局限性低位部分胸骨劈开心内直视手术的解剖学基础与临床应用研究

Study on the Clinical Application and Applied Anatomy Basis of Limited Lower Sternotomy for Minimally Invasive Cardiac Operation

目的 :探索美观、损伤小的局限性低位部分胸骨劈开小切口开胸技术在心内直视手术中的解剖学基础和临床应用价值。方法 :应用局限性低位部分胸骨劈开小切口行心内直视手术 14例 ,观测皮肤切口、胸骨纵切口、显露主动脉、肺动脉、右心及左心范围。病种包括 :房间隔缺损 (ASD) 5例、室间隔缺损 (VSD) 4例、房缺合并室缺 (A +V) 2例、肺动脉狭窄 (PS) 1例、风湿性心脏病二尖瓣狭窄并关闭不全 2例。其中房缺 (ASD) 5例、室缺 (VSD) 3例、房缺合并室缺 (A +V) 1例、肺动脉狭窄 (PS) 1例均在浅低温心脏不停跳心内直视下完成手术 ,室缺 (VSD) 1例、房缺合并室缺 (A +V) 1例、风湿性心脏病二尖瓣置换术 2例则在低温心脏停跳下顺利完成手术。结果 :全组无手术死亡 ,均顺利地完成了手术治疗 ,术中及术后均无合并症发生 ,术后无明显疼痛。皮肤切口长度 9.5± 3.5cm ,胸骨纵切口长度 10 .8± 3.6cm ,皮肤切口 /胸骨长度系数为 0 .72± 0 .15 ,显露主动脉 2 .7± 0 .7cm ,显露肺动脉 1.3±0 .5cm。术中心脏停跳者心肌阻断 8～ 72min ,平均 2 3.6min ,体外循环时间 2 7～ 10 8min ,平均 4 8.5min。术后胸液引流量 6 0～ 35 0ml,平均 14 0± 5 0ml,术后住院 6～ 14d ,平均 8.5d。全组切口均甲级愈合 ,无胸骨畸形 。

Objective To search for the clinical feasibility and advantages and applied anatomy basis of limited lower sternotomy for minimally invasive cardiac operation. Methods From August 2003 to May 2004, 14 patients underwent limited lower sternotomy for cardiac operation. The age ranged from 3 to 42 years with a mean age of 16.3 years. A 8.5 cm (randed 6 to 13 cm) midline incision was made from the third rib to the base of xiphoed process. A transverse half sternotomy was made in the second intercostals space from the right border to the center of the sternum. Cardiopulmonary bypass was set up through the same access. Open heart surgery included repair of ventricular septal defect (VSD) in 4 patients, Repair of auricular septal defect (ASD) in 5 patients, Repair of VSD and ASD in 2 patients, Mitral valve replacement (MVR) in 2 patients and incision of pulmonary stenosis (PS) in 1 patient. 10 cases of patients treated with open heart surgery in the beating heart and 4 cases of patients underwent cardiac operation without beating during cardiopulmonary bypass. Results The operations were successfully performed with good exposure.There were not operative deaths. There was no intraoperative and post-operative complications, and the post-operative convalescence was much shortened. Aortic cross-clamp time and cardiopulmonary bypass time averaged 23.6 and 48.5 minutes, respectively. All patients could be discharged at an average of 8.5 days. The median blood loss was 140±50ml (range 60 to 350). Conclusion Limited lower sternotomy is a safe alternative method for minimally invasive cardiac operation which is cosmetically acceptable, less blood transfusion, reduce bleeding, reduce post-operative pain and short hospital stay. This surgical pattern can direct the development and practice of minimal invasive surgery.