Menu
Subscribe
Miami Minimally Invasive Valves
Joseph Lamelas, MD
Dedicated to the Advancement of Minimally Invasive Cardiac Surgery
X

Posts tagged as incision

When performing a minimally invasive AVR or MVR via a right mini-thoracotomy approach, assessing whether you are in the right interspace is sometimes questionable.  Even after performing thousands of cases, I question this at times. I have come to the conclusion that there is one landmark that I need to see in order to confirm that I have entered the correct interspace.  That structure is the Right Superior Pulmonary Vein.

During a mini AVR, after instituting CPB and opening the pericardium, if I see the RSPV directly in line with interspace that I entered, I know that I should be able to perform the operation, even if the aorta is displaced. It is key to then take your time and place as many pericardial stay sutures as needed to develop the exposure. This is crucial to optimizing the exposure. (TOP picture)

During a mini MVR, after instituting CPB and opeing the pericardium, if I see the RSPV directly in line with the interspace that I entered, or one interspace above the site that I entered, I know that I am in the correct interspace. I don’t what to be in line with the IVC. This will be very low and if this were the case, I would move to the next higher interspace. Again, use the pericardial stay sutures to optimize exposure. (BOTTOM picture)

Mini AVR

Mini AVR

Mini MVR

Mini MVR

 

I know that we are all busy in our daily work and family lives , but please take the time to answer a few questions.
Everyone who has subscribed to the blog has an interest in minimally invasive surgery.
To those that don’t accept it, it is disruptive. To those that embrace it, realize that the future is minimally invasive surgery.

1. How can we disseminate the word to the public?
2. How can we better train surgeons?
3. Why is adoption slow?
4. How can we facilitate the operation? (Different techniques or instruments)
5.  Should these techniques be offered to all surgeons? (Recently graduated or experienced surgeons)

Our patients have benefited and there is a real benefit. Don’t let the skeptics and antagonists cloud our vision of the future. Remember, nothing comes easily, but those who change the current philosophies in cardiac surgery are those who contribute to its advancement.

Please respond directly through the blog or my personal email (jlamelasmd@aol.com)

I value EVERYONE’S response. They will be kept anonymous unless you chose otherwise.

I have gone away from using a diaphragm suture to facilitate exposure on my mini MVR’s.  I not only think that it has the potential to add complexity to the procedure, but can also be dangerous.  This suture can cause liver injury, sub-capsular hematoma of the liver, as well as bleeding from the abundant vascular network on the tendinous portion of the diaphragm.

I utilize 3 pericardial sutures on the inferior aspect of the pericardium.  I initiate my pericardiotomy approximately 2-3 cm above the phrenic nerve (BTW, I think that all of those surgeons out there that are skeptics or antagonists, overplay the incidence of phrenic nerve injury causing diaphragmatic palsy – I REALLY DON’T SEE IT, IN MORE THAN 250 MINI- MITRAL VALVE OPERATIONS THAT I PERFORM YEARLY!). I extend the pericardiotomy inferiorly towards the diaphragm. Once I am 4-5 cm from the diaphragm, I now continue the pericardiotomy towards the left of the patient. I will place one retraction suture at this angle, and one on either side of this as well.  If I need additional retraction, I will place more pericardial sutures on the pericardium over the diaphragm. These sutures are then pulled through my utility port (chest tube incision) and retracted with the aid of a hemostat.

I have enclosed pictures of my new approach to make this clear.

DSCN9755 DSCN9758 DSCN9761 DSCN9764 DSCN9773 DSCN9779 DSCN9808

Another reason to become comfortable with the mini – thoracotomy AVR’S is that it prepares you for a direct aortic TAVR.   This  DIRECT AORTIC access for a TAVR was performed via 3-4 cm mini-thoracotomy without rib dislocation. The 18 Fr. sheath was passed through a separate incision.  There is obviously a need for the sheath’s to be made shorter as well as the delivery device.

Becoming comfortable with this access will also prepare you for the sutureless valve implants.

20130903_11195520130903_111919