Minimal access cardiac surgery

 

Cardiac surgery has evolved as field over the last two decades and what has come to the forefront is the need to do minimal access procedures. These range from trying to do minimalaccess bypass surgery or valve repair/replacement surgery or 
even more state of the art such as endoscopic and robotic cardiac surgery. New technology and instrumentation has made this possible and with world becoming flat these advances are available at affordable prices.

Mini Bypass surgery:

This is a new concept in bypass surgery. The procedure is:

The length of the incision is 8cms and the lower part of the chest bone is divided partially. The bypass surgery is done on
a beating heart using a vacumm stabilizer. Multivessel bypass procedures can be done. The advantages are less pain, low risk
of infections, and faster recovery. The only contraindication to this procedure are poor heart function, emergency bypass
surgery and morbid obesity.

Minimally invasive direct coronary bypass surgery(MIDCAB)

Coronary artery bypass done through a lateral thoracotomy (incision through the rib spaces) applied to do a single vessel bypass. This is used only for left internal mammary artery(LIMA) to the left anterior descending artery(LAD) graft.The length of the incision is 6-8cm. The incision is now being tried for multivessel bypass surgery by some groups but the initial results are questionable, long term data will tell us if it is better than conventional or Mini bypass. The other drawback
is that thoracotomy incisions are clearly more painful than sternotomy incisions.

Endoscopic heart surgery

The era of long incisions is history, technology has advanced in the years gone by and today imaging technology has made
what was in the late nineties a dream a reality. Endoscopic heart surgery is here to stay.

What is endoscopic heart surgery?

The endoscope is a cylindrical instrument at the end of which is mounted a high definition camera with a magnification of
sixteen times what the human eye sees. With the help of this device we can image the heart and its interior structures on a
television monitor and the surgeon can perform most open heart surgical procedures.

What surgeries are done this way?

The list is growing with improvements in instrumentation and the size of the incision required to navigate these instruments
has gone from 6cm to around 4cms now. The number and complexity of the procedures is also growing.

The procedures currently available are :

1. Closure of Atrial septal defect- Also known as a hole in the heart it is an abnormal communication between the two collecting chambers of the heart.

2. Closure of Patent Ductus arteriosus The ductus is a communicating channel that is essential when we are in the fetal stage once we are born this closes sometimes it stays open and diverts blood from the aorta to the left pulmonary artery and can if left untreated damage the blood vessels in the lung. This can be easily clipped or tied off using endoscopic techniques.

3. Closure of Ventricular septal defect- This is an abnormal communication between the pumping chamber of the heart. Some of them can be closed endoscopically depending on their location.

4. Mitral valve repair/ replacement surgery This approach has revolutionized mitral valve surgery which was done through the long painful incisions. Now we can do it with a 4 cm incision and patient leaves the hospital in 48 hours. The approach can be applied to all forms of mitral valve surgery.

5. Arrthymia surgery/ MAZE procedure- Some patients present with debilitating palpitations that can lead to formation of a clot in the heart and eventually stroke and death if left untreated. This can now be treated endoscopically using either bipolar heat energy or cryo energy to cause the lesions.