Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3753_Библиотеки_им_академика_М_И_Перельмана
.pdf
132 P. Perier
Fig. 2 Waste in the OR after the use of an external clamp
to start the heart lung machine after having
opened the thorax and wean the patient off
bypass when the thorax is ready to be closed. On
the contrary, the use of a double lumen tube
allows to shorten the hear lung machine time, but
the operation altogether is longer, because of the
placement of the tube, the necessity to change it
at the end of the operation. Many centers use one
lumen tube.
The patient is in supine position, with a small
elevation of the right hemithorax with the right
arm minimally hyper-extended so that the forearm is just below level of the table (Fig. 3).
Special care is taken to protect the bony prominences of the right arm.
Drape ensuring exposure of the right neck,
sternum, right chest superiorly to axilla and
posteriorly to the posterior axillary line, both
groins and both legs. It is necessary to be able to
control the colour and the aspect of the leg after
cannulation to make sure that the cannula is not
obstructing distal blood flow. Mark the groin
creases and femoral pulses bilaterally. Mark the
sub-mammary fold, including the 4 cm limits of
the planned skin incision.
The Iron-Assist™ instrument holder (Geister
Medizintechnik GmbH, Tuttlingen, Germany)
and camera holder are positioned at the left and
right head of the table respectively.
5 Cannulation
and Cardiopulmonary Bypass
(Video 1)
Routinely a single femoral venous cannula is
used except when the patient is above 1, 9 m or
weighs more than 100 kg. In those instances, an
Edwards Fem-Flex II 16 FR cannula (Edwards
Lifesciences, Irvine, CA) is placed by the
Endoscopic Mitral Valve Surgery Using the External Clamp 133
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 3 Position of the patient
anesthesiologist in the jugular vein under transoesophageal echocardiographic (TEE) guidance.
In case of tricuspid repair, a dual stage venous
canula is used, and the IVC and SVC are snared
on the canula, controlling that the portion without side holes is in the right atrium.
A longitudinal 3 cm skin incision, 2-fingers
lateral to the femoral pulse, has been observed to
reduce seroma formation. Dissect ion proceeds
medially to expose the anterior aspect of the
femoral vessels only, without encircling. After
palpation of these vessels confirms them to be
suitable a full dose of heparin is given. 2 adventitial arterial and 1 partial thickness venous 5-0
®
Prolene
(Ethicon, Somerville, United States)
purse strings are placed and the bypass lines are
handed out.
Using the TOE bicaval view for Seldinger
guided venous cannulation the wire is crossed to
the SVC ensuring no kinks or confusion with
other lines occur. The dilator is used and a 1–
2 mm cut anteriorly placed on the vein onto the
dilator. A 22, 24 or 28French QuickDraw™
single stage venous cannula (Edwards, Irvine,
Unites States) is inserted with TOE. The arterial
cannula with Seldinger wire and a 1 mm anterior
cut onto the dilator is placed. (16, 18 (up to
5 l/min), 20, 22French EOPA
®
arterial cannula,
collar at 5 cm (see Video 1).
134 P. Perier
Video 1 Safe peripheral cannulation (▶ https://doi.org/10.1007/000-a7n)
It is also possible to cannulate the femoral
vessels percutaneously.
Bypass is commenced before entry into the
pleural space to allow the ventilator to be disconnected, and the patient is cooled to 32 °C. All
peripheral venous lines must be closed before the
vacuum-assist bypass is initiated. If adequate
bypass flow is not achieved have a low threshold
for bilateral femoral arterial cannulation.
Visually inspect the leg for adequate perfusion
periodically during bypass. Poor leg perfusion
will necessitate distal femoral artery cannulation,
via the main femoral cannula’s side arm, using an
8French cannula and purse string.
