increased by 45%. VC and blood gas levels did not improve in the three patients that were only observed during the 2-year period. All three surgical patients could sleep in the supine position after the operation. Bilateral plication of the diaphragm for NA-induced paralysis results in improvement of ventilation and blood gas exchange, allowing patients to sleep in the supine position without dyspnea.

Decorticação pleural precoce no tratamento do empiema pleural complicado na criança

Os autores avaliam dez casos de empiema pleural tratados inicialmente pela drenagem pleural fechada e que tiveram evolução desfavorável e arrastada. Pacientes que evoluíram com septação do empiema, persistência de fístula broncopleural de alto débito ou de falta de expansão pulmonar após a drenagem pulmonar foram submetidos a estudo pela tomografia computadorizada e encaminhados para a decorticação pleural precoce como alternativa para o tratamento. Todos os pacientes tratados desta forma tiveram uma rápida melhora clínica, evoluindo com boa expansão pulmonar, recebendo alta hospitalar num prazo máximo de dez dias após a cirurgia. Concluem os autores que tal procedimento é seguro devendo ser considerado para o tratamento do empiema pleural de má evolução.

Role of limited posterior thoracotomy for open-heart surgery in the current era

Background. The earliest open-heart operations were performed employing the thoracotomy approach. Over the years, median sternotomy has become the routine way of approaching the heart. However, lately there has been progressive enthusiasm in minimally invasive techniques for accessing the heart. We present our technique of correction of congenital heart defects employing the limited posterior thoracotomy approach.Methods. From June 1997 to April 1998, 27 patients underwent correction for various intracardiac defects without any mortality. There were 19 ostium secundum defects, with or without other associated anomalies. There were six sinus venosus defects with partial anomalous pulmonary venous connections. Two patients had perimembranous ventricular septal defects, while 2 patients had partial atrioventricular defects. In 2 other patients, pulmonary stenosis was repaired, using pulmonary valvotomy in 1 patient, whereas the other patient required short transannular patch.Results. The median age was 7 years and the median weight was 20 kg. The median skin-to-skin time was 260 minutes. The median bypass time was 63.25 minutes and the median cross-clamp time was 35.0 minutes. All the patients were extubated within 12 hours following surgery and the median ICU stay was 24 hours. Three patients required blood transfusions in the ICU for significant blood loss and the mean chest drainage was 85 cc per 24 hours. None of the patients had phrenic nerve palsies. None of the patients required additional analgesics other than routine ibuprofen or ketorolac tromethamine. Short-term follow-up revealed no functional or physical disability of the thoracic wall and the right arm. All who underwent surgery with this approach were happy with the limited visibility of their scars.Conclusions. Limited posterior thoracotomy offers a viable alternative for midsternotomy and submammary thoracotomy. It has the advantage of a scar in the back that does not impede the future growth of the breast tissue and the pectoralis major. Our approach does not need any new instruments and hence no contraptions are necessary to perform the operation with this approach. Our results have shown satisfactory short-term results and better cosmesis.

Minimally invasive cardiac surgery: surgical techniques and anesthetic problems

To review current data on minimally invasive cardiac surgery. Search through the Medline data base of French or English articles. The articles were analysed to make a synthesis of the various techniques with their main indications and contra-indications. Minimally invasive cardiac surgery includes various surgical procedures. The usual techniques are described, their major benefits and drawbacks are discussed. The main goals of anaesthetic management are preservation of ventricular function and systemic perfusion, detection and treatment of myocardial ischaemia, prevention of hypothermia in case of coronary artery bypass grafting on the beating heart via sternotomy, intermittent selective ventilation of the collapsed lung using CPAP in case of limited thoracotomy. Expertise in transoesophageal echocardiography is essential for insertion and checking the accurate positioning of the various catheters of the endovascular CPB Heartport system (pulmonary vent, endosinus catheter, venous cannula, endoaortic clamp) allowing coronary artery bypass grafting and mitral valve surgery through limited thoracotomy and finally, detection of retained intracardiac air and assessment of complete clearing of cardiac cavities after mitral valve surgery through limited thoracotomy and aortic valve surgery via ministernotomy. Short-acting anaesthetic agents allow rapid recovery from anaesthesia, early extubation and discharge to the surgical ward within 24 h, whereas overall time spent in the operating room is often longer than with conventional cardiac surgery.