Traditional Median Sternotomy Research Articles

Minimally invasive mitral valve replacement is a safe and effective surgery for patients with rheumatic valve disease: A retrospective study.

The aim of the study was to evaluate the treatment of minimally invasive mitral valve replacement (MIMVR) through a right minithoracotomy for patients with rheumatic mitral valve disease.From February 2009 to December 2016, 360 patients with rheumatic mitral valve disease underwent mitral valve replacement by the same surgeon. Among them, 150 patients accepted MIMVR through a right minithoracotomy, whereas the other 210 accepted a traditional median sternotomy. After matching by patients by age, sex, EuroSCORE, New York Heart Association (NYHA) classification, renal and liver function, and degree of mitral valve disease, we selected 224 patients for analysis in our retrospective study.In the MIMVR group (112 patients), the aortic cross-clamp time (ACC time) (55.25 ± 2.18 minutes) was significantly longer than that in the control group (112 patients; 36.05 ± 1.40 minutes) (P < .0001). In contrast, the cardiopulmonary bypass time (CPB time) was shorter in the MIMVR group than in the control group (61.13 ± 2.57 vs 78.65 ± 4.05 minutes, respectively, P < .0001). Patients who accepted MIMVR surgery had less drainage 24 hours postoperation (324.10 ± 34.55 vs 492.90 ± 34.05 mL, P < .0001) and had less total drainage (713.46 ± 65.35 vs 990.49 ± 67.88 mL, P < .0001) than those who underwent median sternotomy. Thirty-two percent of patients in the MIMVR group needed a blood transfusion (1.35 ± .28 units of red blood cells, 155.36 ± 33.43 mL plasma), whereas 67.0% of the control group needed a blood transfusion (2.15 ± .24 units of red blood cells, 287.50 ± 33.54 mL plasma) (Ptransfusion < .001, Pcell = .029, Pplasma = .006). In total, 5 deaths occurred during the perioperative period; 3 occurred in the MIMVR group. The average hospital stay was significantly shorter in the MIMVR group than that in the control group (6.56 ± .23 vs 8.53 ± .59 days, P = .003).MIMVR, an effective and safe treatment approach for patients suffering from rheumatic mitral valve disease, is associated with less trauma and a faster recovery. It is a better choice for treating simple rheumatic mitral valve disease.

Left video-assisted thoracic surgery thymectomy.

Video-assisted thoracic surgery (VATS) for the management of non-thymomatous myasthenia gravis (MG) as well as the management of small thymomas and other benign thymic pathology has been gaining in acceptance and popularity as an alternative to the traditional median sternotomy approach. Although VATS thymectomy has been described in several variations, our current preference is a left sided VATS approach due to the exposure it provides in critical areas of dissection. Here we describe our technique for the left sided VATS thymectomy including patient selection, preoperative preparation, operative steps, and postoperative care. We also share pitfalls and tips to prevent them at each step of the procedure learned from our experience with this approach.

Experience of totally thoracoscopic cardiac surgery of cardiopulmonary bypass in children with congenital heart disease

