Operative Techniques in Thoracic and Cardiovascular Surgery最新文献

Right thoracotomy approach has been gaining popularity in the repair of simple congenital heart diseases; especially, right vertical infra-axillary thoracotomy (RVIAT) provides a cosmetic benefit that is concealed and less evident but often requires peripheral cannulation. The surgical technique for RVIAT involved a 6-cm vertical incision in the right axillary fold, and cardiopulmonary bypass was established with ascending aorta and bicaval cannulations directly through the same surgical field. Intercostal block was routinely performed intra- and postoperatively to facilitate fast-track postoperative recovery. There is still a large potential to expand the selection criteria of RVIAT approach for further complicated diseases as a promising alternative to standard median sternotomy.

We describe a modified Stage I neonatal surgical palliation for hypoplastic left heart syndrome inspired by both the Norwood and hybrid procedures. This new technique consists in: (1) replacement of the patent ductus arteriosus and aortic arch plasty with a pulmonary homograft, (2) banding of both the right and left pulmonary arteries (PA), (3) atrial septectomy, and (4) reimplantation of the Aorta (when needed). This surgery is performed under cardio-pulmonary bypass without aortic cross clamping, except when the ascending Aorta is atretic and needs to be reimplanted. Stage II consists in the division of the pulmonary bifurcation, PA branch plasty (with debanding), bidirectional cavopulmonary shunt and Damus-Kaye-Stansel anastomosis. This new surgical procedure allowed us to obtain hemodynamically stable postoperative patients and decrease by twice our mortality rate after Stage I palliation in hypoplastic left heart syndrome but with frequent left PA stenosis or hypoplasia.

The management of high-risk neonates with hypoplastic left heart syndrome or its variants remains a tremendous surgical and medical challenge for our specialty. The hybrid strategy has been shown to improve outcomes in high-risk patients. This article illustrates the specific technical details of bilateral branch pulmonary artery banding for such high-risk patients.

Minimally invasive surgery (MIS) is gradually becoming the standard of care for the surgical treatment of nonsmall cell lung cancer (NSCLC). Compared with the multiple incision approach, including conventional multiportal video-assisted thoracoscopic surgery (mVATS) and multiportal robotic-assisted thoracoscopic surgery (mRATS), uniportal video-assisted thoracoscopic surgery (uVATS) offers a range of potential benefits such as straight target view from a sagittal plane, better lung exposure, ergonomic instrumentation, reduced postoperative pain, faster recovery, shorter length of hospital stay, and earlier administration of adjuvant therapy when necessary. However, uVATS remains a challenging procedure since all instrumentation shares the same access incision along the videothoracoscope. The learning curve demands a profound knowledge of specific technical details and comfort with specialized equipment to avoid intraoperative complications, essentially vascular accidents. This article provides a step-by-step description of uVATS right upper lobectomy, reviewing practical tips and tricks about operating room set-up, incision strategy, instrumentation management and operative sequence applied to the fissureless technique. This surgical technique is based on the author's preference and experience and therefore should not be taken as the only valid option. Our purpose is to make uVATS surgery accessible for most surgeons in their daily practice.

Pulmonary atresia with an intact ventricular septum (PAIVS) is a rare congenital cardiac disease with various structural abnormalities. For patients with moderate right ventricular (RV) hypoplasia for whom the decision has not been made between biventricular and single ventricular repair, if possible, the ideal treatment choice is biventricular repair, by promoting the growth of the underdeveloped RV. Since RV sinus myectomy has been proposed, various surgical strategies have been introduced to promote RV growth. Herein, we described instances of RV sinus myectomy and the accompanying techniques for “RV overhaul.” Furthermore, we introduced a current approach for small patients with PAIVS within an uncertain area.

Tracheobronchomalacia (TBM) is a chronic condition characterized by collapse of the trachea and bronchi during exhalation as a result of weakened tracheal cartilage and/or redundancy of the posterior airway membrane. Currently, the definitive treatment for TBM is surgical stabilization via mesh plication. While this procedure has traditionally been performed via a posterolateral thoracotomy, we have recently reported the outcomes of the first series of robotically-assisted, minimally invasive tracheobronchoplasty (R-TBP) for the treatment of severe TBM. The purpose of this report is to detail the R-TBP procedure, as well as, the potential pitfalls and pearls for success.

Arterial conduits, especially internal thoracic arteries (ITAs), are rarely affected by intimal hyperplasia or atherosclerosis, major contributors to early and late vein graft failure. Improved survival and freedom from reintervention with multi-arterial grafting (MAG) are reported in large observational studies, particularly when more than one anatomically important coronary territory is supplied. Several grafting configurations are possible depending on conduit and target characteristics, with the left ITA to the left anterior descending (LITA-LAD) typically being the cornerstone around which the rest of the conduits are constructed. The right ITA (RITA) or radial artery (RA) is used to bypass the second most important target after the LAD. The fundamentals of MAG depend on thorough preoperative evaluation, meticulous surgical technique and intraoperative flow assessment. Pitfalls to avoid include tension in short conduits or kinks in longer ones, poor ITA inflow, competitive native and graft flow, flow imbalance between segments of a composite graft, and sequentially grafting deep intramyocardial targets. Versatility and flexibility are critical in mitigating difficulties or potential complications in MAG. Refinements in complex bilateral ITA (BITA) and RA grafting require a deliberate iterative process that ideally incorporates dedicated training and mentorship by experienced MAG surgeons.