6 Surgical Access
Most often it is possible at palpation to feel the
4th intercostal space and therefore to guide where
the incision should be located. Most of the time it
is in the immediate vicinity of the nipple. In men,
a 2 to 3 incision is made at the border of the
areolar depending on the location of the intercostal space between 11 and 5 or 9 and 3 (Fig. 4
and Video 2). In women, if possible, a peri areolar
incision is performed in the same way, but
sometimes it would be too anterior, whi ch will
lead to an approach of the mitral valve with a too
marked angle, making the operation difficult. In
this case a more lateral incision trough the breast
is indicated. A posterior incision in the mammary
groove is too posterior and will increase the distance between the incision and the mitral valve,
furthermore, there will be no angle with the mitral
valve, making the visualization of some aspect of
the mitral apparatus difficult. After opening the
intercostal space, a soft tissue retractor is placed
to spread the tissues and to avoid that debris are
brought in the cardiac cavity with the motions of
the instruments. No rib retractor should be used!
The port for the endoscope is placed in the same
intercostal space as the incision (Video 2).
Endoscopic Mitral Valve Surgery Using the External Clamp 135
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 4 Peri-areolar Incision 9-3
Video 2 Creating the Peri-areolar incision (▶ https://doi.org/10.1007/000-a7m)
136 P. Perier
7 The Set Up (Figs. 3, 4, 5 and 6)
Everything should be made as simple as possible,
but not simpler.
Albert Einstein
The set up should always be the same and kept
simple. A 10 mm 30° angle high-definition 3D
endoscope is inserted through a port made in the
4th intercostal space, posterior to the internal part
of the soft tissue retractor. Significant pericardial
fat at the sterno-diaphragmatic area is removed.
An L-shaped incision is cut in the pericardium
far away from the phrenic nerve using the diathermy, from the diaphragm to the aortic reflection superiorly, then adjacent to the diaphragm
surface, posteriorly, to a level just anterior to the
inferior vena cava (IVC) avoiding the phrenic
nerve (Video 3).
Three 2-0 Vicryl
sutures are placed with the Endo Close™
(Medtronic) using a finger to protect the lung,
posterior to the camera port, 2 intercostal spaces
below (posterior axillary), and 1 space above
(axillary) where they are clipped in place or tied
around rubber tubing. The inferior pericardial
®
(Ethicon) pericardial stay
stay suture should be placed close to the diaphragm, pulling on the suture will take the diaphragm out of the way, avoiding placing stay
sutures directly on the diaphragm.
The pericardial reflection posterior to the IVC is
opened with long Metzenbaum scissors then rough
sucker. This facilitates the left atriotomy; the inferior vena cava is encircled twice with a 0 black silk
to snare the IVC, if required, in case of concomitant
tricuspid surgery. A small stab and blunt dissection
are made-1-2 rib spaces inferior to camera port,
midaxillary, for the sump sucker. This is temporarily positioned posterior to the IVC.
Ensure the heart is empty and properly
decompressed when entering the pericardium.
The operation should not be started if the venous
return is not satisfactory. A simple measure is to
make sure that the venous canula is at the top of
the thorax, at the level of the innominate vein, at
the limit of the camera view.
If a SVC snare is necessary, the pericardial
incision is extended superiorly for full exposure.
The pericardial reflection over the SVC is cut and
a right-angle clamp is used to blunt dissect.
The operative field should be flooded with
CO
to avoid air in the heart cavities and to
2
Video 3 Opening the pericardium (▶ https://doi.org/10.1007/000-a7k)
Endoscopic Mitral Valve Surgery Using the External Clamp 137
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 5 The setup
Fig. 6 Peri-areolar incision
facilitate the deairing. At the beginning of our
experience, we started CO
insufflation as soon
2
as the thorax was open at a rate of 3 L/Mn. The
perfusionists and the anesthetists complained
because of blood acidosis and hypercapnia. We
progressively reduced the flow to 1 L/Mn, which
was not enough. At the present time, we start
CO
insufflation when we place the sutures for
2
the ring, at the end of the repair, with the same
efficiency.
138 P. Perier
8 Placement of the External Clamp
(Video 4)
It is certainly possible to place the external clamp
in the transverse sinus, but there are drawbacks:
the left appendage is in the vicinity vulnerable to
injury as well as the pulmonary artery. Moreover,
there is not much space left on the ascending
aorta below the clamp for the cardioplegia needle. After having had all the complications
mentioned, we looked for another method.
