Del Nido Pedro J., Bichell David P.
Department of Cardiac Surgery, Children's Hospital, Boston, MA.
Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 1998;1:75-80. doi: 10.1016/s1092-9126(98)70010-9.
Improved results with lower operative mortality and morbidity for corrective surgery for many congenital cardiac defects has stimulated a renewed interest in the use of surgical approaches other than a full midline sternotomy. In an effort to decrease pain and discomfort, shorten the recovery period, and improve the cosmetic result, several alternative approaches have been proposed and implemented, with varying results. Anterior thoracotomy in the inframammary area has been the most widely used incision and is most applicable to females patients past puberty, in whom the extent of breast tissue can be assessed more accurately. Complications with this approach including phrenic nerve injury and breast and chest wall deformities have been reported, although most reports describe satisfactory cosmetic results. We have used a midline approach limiting the incision over the xyphoid process either without a sternal incision (infants) or with division of the lower segment (patients younger than 3 to 4 years) with cephalad retraction to expose the heart and great vessels. From May 1996 to June 1997, 54 children had repair of a secundum-type atrial septal defect using a transxyphoid or ministernotomy approach. In 29, arterial cannulation was performed through the ascending aorta, and in 25 via the femoral artery. There were no instances in which conversion to full sternotomy was required, and complete repair with comparable ischemic and bypass time to full sternotomy was achieved in all patients. We have also used the same technique for repair of other congenital cardiac lesions, including ventricular septal defect and partial or complete atrioventricular canal defects, and in selected infants with tetralogy of Fallot. With this approach, cardioplegia for myocardial protection and left ventricular venting to prevent distention and to remove air from the heart can be used routinely. The adaptability of this technique to various cardiac defects and the ability to extend the incision if necessary make it an attractive alternative to other approaches for minimal-access cardiac surgery for congenital defects. Copyright 1998 by W.B. Saunders Company
许多先天性心脏缺陷矫正手术的效果得到改善，手术死亡率和发病率降低，这激发了人们对除全胸骨正中切开术之外的其他手术方法的新兴趣。为了减轻疼痛和不适、缩短恢复期并改善美容效果，人们提出并实施了几种替代方法，结果各不相同。乳房下区域的前外侧开胸术是使用最广泛的切口，最适用于青春期后的女性患者，因为在这些患者中可以更准确地评估乳腺组织的范围。尽管大多数报告描述了令人满意的美容效果，但也有报道称这种方法会出现并发症，包括膈神经损伤以及乳房和胸壁畸形。我们采用了一种正中入路，在剑突上方限制切口，对于婴儿不做胸骨切开，对于3至4岁以下的患者则切开下段并向上牵拉以暴露心脏和大血管。1996年5月至1997年6月，54例儿童采用经剑突或小胸骨切开术修复继发孔型房间隔缺损。其中29例通过升主动脉进行动脉插管，25例通过股动脉插管。没有一例需要转为全胸骨切开术，所有患者均实现了完全修复，缺血和体外循环时间与全胸骨切开术相当。我们还使用相同技术修复其他先天性心脏病变，包括室间隔缺损、部分或完全房室通道缺损，以及部分法洛四联症婴儿。采用这种方法，可以常规使用心肌保护停搏液以及左心室引流以防止心脏扩张和排出心脏内的空气。该技术对各种心脏缺陷的适应性以及必要时延长切口的能力，使其成为先天性缺陷微创心脏手术其他方法的有吸引力的替代方案。版权所有1998年，W.B. 桑德斯公司