Objective To review the experiences of 31 cases of totally thoracoscopic cardiac surgery of cardiopulmonary bypass in children with congenital heart disease. Methods Thirty one children with congenital heart disease received totally thoracoscopic cardiac surgery procedures during the period from October 2012 to May 2016. The ages of these children were ranged from 2 years and 7 months old to 6 years old with average value (4.6±1.4)years old. The body weights were ranged from 12~24 kg with average value (17±3.5)kg. Among 31 children, there were 12 cases of atrial septal defect, and 19 cases of ventricular septal defect. Through three-hole shape incision at the right chest wall, each hole was 1.5 to 2.0 cm long, and operation field were revealed totally by thoracoscope. Cardiopulmonary bypass was built through femoral arteriovenous intubation. Results Thirty one children were all cured. None of them suffered severe complications such as renal failure, respiratory failure, low cardiac output syndrome, atrioventricular block, and residual shunt. Duration of cardiopulmonary bypass was 62~185 (126.4±45.2)min, and duration of myocardial ischemia was 18~118 (53.4±31.2)min. Duration of Postoperative mechanical ventilation was 2~7 (5.3±1.5)h. Duration of intensive care unit (ICU) stay was 15~21 (19±1.3)h. Drainage volume of 24 hours after operation was 0~130(57±36.2)ml. Volume of red blood cell transfusion was 0~2 (1.2±0.8)U. Postoperative hospital stay was 4~7 (6.2±1.2)d. Conclusions For children with congenital heart disease as simple atrial septal defect or ventricular septal defect, thoracoscopic surgical repair can be achieved the same therapeutic results as traditional median sternotomy surgery while having advantages such as smaller incision, less bleeding and none sternal malunions. Key words: Thoracoscopy; Heart defects, congenital/SU; Extracorporeal circulation

Hybrid coronary revascularization: a systematic review.

The hybrid approach to coronary revascularization is an evolving technique that is being used as an alternative to the traditional median sternotomy coronary artery bypass graft surgery. It combines a minimally invasive approach to bypass the left anterior descending coronary artery with a percutaneous approach to revascularize the other coronary arteries. A systematic review of the available literature was conducted to evaluate the benefits, and the short- and long-term outcomes of this procedure.

The minimal access technique for cavoatrial renal cancer thrombectomy - should it be used in all cases?

As it is well known from worldwide literature, an aggressive surgical approach is the most effective therapeutic option in patients with renal cell carcinoma at any level of tumor thrombus and offers a reasonable long-term survival results [1]. Even cytoreductive surgery appears to be beneficial for patients with metastatic disease, especially when consecutive therapy is performed. Nevertheless, doubts still remain concerning the best approach for surgical treatment of these patients. Minimal access techniques resulted in significantly shorter operating time compared with traditional median sternotomy [2]. The authors [3] presented a relatively small cohort of patients treated with a modified technique of cavoatrial thrombus removal without the need of cardiopulmonary bypass and hypothermic circulatory arrest. First of all, the technique with the use of Fogarty-like Foley catheter was previously described [4]. The safety of the presented method is definitely debatable and based on rather limited experience shown in the manuscript. As a consequence, it cannot be widely adopted without caution, as it can be highly morbid. There is always a risk of thrombus adherence to the atrial endocardium, which cannot be easily disintegrated. Furthermore, these manoeuvers can result in the sudden rupture of the distal part of the thrombus, forming a life-threatening embolus; in this case, the only solution would be an immediate open intrathoracic embolectomy via sternotomy approach. Hence, in the reviewer's opinion, the technique using a Foley catheter cannot be implemented in all cases. Additionally, the literature does not provide the answer in which particular cases this technique could be applied [5]. Most probably, the technique as described should be reserved for cases with “free atrial tail” of the thrombus documented on imaging studies. Of special value at the time of catheter insertion was the transoesophageal echocardiography (TOE) [3]. Now, magnetic resonance imaging has become the gold standard for assessing the level of IVC thrombus when diagnosing the patient [8], but during surgery, TOE enables real-time visualization of the thrombus. Unexpectedly, the reported blood loss as it exceeded mean 3000 ml, seems to be relatively high in comparison to published data e.g. median 2500 ml in [6] or average 1300 ml (750–2500) in [7]. The presented follow-up period is rather short, therefore no oncological results can be obtained, especially as far as radically treated patients (n = 3 out of all 4) are concerned. The paper documents a continuous search for an optimal surgical approach, just as the earliest publication about the use of an aortic occlusion balloon to reduce inflow at the time of thrombectomy [9], or most current publications about successful robotic level III inferior vena cava thrombectomy [10, 11]. In summary, the paper represents an interesting concept of a multidisciplinary approach and should be considered as a valuable option for surgical treatment of inferior vena cava tumor thrombectomy without thoracotomy.

