Minimally invasive ASD repair via right minithoracotomy in children

1. Minimally invasive ASD repair via right minithoracotomy in children HAMID BIGDELIAN MD MOHAMMAD REZA SABRI MD ALIREZA AHMADI MD GHADERIAN MD Department of Cardiovascular Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan

2. Department of Cardiovascular Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, chamran hospital

3. REFERENCES

6. Minimally invasive cardiac surgery The terms minimally invasive and limited access cardiac surgery have connoted either the size of the incision, the avoidance of a sternotomy, use of a partial sternotomy, or abstention from cardiopulmonary bypass.

7. Minimally Invasive Cardiac SurgeryClassification Level 1 Direct vision • Mini-incisions (10 to 12 cm) all operations were done under • direct vision Level 2 • Video assisted cardiac surgeons are the last to explore • the benefits of operative video assistance Micro incisions (4 to 6 cm) Level 3 Video directed and robot assisted Micro incisions or port incisions (1 cm) Level 4 Robotic telemanipulation Port incisions (1 cm)

8. Level 1: Direct Vision Minimally InvasiveMitral Valve Surgery

12. 7 years girl

22. Robotic Technology for MinimallyInvasive The da Vinci Surgical System (Intuitive Surgical, Inc., Mountain View, CA) comprises three components: a surgeon console, an instrument cart, and a visioning platform

23. da Vinci robotic telemanipulation system.

29. INDICATIONS FOR OPERATION The indication can be restated as a Q p/Q s of 1.8 or more and at times, if the anomaly is uncomplicated, of greater than 1.5.

30. Optimal age for operation is 1 to 2 years because of the • deleterious effects of longer periods of RV volume overload.

31. Closure of Atrial Septal Defectsby Percutaneous Techniques • The procedure is limited“central” defects with well-defined margins and size of 5 • to 20 mm

32. CONTRAINDICATIONS TODEVICE CLOSURE OF A SECUNDUM ASD • If the ASD is too large to be adequately closed by a catheter-based closure device. • If the particular patient’s heart structure will not allow an ASD closure device to be used (for example, if there is not enough atrial septal tissue left to secure the device). • If the particular patient’s blood vessels are too narrow to allow the catheter-based delivery system to be used.

33. • If the patient has blood clots in his/her heart. • • If the patient needs surgery to fix other heart • defects. • • If the patient has a bleeding disorder, untreated • ulcer, or is unable to take aspirin. • • If the patient has an active infection anywhere • in the body (the device can be implanted after • the infection is completely gone).

34. However, at present, no device is suitable for closure of a primumASDor is designed to be applicable for a coronary sinus septal defect or sinus venosusASD.

35. Minimally Invasive Surgical Closureof Secundum ASD s in children 1-Minimally invasive partial lower sternotomy approach has become the standard surgical management for the secundumASD over the last decade.

36. lower sternotomy approach

38. No significant differences were identified between the mini- and full sternotomy approaches. No adverse outcomes were detected. Only improved cosmesis was identified as an advantage for the mini-sternotomy approach. In 1999, Khan et al.34 described an experience with minimally invasive surgical repair of ASD at UCSF California.

39. Our experience • Advantage technique: 1- simple technique 2- possible to change to standard midsternotomy • Disadvantage : 1- over tension to skin and increase collide 2- crossed to langers skin lines therefore decrease cosmetics view 3- difficult to aorta cannulation and increase peripheral cannulation

40. RightThoracotomy Approach • 1-Limited Anterolateral Thoracotomy 2-Posterolateral Thoracotomy

41. Limited Anterolateral Thoracotomy disadvantage 1-of the anterolateral thoracotomy is that it is impossible to define subsequent breast development in girl 2- high incidence of phrenic nerve weakness has been reported using this approach

42. Advantage Anterolateral Thoracotomy • majority of patients were pleased with the cosmetic result • Good exposure and possible to central cannulation and possible use video assist

43. 2-Posterolateral Thoracotomy • advantage:Posterolateral thoracotomy which avoids the problem of breast distortion and results in a transverse scar on the back • disadvantage: scoliosis has been described in association with posterolateral thoracotomy and difficult exposure

44. Repair of Atrial Septal Defect via Right Submammary • Minithoracotomy in Children • Hamid Bigdelian 1, Mohsen Sedighi 2, *, FaranakMovahedi 2 • 1 Department of Cardiovascular Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran • 2 Cardiac Surgery Department, Chamran Heart Center, Isfahan University of Medical Sciences, Isfahan, IR Iran

45. Patients and Methods Between August 2010 and August 2013, 35 children underwent heart operations for ASD closure via right submammary thoracotomy. The standard anterolateral thoracotomy technique entailed a 4 - 5 cm right submammary incision. After establishment of cardiopulmonary bypass, the right atrium was opened and defect was closed by pericardial patch. The thoracotomy was closed in a routine fashion.

48. Children patient Adolescent patient

50. Results • The study patients included 5 males (14.29%) and 30 females (85.71%) whose age • ranged from 1 to 7 years. Among the patients, 30 had ASD and 5 had a sinus venosus type. • There were no intraoperative complications regarding exposure, cannulation, or bleeding. • There were also no deaths in the post-operative period. Postoperative complications • included significant hemorrhage from the suture line in one case and sick sinus syndrome • requiring pacemaker implantation in another case. The mean length of stay in the intensive • care unit was 2 days and the mean length of hospital stay was 4.5 days.