We lift the aorta away from the pulmonary
artery with long-shafted forceps, divide the
adventitia with long-shafted scissors. Proceed
between the aorta and the pulmonary artery
towards the left shoulder with blunt dissection,
using the rough sucker and long-shafted forceps
until the contralateral pericardial space is entered,
and the pericardium seen. Using a small stab with
blunt dissection 1 or 2 intercostal space superior
to camera and working port, mid-axillary at the
level of the video port, insert the aortic clamp
curved caudally, and once in the thorax turn it
cranially. Place the clamp across the aorta at its
upper visible limit, taking care to avoid the pulmonary artery and left atrial appendage, and
leave open.
Clear any significant fat on the ascending
aorta to make a suitable landing zone for the
cardioplegia canula. A double purse string with
4-0 nonabsorbable polypropylene is placed. This
is proximal to the aortic clamp and lateral to the
uppermost aortic aspect, using forceps to stabilize and ease the placement of the sutures.
A long, single lumen cardioplegia cannula (2
notches for stays) is placed, snared and spigoted.
Tuck the snare away in the left pericardial cavity.
A mid-clavicular stab in the 2nd intercostal space
is used to externalize and connect the clamped
cardioplegia line.
A 5 cm jaw transthor acic aortic clamp is
usually used although a 7.5 cm transthoracic
aortic clamp is preferable with larger aortae or
obstructive shoulders or patient with a large
thorax.
The end of the cardioplegia cannula is cut off
to remove fat debris before connecting it to the
cardioplegia line via a 3-way tap.
Video 4 Placement of the external clamp (▶ https://doi.org/10.1007/000-a7p)
Endoscopic Mitral Valve Surgery Using the External Clamp 139
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Cardioplegia is then given. We use
Bretschneider solution. Typically, the heart arrest
occurs after 200–300 ml. If cardioplegic arrest is
delayed it may be due to an aortic insufficiency, a
displacement of the cardioplegia canula or a lack
of efficiency of the aortic clamp. It is necessary to
find the cause of this delay. We routinely infuse
1500 ml for patients above 80 kg; for those with
a lower weight to decrease the evolution we
infuse only 1000 ml. After 90 mn of aortic cross
clamping, if obviously the operation will last
longer than 2 h, we inject another 500 ml
cardioplegia.
9 Atriotomy
A 2-0 Vicryl®stay suture is placed in the fat
anterior to the interatrial groove, exerting traction
will improve the exposure of the left atrium, for
the opening, the closure and later to control the
lack of bleeding. A long needle is used as a guide
by placing through the chest wall lateral after
having palpated the intercostal space (4th) the
needle has to be delicately handled; its role is to
avoid hitting the internal mammary vessel.
Internally this is located just medial to the
®
Alexis
A 5 mm stab is done at the level of the exploring
needle and pass the interatrial stay suture and the
shaft for the left atrial retractor.
right inferior and towards the right superior
pulmonary vein. A hand held sump sucker in left
atrium retracting inferiorly provides a good view.
A 2-0 Ethibond
in the fat anterior to the interatrial groove. A long
needle is used as a guide by placing through the
chest wall lateral to the internal mammary artery,
level with working ports, and left atrium. Internally this is located just medial to the Alexis
inner ring using fingertip proprioception.
A 5 mm stab lateral to the needle is made and a
Pean artery clip is used to develop the tract. Use
the above stab hole to pass through the atriotomy
stay suture and site the shaft of atrial retractor.
inner ring using fingertip proprioception.
Incise the left atrium midway between the
®
atriotomy stay suture is placed
Incise the left atrium midway between the
right inferior and towards the right superior
pulmonary vein. A handheld sump sucker in left
atrium retracting inferiorly provides a good view.
The left atrial incision is carried out with long
shafted scissors towards the roof of the left
atrium and under the IVC. The atrial wall is
retracted anteriorly by inserting the blade of the
atrial retractor and fixing the shaft with the IronAssistant™ and clamp at the base of the atrial
retractor shaft. Most of the time the inferior wall
of the left atrium is blocking the view of the
mitral valve.