Comparison of clinical outcomes and postoperative recovery between two open heart surgeries: minimally invasive right subaxillary vertical thoracomy and traditional median sternotomy

ObjectiveTo compare the clinical outcomes of minimally invasive right subaxillary vertical thoracotomy and traditional median sternotomy through right atrium in treatment of common congenital heart diseases. MethodsClinical data of 59 cases of common congenital heart diseases treated with minimally invasive right axillary vertical thoracotomy from May, 2011 to February, 2013 and 77 cases of same diseases with traditional median sternotomy in the past three years were retrospectively analyzed, including atrial septal defect, membranous ventricular septal defect and partial endocardial cushion defect. The results were compared from the two groups, including the time for operation and cardiopulmonary bypass, amount of blood transfusion, postoperative drainage, ventilation time, hospital stay, and prognosis. ResultsNo severe complications happened in both groups, like deaths or secondary surgery caused by bleeding. No significant differences were in CPB time and postoperative ventilator time between groups (P>0.05), while for all of the operative time, the length of incision, postoperative drainage and hospital stay, minimally invasive right axillary vertical thoracotomy was superior to median sternotomy, with statistically significant differences (P<0.05). In six-month followup after operation, no complications of residual deformity and pericardial effusion were found in both groups by doing echocardiography, but mild pectus carinatum was found in 8 patients in the traditional median sternotomy group (traditional group), whereas patients in another group were well recovered. ConclusionsMinimally invasive right subaxillary vertical thoracotomy for common congenital heart diseases is as safe as traditional median sternotomy, without the increasing incidence of postoperative complications. Additionally, compared with traditional median sternotomy, minimally invasive right subaxillary vertical thoracotomy is better in the aspects of hidden incision, appearance, and postoperative recovery.

Optimizing outcomes of robotic mitral valve repair for all prolapse anatomy: the Suri-Burkhart technique.

Early mitral valve (MV) repair is the evidence-based care standard for those with severe degenerative MV regurgitation and has been shown to improve long-term patient outcomes in comparison to non-surgical management (1). Despite evidence favoring the performance of MV repair prior to symptom onset or the appearance of left ventricular (LV) dysfunction, some physicians are hesitant to refer asymptomatic patients for MV repair involving traditional median sternotomy (2). Alternatively, cardiac surgical procedures including MV repair performed through small incisions utilizing videoscopic assistance are now common-place, and have been shown to be capable of sparing patients the physiological challenge of recuperating from a sternum-dividing operation (3,4). The spectrum of benefits potentiated by use of minimally invasive incisions is well documented in the literature (5). Several large health care delivery systems have embraced minimally invasive surgical approaches aiming to replicate the “gold standard” results of a trans-sternal (open) MV repair aiming to improve patient acceptance and facilitate earlier referral. This thereby minimizes the delayed but substantial costs associated with the evolution of chronic debilitating heart failure or the poor outcomes of rescue surgery once symptoms or LV dysfunction develop (3,6). Recent efforts to uphold the safety and efficacy of standard open operations while decreasing costs have launched robotic MV repair to the forefront of available treatment options for asymptomatic mitral regurgitation (MR).

Totally endoscopic congenital heart surgery compared with the traditional heart operation in children

