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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3753_Библиотеки_им_академика_М_И_Перельмана
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Totally 3D-Endoscopic Aortic Valve
Replacement
Soh Hosoba and Toshiaki Ito
Abstract
Minimally invasive cardiac surgery (MICS)
has evolved over the last 25 years. In aortic
valve disease, MICS has been used commonly
to treat both aortic stenosis and regurgitation,
although the common approach relies on
direct visualization via thoracotomy, often
with rib spreading. In mitral valve surgery,
totally endoscopic surgery with or without
robotic assists has been evolving for over
twenty years. Without rib spreading or longer
incision, this endoscopic approach has
emerged as an attractive procedure and is
widely performed. We describe our approach
to performing totally endoscopic aortic valve
replacement, which we have refined over the
years with cumulative experience of 131
cases.
Supplementary Information The online version
contains supplementary material available at
https://doi.org/10.1007/978-3-031-21104-1_12. The
videos can be accessed individually by clicking the
DOI link in the accompanying figure caption or by
scanning this link with the SN More Media App.
S. Hosoba (&) T. Ito
Department of Cardiovascular Surgery, Japanese
Red Cross Nagoya First Hospital, Nagoya, Japan
e-mail: soh.hosoba@gmail.com
Keywords
Minimally invasive cardiac surgery
EndoscopyAortic valve replacement
Three-dimensional endoscopeTotally
endoscopic
1 Introduction
The first minimally invasive aortic valve surgery
was reported through a mini sternotomy or right
anterior thoracotomy in the early 1990s [1–3].
Since then, the mini-sternotomy approach gained
popularity. It has been the mainstay of minimally
invasive aortic valve replacement (AVR) at many
centers over the world. On the other hand, AVR
through right anterior thoracotomy (RAT) has
also been reported [4–6]. The RAT approach
usually does not require an endoscopic vison, but
when it is used, it is only to assist with visualization. Twenty percent has been performed in
thoracotomy approach in the recent Society of
Thoracic Surgeons (STS) Adult Cardiac Surgery
database report, [7].
In modern area, rapid deployment valves
(RDV) have also played an important role in
AVR, and the results have been favorable [8, 9].
RDV may accelerate the current momentum of
mini-thoracotomy AVR.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
J. Zacharias (ed.), Endoscopic Cardiac Surgery,
https://doi.org/10.1007/978-3-031-21104-1_12
175
176 S. Hosoba and T. Ito
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Carpentier et at reported their first experience
in endoscope-assisted surgery for valves [10].
Totally endoscopic cardiac surgery for mitral
valve was also reported [11, 12]. A totally
endoscopic platform has been reported in many
countries with or without robotic assistance,
since then [13–15].
However, the reported experience has represented only a small fraction of the actual totally
endoscopic aortic valve treatment to date [16–
18].
Our experience in MICS AVR started in 2011
with the right anterior thoracotomy (RAT) approach and we have modified it to trans-axillary
minimally invasive AVR [ 19 ]. We switched our
platform to a total endoscopic platform for AVR
in 2015 after we gained expertise in 3Dendoscope for the mitral procedure [20]. We
reported our initial experience for totally
endoscopic AVR [21]. We subsequently broadened our application to double valve procedure
[22]. We, herein, describe our approaches and
results for totally endoscopic AVR in more than
130 patients.
2 Operative Technique
2.1 The Set Up: Patient Positioning,
3D Endoscope, and Monitor
We initiate the operation under general anesthesia. For single-lung ventilation, a double-lumen
endotracheal tube or a bronchial blocker is used.
The patient is placed in a 30-degree left lateral
decubitus position with the right arm fixed over
the head (Fig. 1). We place a large pillow beneath
the axilla to vent over the right lateral chest. All
Fig. 1 The figure shows position of the patient
Totally 3D-Endoscopic Aortic Valve Replacement 177
Fig. 2 OR set up for endoscopic aortic valve replacement
intracardiac component of the procedure is performed by looking at the monitor. The first
assistant stands on the right side of the surgeon.
The second assistant holds the 3D endoscope and
stands at the left side of the surgeons (Fig. 2). The
surgeon and assistants wear polarized glasses to
view objects stereophonically. We make sure the
monitor is placed at the correct height.
2.2 The Three-Port Technique
(Video1)
We insert a 10-mm trocar for a 3D endoscope
(Karl Storz, Tuttlingen, Germany) through the
fourth intercostal space on the right mid-axillary
line. A main 4.0 cm incision is made at the fourth
intercostal space. Depending on the patients’
anatomy, sometimes the 3rd or 5th intercostal
space is used. The intercostal space is opened
without a rib-spreader. A 5-mm port for lefthanded instruments is placed at the second or
third intercostal space on the right anterior axillary line. A soft tissue retractor is applied to the
main port (“The three-port system” Fig. 3). The
surgeon drives forceps with the left hand and
needle-driver with the right hand. A 3D endoscope is placed in between the right- and lefthand ports, equidistance from each port.
