Minimally invasive approaches to pediatric cardiothoracic surgery: maintaining efficacy while improving cosmetic results for our young patients

Surgical advances over the past two decades have led to the establishment of minimally invasive techniques as the standard of surgical care for many maladies. It is the rare patient who undergoes a full incision for removal of a gall bladder, for instance. Video laparoscopic technology has dramatically improved cosmesis and shortened hospital stays for that and many other general surgical procedures. In adult cardiac surgery, attempts to minimize the trauma of cardiothoracic surgery have involved the similar use of video thoracoscopic techniques for an expanding number of non-cardiac surgical indications. Techniques for the reduction of incision size have involved the development of novel instrumentation and incision locations. Finally, the morbidity of the heart-lung machine can be avoided for many patients who may be offered an "off-pump" coronary artery bypass grafting procedure.

Minimally invasive techniques can also be offered to children who need cardiothoracic surgery for a number of congenital heart defects. The "mini-sternotomy," with reduction of the midline chest incision to about two inches or less, and the division of only a lower portion of the sternum, as opposed to the traditional full sternotomy, has been shown to allow for safe performance of many intracardiac repairs. A large number of defects requiring open-heart surgery including atrial septal defect, ventricular septal defect, atrioventricular canal defects, and mitral valve surgery can be safely repaired using this minimally invasive approach. Several studies examining this surgical strategy in greater than 200 patients have confirmed comparable safety and accuracy of intracardiac repair. Cosmesis is superior with an incision that ends below the level of the nipples also below the neckline of most clothing.

Video-assisted thoracoscopic surgical (VATS) techniques can be used for the division of vascular rings in both infants and children. This involves the placement of three or four operative port sites (3-5mm in length) on the chest rather than the performance of a complete lateral thoracotomy. The ligamentous, or minimally patent segment of the vascular ring is occluded with thoracoscopically introduced clips and divided. A recent review of the author's experience with this procedure in Atlanta is in publication. As others have noted, the procedure can be performed with safety, efficacy, and hospital stays that are significantly shorter than for patients undergoing a traditional thoracotomy. Most patients are discharged less than 48 hours following the procedure. VATS can also be used to safely clip occlude the patent ductus arteriosus in patients who are not candidates for a transcatheter device closure.

In summary, recent experience has shown that a significant number of congenital heart defects can be safely and accurately repaired with incisions offering superior cosmetic results for our young patients.

For more information, contact Joseph M. Forbess, M.D., director, Division of Pediatric Cardiothoracic Surgery, Children's Medical Center Dallas, at 214-456-5000 or joseph.forbess@utsouthwestern.edu.