SummaryObjectiveTotally endoscopic surgery compared with the conventional heart operation in children is described in this article to find a preferable treatment for congenital heart diseases.MethodsBetween May 2000 and December 2007, 708 children with congenital heart disease were divided into two groups: endoscopic group and conventional group. For the endoscopic group, all children underwent total endoscopic procedures with peripheral cardiopulmonary bypass, transthoracic aortic cross-clamp, and antegrade cardioplegia, whereas for the conventional group, all children were operated in traditional way. Three 1–2-cm intercostal ports in the right chest were used for access in the endoscopic group. The intrathoracic part of the operation was performed completely under two-dimensional video, using conventional instruments. Directly closureed of the atrial septal defect was performed in 74 cases, patch closureed of the atrial septal defect in 48 cases, directly closureed of the ventricular septal defect in 158 cases, patch closureing of the ventricular septal defect in 116 cases. For the conventional group, all operations were done with traditional median sternotomy. Directed closureing of the atrial septal defect was performed in 38 cases, patch closed of the atrial septal defect in 56 cases, directly closureed of the ventricular septal defect in 76 cases, patch closureed of the ventricular septal defect in 142 cases.ResultsThere was no hospital mortality in both groups. For the endoscopic group, operations were performed successfully in 390 (98.5 %) patients, enlarging a port to a 5-cm incision in 4 children. Reoperation was necessary in two children, and no conversion to median sternotomy incision was necessary. The mean duration of operation was 132 ± 48 min, and cardiopulmonary bypass and aortic cross-clamp times were 54 ± 16 min and 25 ± 8 min, respectively. Major postoperative complications occurred in nine (2.3 %, p < 0.05) cases. For the conventional group, all children were operated by median sternotomy, and the mean duration of operation was 118 ± 41 min (p < 0.05); cardiopulmonary bypass and aortic cross-clamp times were 51 ± 13 min and 21 ± 6 min (p < 0.05), respectively. Major postoperative complications occurred in 16 (5.1 %) cases. Also, the intensive care unit stay time (8.3 ± 2.8 h versus 8.9 ± 2.9 h, p < 0.01), postoperative drainage (120 ± 21 ml versus 433 ± 140 ml, p < 0.05), and hospital time (8.6 ± 1.8 days versus 11.5 ± 1.9 days, p < 0.05) were statistically different.ConclusionsTotally endoscopic closed chest congenital heart surgery in children was feasible and safe. The results were similar or even superior to the traditional operations due to the decreased use of blood products and shortened hospital time. Degree of satisfaction with cosmetic result and postoperative comfort were very high. Therefore, endoscopic surgery will become a new popular choice for some congenital heart disease patients in the future.

Past, present, and future of minimal access cardiac surgery.

Minimal access cardiac surgery (MACS) has seen a tremendous evolution since the start of the 21st century. Over the past decade, significant advances in techniques and technology have made MACS a valid option for performing a variety of cardiac surgical procedures that were only deemed possible through traditional full median sternotomy. A desire to minimize the morbidity associated with full sternotomy, such as decreased pain and reduced surgical trauma, and a perception that reduced morbidity translates into speedy recovery are the main drivers for increasing growth of MACS (1). At the same time skepticism regarding the safety of MACS, particularly concerns over reduced surgical exposure in highly complex operations, the potential for prolonged operative times, difficulty to deal with technical complications through limited exposure, and last but not the least a steep learning curve, has precluded universal adoption of MACS.

Totally thoracoscopic surgery for the treatment of atrial septal defect without of the robotic Da Vinci surgical system

