Gil-Jaurena Juan-Miguel, Pérez-Caballero Ramón, Pita-Fernández Ana, González-López María-Teresa, Sánchez Jairo, De Agustín Juan-Carlos
Department of Pediatric Cardiac Surgery, Hospital Gregorio Marañón, Madrid, Spain; ; Department of Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.
Department of Pediatric Cardiac Surgery, Instituto Cardiológico, Bucaramanga, Colombia.
Transl Pediatr. 2016 Jul;5(3):125-133. doi: 10.21037/tp.2016.06.01.
Mid-line sternotomy is the commonest incision for cardiac surgery. Alternative approaches are becoming fashionable in many centres, amidst some reluctance because of learning curves and overall complexity. Our recent experience in starting a new program on minimally invasive pediatric cardiac surgery is presented. The rationale for a stepwise onset and the short-medium term results for a three-year span are displayed.
A three-step schedule is planned: First, an experienced surgeon (A) starts performing simple cases. Second, new surgeons (B, C, D, E) are introduced to the minimally invasive techniques according to their own proficiency and skills. Third, the new adopters are enhanced to suggest and develop further minimally invasive approaches. Two quality markers are defined: conversion rate and complications.
In part one, surgeon A performs sub-mammary, axillary and lower mini-sternotomy approaches for simple cardiac defects. In part two, surgeons B, C, D and E are customly introduced to such incisions. In part three, new approaches such as upper mini-sternotomy, postero-lateral thoracotomy and video-assisted mini-thoracotomy are introduced after being suggested and developed by surgeons B, C and E, as well as an algorithm to match cardiac conditions and age/weight to a given alternative approach. The conversion rate is one out of 148 patients. Two major complications were recorded, none of them related to our alternative approach. Four minor complications linked to the new incision were registered. The minimally invasive to mid-line sternotomy ratio rose from 20% in the first year to 40% in the third year.
Minimally invasive pediatric cardiac surgery is becoming a common procedure worldwide. Our schedule to set up a program proves beneficial. The three-step approach has been successful in our experience, allowing a tailored training for every new surgeon and enhancing the enthusiasm in developing further strategies on their own. Recording conversion-rates and complications stands for quality standards. A twofold increase in minimally invasive procedures was observed in two years. The short-medium term results after three years are excellent.
正中胸骨切开术是心脏手术最常用的切口。由于学习曲线和整体复杂性，一些中心对此有所顾虑，但替代方法在许多中心正逐渐流行起来。本文介绍了我们开展小儿微创心脏手术新项目的近期经验。展示了逐步开展该项目的基本原理以及三年期间的短期和中期结果。
计划了一个三步方案：首先，由一位经验丰富的外科医生（A）开始进行简单病例的手术。其次，根据新外科医生（B、C、D、E）各自的熟练程度和技能，向他们介绍微创技术。第三，促使新采用者提出并进一步开发微创方法。定义了两个质量指标：转换率和并发症。
在第一阶段，外科医生A采用乳房下、腋窝和低位小胸骨切开术治疗简单的心脏缺陷。在第二阶段，外科医生B、C、D和E开始采用这些切口。在第三阶段，外科医生B、C和E提出并开发了新的方法，如高位小胸骨切开术、后外侧开胸术和电视辅助小切口开胸术，以及一种将心脏状况与年龄/体重与特定替代方法相匹配的算法。148例患者中有1例转换。记录到两例主要并发症，均与我们的替代方法无关。记录到4例与新切口相关的轻微并发症。微创与正中胸骨切开术的比例从第一年的20%上升到第三年的40%。
小儿微创心脏手术在全球正成为一种常见的手术。我们建立该项目的方案被证明是有益的。根据我们的经验，三步法很成功，可为每位新外科医生提供量身定制的培训，并增强他们自主开发进一步策略的积极性。记录转换率和并发症代表了质量标准。两年内观察到微创操作增加了一倍。三年后的短期和中期结果非常好。
