J Thorac Cardiovasc Surg 1998;115:258-259
© 1998 Mosby, Inc.
Minimal-access or minimally invasive surgery?
Federico Benetti, MD
Reply to the Editor:
The conception that the trauma generated by the surgical procedure is as important as the treatment of the disease has changed the surgical approach and is the basis for minimally invasive surgery.
The surgery of the coronary arteries without cardiopulmonary bypass has demonstrated its benefits and has allowed the development of minimally invasive surgery of the coronary arteries. The decrease of the inflammatory process is one of these aspects, solving secondary phenomena to the extracorporeal circulation, as well as protection of the myocardium.
The intercostal incision also has benefits. The first of them is that pain can be controlled more easily, by means of balanced analgesia.
1 The use of nonsteroidal antiinflammatory medications and the blockade of the intercostal nerves improve breathing function and allow more rapid physicosomatic recovery. This approach coordinates the management of analgesia, which is so essential. 2
Another important point is to limit the surgical procedure to a selective area. This new surgical approach is of interest in elderly patients with osteoporotic breastbones and reduced lung capacity. It might have equal importance in those with a bleeding tendency. Also important is infection in the surgical wound, which in the case of a sternotomy could be devastating (mediastinitis). 3 In minimally invasive surgery the extension only reaches the costal plane. Finally, another consequence of sternotomy is injury of the brachial plexus, occurring with a frequency similar to that of infections of the breastbone (1.4% to 1.6%). 4 This approach is an alternative of great interest, especially in elderly men.
Benetti FoundationM.T. de Alvear 2323-2C
1122 Cap Fed
Buenos Aires, Argentina
References
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Rizzard JL, Concetti C, Benetti F. Control of the postoperative pain of the minithoracotomy. XVI National Congress of Cardiology, Rio Hondo. 1977.
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Eng J, Sabanathan S. Post-thoracotomy analgesia. J R Coll Surg Edinb 1993;38:62-8.[Medline]
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Kutsal TO, Ibrisim A, Catav Z, Tasdemir OR, Bayatzit K. Mediastinitis after open heart surgery: analysis of risk factors and management. J Cardiovasc Surg 1991;32:38-41.
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Stangl R, Altendorf-Hoffmann TO, von der Emde J. Brachial plexus lesions following median sternotomy in cardiac surgery. Thorac Cardiovasc Surg 1991;39:360-4.[Medline]