BackgroundMore and more surgeons and patients focus on the minimally invasive surgical techniques in the 21st century. Totally thoracoscopic operation provides another minimal invasive surgical option for patients with ASD (atrial septal defect). In this study, we reported our experience of 61 patients with atrial septal defect who underwent totally thoracoscopic operation and discussed the feasibility and safety of the new technique.MethodsFrom January 2010 to October 2012, 61 patients with atrial septal defect underwent totally thoracoscopic closure but not traditional median sternotomy surgery. We divided the 61 patients into two groups based on the operation sequence. The data of group A (the first 30 cases) and group B (the last 31 cases). The mean age of the patients was 35.1 ± 12.8 years (range, 6.3 to 63.5 years), and mean weight was 52.7 ± 11.9 kg (range, 30.5 to 80 kg). Mean size of the atrial septal defect was 16.8 ± 11.3 mm (range, 13 to 39 mm) based on the description of the echocardiography.ResultsAll patients underwent totally thoracoscopy successfully, 36 patients with pericardium patch and 25 patients were sutured directly. 7 patients underwent concomitant tricuspid valvuloplasty with Key technique. No death, reoperation or complete atrioventricular block occurred. The mean time of cardiopulmonary bypass was 68.5 ± 19.1 min (range, 31.0 to 153.0 min), the mean time of aortic cross-clamp was 27.2 ± 11.3 min (range, 0.0 to 80.0 min) and the mean time of operation was 149.8 ± 35.7 min (range, 63.0 to 300.0 min). Postoperative mechanical ventilation averaged 4.9 ± 2.5 hours (range, 3.5 to 12.6 hours), and the duration of intensive care unit stay 20.0 ± 4.8 hours (range, 15.5 to 25 hours). The mean volume of blood drainage was 158 ± 38 ml (range, 51 to 800 ml). No death, residual shunt, lung atelectasis or moderate tricuspid regurgitation was found at 3-month follow-up.ConclusionThe totally thoracoscopic operation is feasible and safe for patients with ASD, even with or without tricuspid regurgitation. This technique provides another minimal invasive surgical option for patients with atrial septal defect.

Totally Thoracoscopic Surgical Treatment for Atrial Septal Defect: Mid-Term Follow-up Results in 45 Consecutive Patients

Totally thoracoscopic operation provides minimally invasive alternative for patients with atrial septal defect. In this study, we report the mid-term follow-up results of 45 patients with atrial septal defect who underwent totally thoracoscopic operation and discuss the feasibility and safety of this new technique. From January 2010 to February 2012, 45 patients with atrial septal defect underwent totally thoracoscopic closure as an alternative to traditional median sternotomy surgery. The mean age of the patients was 33.2±12.5 years (range 6.3-61.5 years), and mean weight was 55.7±11.1 kg (range 30.5-80 kg). Based on echocardiography the mean size of the atrial septal defect was 16.0±10.8mm (range 13-39 mm). All patients underwent totally thoracoscopic repair. Twenty-five patients with a pericardial patch and 20 patients were sutured directly. Five patients underwent concomitant tricuspid valvuloplasty with Kay technique. No death, reoperation or complete atrioventricular block occurred. The mean time of cardiopulmonary bypass was 70.5±20.6 min (range 31.0-153.0 min), the mean time of aortic cross-clamp was 28.8±13.3 min (range 0.0-80.0 min) and the mean time of operation was 155.8±36.8 min (range 65.0-300.0 min). Postoperative mechanical ventilation averaged 5.1±2.8h (range 3.6-12.6h), and the duration of intensive care unit stay 20.0±5.6h (range 16.2-25 h). The mean volume of blood drainage was 156±36 ml (range 51-800 ml). No death, residual shunt, lung atelectasis or moderate tricuspid regurgitation was found at three-month follow-up. Totally thoracoscopic repair is feasible and safe for patients with ASD, even with or without tricuspid regurgitation however more clinical data is needed in the future study.

Are you ready to take off as a robo-surgeon?

Robotic-assisted surgery is the latest iteration toward less invasive techniques. Surgeons have slowly adapted minimally invasive and robotics techniques into their armamentarium. We have developed a robotic cardiac surgery program in Japan that utilizes the da Vinci Surgical System, allowing the surgeon to perform complex procedures through 5-mm port sites rather than a traditional median sternotomy. In this rapidly evolving field, we review the evolution and clinical results of roboticassisted surgery and take a look at the other general surgical procedures for which da Vinci currently being used.

Robot-assisted cardiac surgery

Recognition of the significant advantages of minimizing surgical trauma has resulted in a substantial increase in the number of minimally invasive (MI) cardiac surgical procedures being performed. Synchronously, technological advances in optics, instrumentation and perfusion technology have facilitated routine totally endoscopic robotic cardiac surgery using the da Vinci((R)) telemanipulation system (Intuitive Surgical Inc). This technology has been applied to many cardiac surgical procedures, in particular, mitral valve repair (MVP) and totally endoscopic coronary artery bypass grafting (TECAB), allowing the surgeon to operate through 5 mm port sites rather than a traditional median sternotomy. In this rapidly evolving field, we review the clinical results of robotic cardiac surgery.