A 4-0 Prolene is passed through the atrial wall
at around 5 o’clock, 2 cm behind the inferior
wall and will nicely expose the mitral valve. The
endoscope is then placed to have the mitral valve
in full view, in the mid dle of the screen. Instead
of bringing the endoscope close to the mitral
valve, it is preferable to use the zoom properties
of the equipment. The endoscope should remain
as close to the thorax wall as possible to avoid
conflicts with the instruments.
10 Mitral Valve Repair
Mitral valve repair is performed according to the
standard techniques. After careful analysis, the
proper technique can be selected and implanted
according to the lesions. Surgery must be driven
by the strategy, which is to restore a good surface
of coaptation, smooth and regular, as long as
possible and located in the inflow of the left
ventricle.
A ring annuloplasty is routinely used, special
care has to be taken to avoid an injury of the
aortic valve or the circumflex arter y.
®
11 Mitral Valve Replacement
Any type of mitral valve replacement can be
carried out, mechanical or biological. The only
particularity is that the incision of the working
port is planned long enough to accommodate to
140 P. Perier
the bulky prosthesis. Using the Cor-knot®device
(LSI Solutions) may help to have a standard
tension on the knots.
12 Concomitant Tricuspid Repair
In case of indication of a tricuspid repair, it is
necessary to carefully take this into account in the
planning of the operation. In contrast to an
operation performed through sternotomy, a minimally invasive tricuspid repair is time consuming, around 45 mn. The exposure is not always
easy, and the closure of the right atrium has to be
perfect with no bleeding, and this takes time.
In our daily practice we start with the tricuspid
repair before the mitral valve. It avoids having
the stay suture in the way.
13 End of the Operation
and Deairing
It is crucial that, after the closure of the left
atrium and before deairing, when the heart is still
totally decompressed, a pacemaker wire is placed
on the diaphragmatic face of the right ventricle.
A left vent is placed in the left ventricle,
suction is applied on the cardioplegic needle, the
heart is filled. Deairing should be controlled with
echocardiography. CO
of the time, there are just isolated bubbles, at the
most.
After unclamping the aorta, and some reperfusion, ventilation may be resumed, and the
HLM flow may be reduced to ½ liter, while
controlling the oxygen saturation. A “preview”
echocardiographic control is performed. It saves
a lot of time if at that stage the result is not
satisfactory, and if it is necessary to improve the
result of the repair. Everything is still in place.
In case of a good result, the HLM can proceed
again full flow, the ventilation has to be stopped.
The cardioplegia line is removed and the hole is
secured with a 4-0 Prolene.
Closure, hemostasis, discontinuation of CPB,
decannulation and echoc ardiographic control are
performed in a normal way.
is very potent and most
2
This minimally invasive mitral surgery is
increasingly being shown to yield comparable or
better resul ts to open mitral surgery with all the
added benefits associated with endoscopic procedures, and foremost is associated with an
extremely high patient satisfaction. One motto is
never losing sight of patient safety and quality of
the results. This non compromise attitude is best
achieved with a dedicated team approach. A team
is made of surgeons, anesthetists, perfusionists,
and nurses. As Simon Sinek as taught us, “a team
is not only a group of people working together,
but a team is also a group of people trusting each
other”. Another point is the necessity of building
a routine, which will allow the team to develop
the required skills and to build an experience on
which everyone can rely. It means that a minimal
number of cases per year is necessary to start a
program of minimally invasive mitral surgery. It
is even more important in the beginning to be
able to select patients according to one’s level of
expertise.
Endoscopic minimally invasive mitral surgery
is a fantastic training tool. The trainees can perfectly see what the senior surgeon is doing,
contrary to what happens in the conventional
surgery. When assisting a younger surgeon, it is
possible to totally control each manoeuvre of the
operation.
Tips
1. Maintaining a regular theatre team allows
for a smooth procedure.
2. Having good TOE images are crucial for
safe peripheral cannulation.
3. The external clamp is best placed by
making the incision on the upper border of
the rib to avoid the neuromuscular bundle
running at the lower aspect of each rib.