178 S. Hosoba and T. Ito
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Video 1 The three-port technique and (▶ https://doi.org/10.1007/000-a85)
Fig. 3 Our setup of three port method for totally 3D endoscopic right mini-thoracotomy approach. The main, second,
and camera ports were made at the fourth, the third, and the fourth intercostal spaces, respectively
Totally 3D-Endoscopic Aortic Valve Replacement 179
3 Cardiopulmonary Bypass
to Cross-Clamp
A cardiopulmonary bypass is established through
the right femoral artery and vein for most cases.
The pericardium is opened after initiating cardiopulmonary bypass. Four pericardial stay
sutures are placed. The left upper suture is pulled
through the right anterior chest wall using the
crochet hook (Video). The lower two sutures are
retracted to the outside of the chest wall utilizing
a crochet hook, 5 cm below the camera port. An
antegrade cardioplegia line are inserted through
the main port. The inferior vena cava (IVC) is
snared with CV-0 (W.L. Gore & Associates,
Flagstaff, U.S.A.) to facilitate venous drainage
for any valve cases. The left ventricular vent tube
is inserted through the right superior pulmonary
vein. Simultaneously, the patient is cooled systemically to 32C.
The ascending aorta is cross-clamped with a
flexible clamp through the main port. Cardiac
arrest is achieved with antegrade (and retrograde
when needed) cardioplegia (Fig. 3). In cases of
severe aortic regurgitation, we open the aorta and
cannulate the coronary ostia directly. In concomitant mitral valve cases, we open the right
atrium and inject retrograde cardioplegia directly
into the coronary sinus.
Aortic valve replacement (Video 2)
An aortotomy is extended towards the left-non
commissure. Two polypropylene stay sutures are
placed at the right-left and right-non commissure.
The aortic valve leaflets are excised, and annular
calcium is debrided carefully. Everting mattress
stitches are placed at each commissure. Three to
four single interrupted stitches are placed
between commissures. A standard pericardial
stented valve is used for AVR. The pericardial
valve is seated in the annulus through the 4 cm
incision. The valve stiches are tied with a knot
pusher with diamond like carbon coated-head
(EMI Factory Co., Nagano, Japan) (Fig. 4). The
aortotomy is closed with two-layer 4–0
polypropylene sutures. The cardiopulmonary
bypass is weaned after meticulous hemostasis.
Video 2 Aortic valve replacement (▶ https://doi.org/10.1007/000-a84)
180 S. Hosoba and T. Ito
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Fig. 4 Knot-pusher designed for endoscopic cardiac surgery. (EMI Factory Co., Nagano, Japan)
learning curve, total operation time shortened to
4 Summary
less than three hours routinely.
In conclusion, totally 3D-endoscopic for aor-
Minimally invasive cardiac surgery has evolved
over the past two decades and has changed the
fundamental approac hes for valve treatments. In
mitral surgery, endoscopic mitral valve treatment
is currently considered a gold standard treatment
for its minimal invasiveness. While there are
tic valve utilizing ‘three-port’ technique is a
feasible technique for patients who required
AVR.
Conflict of Interest Statement The authors
have no conflicts of interest to declare.
extremely limited reports of totally endoscopic
AVR, we believe, with our experience, that totally endoscopic AVR can be accomplished if a
References
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2020, 131 patients with 72 ± 11 years of age
underwent totally endoscopic aortic valve
replacement at our institution using the described
technique. Two patients (1.4%) underwent aortic
valve repair, and the other 129 (99%) patients
underwent AVR. 10 patients (7.6%) had aortic
valve replacement with a mechanical valve, and
121 (92%) patients had a tissue valve replacement. Mitral valve repair and replacement
were simultaneously performed in 14 (11%)
and 3 (2.2%) patients respectively, and no failure
in repair was noted. There was one (0.7%) 30day mortality. Conversion to sternotomy was
required in 3 (2.2%) pati ents and after the
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Totally Endoscopic Aortic Valve
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Replacement
Antonios A. Pitsis
and Aikaterini N. Visouli
Abstract
The replacement of the aortic valve is one of
cardiac surgery’s great successes and provides
both life saving and life enhancing benefits.
The median sternotomy and Hemi sternotomy
are the preferred approaches with an anterior
right mini thoracotomy gaining popularity. An
endoscopic approach to aortic valve replacement has been adopted sporadically but is now
gaining interest. In this chapter a step by step
approach is taken to cover all the indications
and contraindications to considering this
approach. The authors are experts at using
the automated suturing device (RAM) and
describe their experience with this.
Keywords
Micro aortic valve replacementAutomated
aortic valve suturing devices
Totally
endoscopic surgery
Supplementary Information The online version
contains supplementary material available at
https://doi.org/10.1007/978-3-031-21104-1_13. The
videos can be accessed individually by clicking the
DOI link in the accompanying figure caption or by
scanning this link with the SN More Media App.