Robotics in Cardiac Surgery

Minimally invasive surgery has revolutionized the surgical field over the last two decades. Robotic assisted surgery is the latest iteration towards less invasive techniques. Cardiac surgeons have slowly adapted minimally invasive and robotics techniques into their armamentarium. In particular, minimally invasive mitral valve surgery has evolved over the last decade and become the preferred method of mitral valve repair and replacement at certain specialized centres worldwide because of excellent results. We have developed a robotic mitral valve surgery program which utilizes the da Vinci telemanipulation system allowing the surgeon to perform complex mitral valve repairs through 5mm port sites rather than a traditional median sternotomy. In this rapidly evolving field, we review the evolution and clinical results of robotically-assisted mitral valve surgery and take a look at the other cardiac surgical procedures for which da Vinci is currently being used.

A Novel Arch-First T-Graft Technique for Extensive Aortic Arch Reconstruction

To reduce the morbidity and mortality associated with extensive aortic arch replacement, the reconstruction technique is the most important part of the treatment. By refining the present techniques, we developed an arch-first T-graft technique. This technique provides a more reasonable arrangement of procedures, least brain ischemic time, less low-body ischemic time, and an easy way of distal aortic anastomosis. This method is performed through a traditional median sternotomy, keeps the lung free from manipulation, and avoids severe kink of major vascular grafts.

Impact Of Minimally Invasive Mitral Valve Surgery

INTRODUCTION Minimally invasive cardiac surgery has been introduced for the surgical treatment of isolated valvular heart disease. Interest among cardiac surgeons is growing as the potential benefits to the patient have become more reproducible. Ten years ago, surgeons began to recognize the advantages of performing smaller incisions compared to the traditional median sternotomy.1 Our group at the Methodist DeBakey Heart & Vascular Center began our anatomic studies relating the cardiac valve position to the surface anatomy of the chest wall in 1998 as we launched our own efforts in this area.2 Since that time, experience with large numbers of cases has shown minimally invasive mitral valve surgery to be reproducible, reliable, and much better tolerated by our patients.3,4 Recently, the Methodist DeBakey Heart & Vascular Center robotic mitral valve surgery program was successfully launched by Dr. Gerald Lawrie and his team with outstanding early results.

Impact of Minimally Invasive Mitral Valve Surgery

Minimally invasive cardiac surgery has been introduced for the surgical treatment of isolated valvular heart disease. Interest among cardiac surgeons is growing as the potential benefits to the patient have become more reproducible. Ten years ago, surgeons began to recognize the advantages of performing smaller incisions compared to the traditional median sternotomy.1 Our group at the Methodist DeBakey Heart & Vascular Center began our anatomic studies relating the cardiac valve position to the surface anatomy of the chest wall in 1998 as we launched our own efforts in this area.2 Since that time, experience with large numbers of cases has shown minimally invasive mitral valve surgery to be reproducible, reliable, and much better tolerated by our patients.3,4 Recently, the Methodist DeBakey Heart & Vascular Center robotic mitral valve surgery program was successfully launched by Dr. Gerald Lawrie and his team with outstanding early results.

