Operative Techniques in Thoracic and Cardiovascular Surgery最新文献

Objective: Reporting our experience of total arch replacement through the left thoracotomy. Patients: From October 1999 to April 2021, 69 patients, aging 62.4 ± 13.7 years (26-84), underwent extensive aortic arch replacement from the ascending aorta, aortic arch, and to the descending aorta. The aneurysm consisted with 2 acute type A dissection, 35 chronic type A dissection, 1 acute type B dissection, 11 chronic type B dissection, 12 non-dissection plus chronic type B dissection, 11 nondissection with mega-aorta, and 4 Kommerell diverticulum. Various segments of aorta were replaced prior to extensive surgery, such as aortic root 7, ascending aorta 25, arch 3, descending aorta 1, thoracoabdominal aorta 1, and AAA 3. Two had ruptured aneurysm, 2 had intraoperative aortic dissection, 3 had graft infection, 2 had tracheotomy, and 1 had cardiac arrest. Methods: Forty-five patients had left posterolateral thoracotomy, 8 had anterolateral left thoracotomy plus partial midsternotomy, 2 had midsternotomy plus left thoracotomy, 2 had right posterolateral thoracotomy, I had Clamshell bilateral thoracotomy, and 13 had left thoracotomy + retroperitoneal approach. All patients underwent total arch and descending aorta replacement. In addition, three had aortic root replacement, 3 had ST junction plication, on had AVR, 12 had reconstruction of the segmental arteries, 13 had replacement of the thoracoabdominal aorta, and 2 had esophagus resection. Sixty-five had antegrade cerebral perfusion and 4 had deep hypothermic circulatory arrest with retrograde cerebral perfusion. Results: There were 4 early deaths (5.8 %). The causes of deaths were preoperative cardiac arrest due to aneurysm rupture, low cardiac output, acute myocardial infarction, and head injury. Conclusion: Extended replacement of the aortic arch and the descending aorta might be useful for the selected patients.

With the continuous decrease in morbidity and mortality associated with cardiac surgery, there has been a trend toward the development of operative techniques that are aimed toward improving other measures such as cosmetic outcomes. We have previously reported on such efforts, where a lower partial mini sternotomy is utilized to limit the skin incision and extent of median sternotomy. In this article we detail the operative technique for lower partial mini-sternotomy for the repair of congenital cardiac defects.

Chest wall resection is indicated in the management of operable primary chest wall tumors and lung cancers with chest wall invasion in carefully selected patients. Traditionally, chest wall resection has been performed via open thoracotomy, which is associated with significant postoperative pain and other associated morbidities. Furthermore, depending on the size and location of the resulting chest wall defect, chest wall reconstruction is warranted to maintain overall chest wall integrity, preserve inherent respiratory mechanics, and protect underlying intrathoracic structures. Video assisted thoracic surgery (VATS) techniques are an emerging and alternative technique to open chest wall resection, and have the potential benefit of minimizing the overall incision size, avoiding extensive rib spreading, and reducing tissue trauma. Given the technical challenges and lack of robust prospective outcomes data, VATS chest wall resection has not been widely adopted, but early reports appear to demonstrate its feasibility without apparent detriment to safety in selected patient populations. In this review, we detail relevant operative steps related to patient positioning and strategic port placement, anatomical dissection, and reconstruction options, as well as provide useful trouble shooting tips and tricks to help optimize outcomes following VATS chest wall resection.

The main reason for common atrioventricular valve regurgitation is the enlargement of the valve annulus contralaterally to the aorta and pulmonary artery. Edge-to-edge repair can be used to address the regurgitation; however, there might be potential disadvantage that a fixed bridging leaflet could have a restrictive motion, leading to recurrence of atrioventricular valve regurgitation. To avoid this issue and address the anteroposterior dilatation of the annulus, we have developed an adjustable annular bridging technique.

Chronic thromboembolic pulmonary hypertension (CTEPH) is an underdiagnosed complication of acute pulmonary embolism that is potentially curable with pulmonary thromboendarterectomy (PTE). Proper patient selection within the scope of a multidisciplinary team and detailed preoperative imaging is essential for successful outcomes. The operation itself is technically demanding and requires complete, bilateral endarterectomy down to the subsegmental branches on cardiopulmonary bypass with brief periods of deep hypothermic circulatory arrest. Finally, postoperative care is unique for PTE patients and is best conducted within the care of a multidisciplinary team.

Now, the standard treatment for clinical stage I non-small cell lung cancer (NSCLC) is lobectomy with systematic nodal dissection. Sublobar resections, such as segmentectomy and wedge resection are often performed in compromised patients with peripheral small-sized NSCLC who are unfit or at high risk for standard lobectomy or even in those with indolent NSCLC who are fit for lobectomy. Anatomical segmentectomy rather than non-anatomical wedge resection as sublobar resection is usually recommended. Segmentectomy could be subdivided according to the number and shape of intersegmental plane. Segmentectomy that creates one, linear intersegmental plane, with a relatively easier procedure, could be considered simple segmentectomy, that is, resection of the superior segmentectomy of the lower lobe, the upper division, or lingula segment of the left upper lobe. Segmentectomy that creates several, or intricate intersegmental planes, with more a complex procedure, could be considered complex segmentectomy, that is, one other than simple segmentectomy, such as non-superior segmentectomy of the basilar segment of the lower lobe. Because of procedural complexity and risk of increased complications and incurability, compared with simple segmentectomy, some general thoracic surgeons may have concerns to perform complex segmentectomies. In this article, we show the technique of posterior basal segmentectomies, which is one of the most challenging procedures in complex segmentectomy, through a hybrid video-assisted thoracic surgery approach.