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J Thorac Cardiovasc Surg 1999;117:410-411
© 1999 Mosby, Inc.
LETTERS TO THE EDITOR |
We read with great interest the article by Tam, Garlick, and Almeida
1 in the October 1997 issue of the Journal and the related correspondence by Morishita, Kuwaky, Sato, and Abe. 2 The discussion concerns an elegant approach to many valve operations through a less invasive sternotomy.
We have different comments related to this approach.
Although minimally invasive direct coronary artery bypass (MIDCAB) procedures, avoiding cardiopulmonary bypass (CPB) and cardioplegic arrest, are truly minimally invasive, in the field of valve surgery, debates continue over what constitutes "less invasive" and which incision provides the best exposure and sufficient space to manipulate the heart. Over the past 2 years less invasive approaches to valve surgery have shown a tendency to switch from paramedian thoracotomy to partial sternotomy. Table I lists different approaches of partial sternotomy reported in the recent literature. Sometimes minimizing access implies maximizing technical difficulty, and the tremendous imagination of the "new sternotomies" inspired, in our minds, the term "sternum calvary."
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The standard median sternotomy, with its 20-cm skin incision, has been the preferred approach since the beginning of the cardiac surgery era for most types of cardiac operations, both primary and redo. Although it provided excellent exposure, it proved to be unnecessarily invasive. The large window over the mediastinum justified sternal and rib fractures and the extension to the linea alba. Postoperative chest wall function and total lung compliance were greatly affected and pain increased. The extensive dissection of the mediastinal tissues and the deliberate use of cautery and multiple chest tube sites have been found to be sources of excessive bleeding, wound infection, and other complications. Last but not least important is an unaesthetic scar.In our minds the "minimally invasive" philosophy should influence our profession to simplify the technique for the surgeon and to provide beneficial results with the least possible morbidity to the patients. In this sense, the various minimalistic approaches are not really new and certainly do not represent the "genie out of the bottle" phenomenon that we have recently read about.
The work of Tam, Garlick, and Almeida introduces into the debate a most appropriate "surgical compromise," which is expressed in the question: "Can we be less invasive through a median sternotomy?"
Our experience of "less invasive" valve surgery began at the end of 1996, and to date more than 170 patients have been operated on with a simple modified median sternotomy that became the routine approach for all the primary interventions. The surgical technique and the results in the first 100 patients have been previously reported. 3 The concept of our technique, named "short cut median sternotomy," includes a median approach to the heart with a 6- to 9-cm skin incision followed by a sub-complete, bone-limited median sternotomy without horizontal transection. The V-shaped sternotomy ends at the xiphoid process, which remains intact. After the sternal edges have been opened, limited to 5 to 6 cm, the pericardium is opened and exposed in the region where the operation is to be performed. Central CPB and valve surgery are performed without any modifications to the operative techniques. The incision may be easily and rapidly extended to a standard sternotomy should technical problems be encountered or exposure be inadequate. We believe that the median approach has many potential and practical advantages: The small skin incision with a limited exposure of the mediastinum reduces the pain from overstretching of the ribs and thoracic ligaments; postoperative respiratory function is consequently preserved, especially in elderly patients. This smaller median sternotomy appears to heal fast, is stable, and is less painful. There is also less potential for wound infection and blood loss. Patient recovery is accelerated, allowing for a shorter hospital stay, with an overall reduction in cost. Reoperations should be less difficult.
Finally, the debate over minimally invasive cardiac surgery will continue, and we would like to take part in answering the above-mentioned question: "We can be less invasive through a median sternotomy," being respectful of our surgical heritage and not using innovative techniques for the wrong reasons.
M. Massetti, MD
G. Babatasi, MD, PhD
S. Bhoyroo, MD
A. Khayat, MD
Thoracic and Cardiovascular Surgery Department
University Hospital
C.H.U. "Cote de Nacre"
14033 Caen, France
12/8/95156
References
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