Management of renal cell carcinoma with vena cava and atrial thrombus: minimal access vs median sternotomy with circulatory arrest

To review our experience with approaches for managing renal cell carcinoma (RCC) with venous thrombi extension at and above the level of the hepatic veins, comparing surgery and peri-operative outcomes in patients with cardiopulmonary bypass (CPB) with deep hypothermic cardiac arrest (DHCA) either by minimal access (MA) or traditional median sternotomy (TMS). From 1986 to 2005, 50 radical nephrectomies with inferior vena cava (IVC) thrombectomies were performed at our institution using TMS (22 patients) and MA (28) techniques. Patient demographics were compared using Student's t-, Fisher's exact and Pearson chi-square tests. The duration of surgery, CPB, DHCA, mechanical ventilation, length of stay, and peri-operative transfusion requirements, were compared using the Mann-Whitney U-test. Estimates of survival were constructed using Kaplan-Meier curves and analysed with the log-rank test. Subgroups were analysed excluding TMS patients undergoing concurrent coronary revascularization. There were no significant differences in patient demographics or comorbidities between the MA and TMS group. There were significant decreases in the MA vs the TMS group (P < 0.05) in the duration of surgery, mechanical ventilation, length of stay and peri-operative transfusion requirements. When patients with coronary revascularization were excluded, the MA group had significant decreases (P < 0.05) in duration of surgery, hospital stay and transfusion requirements. Peri-operative mortality was not statistically different between the TMS (14%) and MA (4%) patients. Overall and organ system-specific complications also were not statistically different. The overall median survival in the TMS and MA groups was 0.62 and 2.84 years, respectively (P = 0.06, hazard ratio 2.02; 95% confidence interval, CI, 0.97-4.72). Patients with tumour thrombus extending into the right atrium had a median survival of 1.02 years, vs 2.84 years with no intracardiac extension (P = 0.15, hazard ratio 1.82, 95% CI 0.81-4.0). MA surgical techniques in conjunction with DHCA for the treatment of RCC with extensive tumour thrombus provides quicker surgery and a shorter hospital stay. In addition there was less requirement for mechanical ventilation and transfusion than with TMS. Our findings suggest that MA techniques provide significant advantages over TMS.

Less Invasive Mitral Valve Surgery via Right Minithoracotomy

Current trends in cardiac surgical intervention are moving toward less invasiveness, with smaller wound or sternum-sparing, less pump time or off-pump, and beating rather than arrested heart. Data on the efficacy and safety of these newer less invasive techniques, as well as their cosmetic results, are limited. This study analyzed the results of a sternum-sparing mitral valve operation. Thirty patients with mitral valve diseases, including 20 who underwent mitral valve repair and 10 mitral valve replacement, were enrolled. Cardiopulmonary bypass was established via femoral cannulation, and blood cardioplegic arrest was induced by using a percutaneous, transthoracic cross-clamp. The main surgical wound was made over the lateral border of the right breast. Two additional small wounds were required for the transthoracic aortic clamp and the mitral retractor. There was no operative mortality, and all patients had an uneventful recovery. Two patients underwent redo mitral surgery. Nine associated procedures were performed including tricuspid valve annuloplasty in six patients, tricuspid valve replacement in two patients and atrial septal defect repair in one patient. The length of the main wound was between 5.8 and 7.8 cm (mean, 7.1 cm). The mean cardiopulmonary bypass time and cross-clamp time were 91.1 and 43.7 minutes, respectively. Although the length of stay was not significantly reduced compared with traditional median sternotomy, all patients had satisfactory results with good cosmesis. Sternum-sparing mitral valve surgery appears to be a safe and effective alternative to conventional mitral valve surgery; it is less invasive and provides superior cosmetic results for patients.

Robotic mitral valve surgery

Traditionally mitral valve surgery has been performed via median sternotomy. However, a renaissance in cardiac surgery is occurring. Cardiac operations are being performed through smaller and alternative incisions with enhanced technological assistance. Specifically, minimally invasive mitral valve surgery has become standard for many surgeons. At our institution, we have developed a robotic mitral surgery program with the da Vinci TM telemanipulation system. This system allows the surgeon to perform complex mitral valve operations through small port sites rather than a traditional median sternotomy. Our techniques and initial results are reported as is a brief overview of the evolution of robotic cardiac surgery. © 2003 Elsevier Inc. All rights reserved.