A. A. Pitsis (&) A. N. Visouli
1st Cardiac Surgery Department, European
Interbalkan Medical Center, Thessaloniki, Greece
e-mail: apitsis@otenet.gr
1 Introduction
“Primum non nocere”.
“First do no harm” is a fundamental principal
of bioethics, universally established, and accepted by the medical community. The principle of
nonmaleficence supports several moral rules,
including the obligation not to cause pain or
suffering.
In medical ethics, nonmaleficence is the duty
to cause no harm intentionally, or inflict the least
harm to reach a beneficial result.
Conventional surgery is associated with significant surgical trauma, a harm considered
inevitable and inherently associated with the
beneficial results of restoring intracorporeal
pathology, being viewed for decades as a fair
tradeoff.
Advancements in technology allowed minimization of the surgical trauma without compromising the beneficial results of surgery.
Although with a latency compared to other
surgical speci alties, cardiac surgery evolved,
incorporating since the mid-1990s minimally
invasive techniques, involving smaller thoracic
incisions, other than the full sternotomy.
The main approaches for surgical Minimally
Invasive Aortic Valve Replacement (MIAVR)
are the mini-sternotomy and the right anterior
mini-thoracotomy, although several other
approaches have been tried. Many potential
advantages of the MIAVR have been reported,
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
J. Zacharias (ed.), Endoscopic Cardiac Surgery,
https://doi.org/10.1007/978-3-031-21104-1_13
183
184 A. A. Pitsis and A. N. Visouli
including decreased postoperative pain, reduced
blood loss and transfusion requirement, better
preservation of the lung function, reduced ventilation time, shorter Intensive Care Unit
(ICU) and hospital stay, earlier return to work,
social life, and regular activity, better patient
satisfaction, and cosmetic results.
While there is demand for further investigation and robust evidence regarding the potential
advantages of MIAVR, cardiac surgery continues
to evolve, seeking to further minimize the surgical trauma with the aid of advanced technology, incorporating totally endoscopic and
robotically assisted techniques.
In this chapter we describe the surgical technique of a Totally Endoscopic Aortic Valve
Replacement (TEAVR), performed under stereoscopic screen vision, through a micro invasive
approach leaving intact the sternum, the ribs, the
cartilages, and the inte rnal thoracic artery,
achieved with enabling technology that allows
aortic valve excision and surgical replacement
with conventional, durable bioprosthetic or
mechanical valves, applied for Aortic Stenosis
(AS), Aortic Regurgitation (AR), mixed aortic
valve disease, and a range of combined operations
(Fig. 1)[1–8].
2 General Overview
Despite the micro invasive approach, TEAVR has
a technical end-result largely similar to the that of
a conventional full sternotomy AVR, as far as the
valve replacement is concerned. TEAVR allows
surgical excision of abnormal ao rtic valves (of
any pathology, including bicuspid valves),
annular decalcification/debridement as required,
and replacement with a conventional biological or
mechanical prosthesis, thus prosthetic valves with
proven durability. Certainly, sutureless valves can
be implanted if appropriate.
Furthermore, edge to edge mitral valve repair
for secondary mitral insufficiency, chordal
replacement for primary mitral insufficiency,
myectomy for hypertrophic obstructive
Fig. 1 Theatre setup for endoscopic aortic valve replacement
Totally Endoscopic Aortic Valve Replacement 185
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cardiomyopathy, and aortic root enlargement can
be performed in combination with the TEAVR.
The operation takes place through a 3 cm
right anterior micro (l) thoracotomy, sparing the
right internal thoracic artery, the sternum, the ribs
and the cartilages, without any division, dislocation or application of any kind of rib spreading,
and ensuring minimal surgical trauma to the
intercostal nerves and the soft tissues (Fig. 2).
This working incision does not allow direct
vision of the operative field, or any kind of
manual activity within the thorax. The operation
is mainly performed under stereoscopic (3D)
screen vision, provided by a 3D endoscope
inserted in the right hemithorax, and is significantly facilitated by specially designed instruments and devices, including automated suturing,
sewing, and suture fastening devices.
The operation is performed under general
anaesthesia, with a double lumen endotracheal
tube, and the use of intraoperative Transoesophageal Echocardiography (TOE), on femorofemoral vacuum assisted Cardiopulmonary
Bypass (CPB), and cardioplegic arrest.
Further to the 3 cm right anterior microthoracotomy, three more thoracic microincisions
(*0.4–1 cm) are necessary for the insertion of 1.
the 3D endoscope (2nd intercostal space, laterally to the micro-thoracotomy working incision),
2. the aortic cross clamp (1st intercostal space, at
a safe distance from the endoscope), while 3. a
4th intercostal space stamp wound microincision
is used for multiple purposes (insertion of surgical instruments to dissect free and open the
pericardium, insertion of a sump sucker that is
also used as a right superior pulmonary vein
Fig. 2 Working incision
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