Tricks
1. Incising the tissue over the pulmonary
artery and creating the bloodless field
below the aorta gives extra space to apply
the clamp and avoids injury to the left atrial
appendage.
Endoscopic Mitral Valve Surgery Using the External Clamp 141
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
2. A circular suture in the adventitia of the
aorta placed above the sino-tubular junction acts as a safe way to anchor the cardioplegia cannula.
3. If an extra suture is required at the cardioplegia site a pledged braided suture can
be tied with a CorKnot to control the
bleeding. This is best done with a reduced
pump flow.
Traps
1. In large patients with a lot of adipose tissue
over the pericardium an energy source is
useful to dissect the fat off the pericardium
prior to opening it.
2. In patients with short aortas avoid the
temptation to place the cardioplegia cannula in the non coronary sinus area as this
can be difficult to control in some patients.
3. In case of bleeding from the stab incisions
a period of pressure applied by a peanut
swab until heparin is reversed helps to
localise the cause and often this can then be
dealt with diathermy to the site.
References
1. Carpentier A, Loulmet D, Carpentier A, Le Bret E,
Haugades B, Dassier P, et al. Open heart operation
under videosurgery and minithoracotomy. First case
(mitral valvuloplasty) operated with success. C R
Acad Sci III. 1996;319(3):219–23.
2. Mohr FW, Falk V, Diegeler A, Walther T, van
Son JA, Autschbach R. Minimally invasive portaccess mitral valve surgery. J Thorac Cardiovasc
Surg. 1998;115(3):567–74;discussion 74–6.
3. Vanermen H, Wellens F, De Geest R, Degrieck I,
Van Praet F. Video-assisted Port-Access mitral valve
surgery: from debut to routine surgery. Will TrocarPort-Access cardiac surgery ultimately lead to robotic
cardiac surgery? Semin Thorac Cardiovasc Surg.
1999;11(3):223–34.
4. Cheng DCH, Martin J, Lal A, Diegeler A, Folliguet TA, Nifong LW, et al. Minimally invasive
versus conventional open mitral valve surgery: a
meta-analysis and systematic review. Innov Technol
Tech Cardiothorac Vasc Surg. 2011;6(2):84–103
https://doi.org/10.1097/IMI.0b013e3182167feb.
5. Perier P, Hohenberger W, Lakew F, Batz G,
Diegeler A. Rate of repair in minimally invasive
mitral valve surgery. Ann Cardiothorac Surg. 2013;2
(6):751–7.
6. Casselman FP, Van Slycke S, Wellens F, De
Geest R, Degrieck I, Van Praet F, et al. Mitral valve
surgery can now routinely be performed endoscopically. Circulation. 2003;108 Suppl 1:II48–54.
7. Suri RM, Antiel RM, Burkhart HM, Huebner M,
Li Z, Eton DT, et al. Quality of life after early mitral
valve repair using conventional and robotic
approaches. Ann Thorac Surg. 2012;93(3):761–9.
8. Murzi M, Cerillo AG, Bevilacqua S, Gasbarri T,
Kallushi E, Farneti P, et al. Enhancing departmental
quality control in minimally invasive mitral valve
surgery: a single-institution experience. Eur J Cardiothorac Surg. 2012;42(3):500–6.
9. Holzhey DM, Seeburger J, Misfeld M, Borger MA,
Mohr FW. Learning minimally invasive mitral valve
surgery: a cumulative sum sequential probability
analysis of 3895 operations from a single highvolume center. Circulation. 2013;128(5):483–91.
10. Vo AT, Nguyen DH, Van Hoang S, Le KM,
Nguyen TT, Nguyen VL, et al. Learning curve in
minimally invasive mitral valve surgery: a singlecenter experience. J Cardiothorac Surg. 2019;14
(1):213.
11. Rival PM, Moore THM, McAleenan A, Hamilton H,
Du Toit Z, Akowuah E, et al. Transthoracic clamp
versus endoaortic balloon occlusion in minimally
invasive mitral valve surgery: a systematic review
and meta-analysis. Eur J Cardiothorac Surg. 2019;56
(4):643–53.
Соседние файлы в папке Библиотека им академика М.И. Перельмана