Minimally Invasive Heart Surgery

Minimally Invasive Cardiac Surgery, also known as Keyhole Surgery, is a technique used in heart surgery to minimize the size of the incision and change the surgical approach to hidden areas that are not visible when the patient is normally clothed. It differs from the traditional method of open-heart surgery, which requires a large incision of about 15-20 centimeters along the midline of the chest, often resulting in a large and visible scar.

 

Technological advancements, particularly in endoscopic imaging and surgical instruments, have greatly improved the ability to perform minimally invasive cardiac surgery, resulting in smaller incisions that are both effective and aesthetically pleasing. The incisions are located in concealed positions, such as the right side of the chest or around the breast, while maintaining the quality and standards of traditional surgery. As a result, minimally invasive surgery has gained popularity and is becoming a standard approach for treatment in the future.

 

Sizes of Minimally Invasive Cardiac Surgery Incisions are categorized into four levels based on the size of the incision and the proficiency of the surgeon and the surgical team:

Level 1: Incision size approximately 10-15 centimeters, performed using direct visualization.

Level 2: Incision size approximately 4-6 centimeters, performed using direct visualization or assisted by endoscopic imaging in certain segments of the procedure.

Level 3: Incision size approximately 1.5-4 centimeters, performed using endoscopic visualization or robotic assistance.

Level 4: Incision size smaller than 1.5 centimeters, performed using robotic assistance or endoscopic surgery.

 

1. Reduced risk of sternal wound infection.

2. Less blood loss during and after surgery.

3. Lower incidence of postoperative atrial fibrillation (irregular heart rhythm).

4. Reduced postoperative pain.

5. Shorter duration of mechanical ventilation, ICU stay, and hospital stay.

6. Smaller incisions result in greater patient satisfaction.

 

However, due to the need to operate through small incisions, surgeons require a longer learning curve and more extensive training compared to traditional open-heart surgery. The initial surgical time may also be longer than open surgery.

 

Minimally invasive cardiac surgery is suitable for various cardiac conditions, including:

-   Patient with Mitral Valve Repair or Replacement

-   Patient with Atrial Septal Defects (ASD)

-   Patient with Aortic Valve Stenosis or Regurgitation

-   Patient with Left Atrial Myxoma

-   Surgery for correcting atrial fibrillation (Maze procedure)

 

The surgical procedure and preparation for minimally invasive cardiac surgery are similar to other cardiac surgeries. Preoperative imaging tests, such as computed tomography (CT) scans, may be performed to assess the heart and major blood vessels for surgical planning.

 

During the operation, the patient is under general anesthesia, and in some cases, a double-lumen tube is used for assisted breathing. The surgical team utilizes high-frequency sound-reflection imaging (echocardiogram) to assess the heart and its functions before and after surgery. This helps in confirming the position of the tubing connecting the patient to the artificial heart-lung machine. The heart-lung machine and artificial lung are connected to the patient's body through blood vessels in the groin area.

 

Mitral valve repair/replacement, atrial septal defect (ASD) closure, or cardiac tumor removal surgeries are performed through small incisions in the right chest, typically in the 4th or 5th intercostal space, or small incisions around the nipple area. Tissue retractors are used to open the incision, avoiding the use of a rib spreader to reduce postoperative pain. The small incisions require the use of surgical cameras, particularly 3D cameras, to provide clear and multidimensional images, facilitating easier and faster surgeries.

 

Additionally, there may be small incisions, approximately 4 incisions, for blood drainage and small instruments to assist in the surgery. After the surgery, once the incisions have healed well, these incisions will fade and become less visible. The techniques used for repairing or replacing heart valves are similar to those used in traditional open-heart surgeries, with comparable success rates.

 

In the early postoperative period, patients receive care in the intensive care unit (ICU) for about 1-2 days, followed by a hospital stay of 3-5 days. Due to the small incisions and minimal bone cutting, patients experience less pain, allowing for faster recovery and an earlier return to normal activities.

 

The risks and severe complications associated with these surgical techniques are not significantly different from those of traditional open-heart surgeries. The incidence of severe complications is estimated to be around 1-4%. Other potential complications that may occur include lymphocele (collection of lymphatic fluid in the groin), unilateral pulmonary edema (swelling of the lung), and others.

 

After minimally invasive heart surgery, postoperative care at home is similar to traditional open-heart surgery. Patients can bathe, and the incisions can come into contact with water. Patients or caregivers should observe and monitor the incision for signs of infection. The sutures or staples used to close the incisions can be removed approximately 7-14 days after the surgery or as instructed by the attending physician. Gradual and progressive physical activity can be initiated according to the patient's tolerance. Follow-up appointments and blood tests are scheduled by the physician approximately 2-4 weeks after the surgery.