心脏外科胸骨旁小切口的解剖学研究

APPLIED ANATOMICAL STUDY ON MINIMALLY INVASIVE PARASTERNAL APPROACH FOR CARDIAC OPERATION

研究心脏外科胸骨小切口的显露范围及手术适应证。方法 :以 15具正常成人福尔马林浸泡尸体 ,建立不同平面的胸骨旁小切口模型。测量皮肤切口长度 ,经牵引后切口的内、外缘及上、下缘的最大长度。观察心脏外表及与心脏手术相关的部位的显露情况。观察经右房右侧壁切口及两房顶切口对心脏内部结构的显露情况。结果 :切除右侧第 2、第 3、第 4、第 2 ,3,第 3,4和第 2 ,3,4肋软骨的胸骨旁小切口的皮肤切口长度分别为 4.3± 0 .8,4.2± 0 .6 ,4.3± 0 .9,9.3± 0 .6 ,9.7± 0 .4和 12 .1± 0 .5cm。切除单个肋软骨可显露一定的部位 ,但范围较小。切除 2 ,3肋软骨对上腔静脉、右房、升主动脉及动脉瓣环有良好的显露 ,下腔静脉显露稍差。切除 3,4肋软骨对上腔静脉和升主动脉显露较差 ,主动脉瓣环、下腔静脉及右房显露较好 ,切除 2 ,3,4肋软骨对上腔静脉、右房、升主动脉、主动脉瓣环及下腔静脉均有较好的显露。结论 :胸骨旁小切口对病人胸前皮肤的美观影响小 ,损伤小。切除单个肋软骨可完成某些手术 ,但难度过大。切除 2、3肋软骨可完成房间隔、二尖瓣及主动脉瓣等处手术。切除 3,4肋软骨可完成房间隔、主动脉瓣、二尖瓣、三尖瓣等处的手术。切除2 ,3,4肋软骨的手术损伤稍大 ,虽操作更为方便 ,不值得提倡。

Objective: To study exposing effects and indications of various minimally invasive parasternal approaches (MIPA). Method: Various models of MIPA were devised with cadavers. Fifteen cadavers were studied in this group. The length of skin incision and four edge of the approach were measured after they have been retracted efficiently. The superficial and the operation-related structures of heart were observed, and the inner cardiac structures through a top incision on the roof of two atria or a lateral incision of right atrium were also observed. The length of the skin incisions of the approaches, which remove the second, the third, the forth, the second and the third, the third and forth, and all this three costal cartilages respectively, were 4.3±0.8,4.2±0.6, 4.3±0.9, 9.3±0.6, 9.7±0.4 and 12.1±0.5cm respectively. Removing of single costal cartilages could expose superior vena cava, right atria, ascending aorta and aortic valvular ring very well. Excisions of the third and the forth costal cartilages could expose inferior vena cava, right atria and aortic valvular ring efficiently, but superior vena cava and ascending aorta could not be exposed well. The approach that removing the second to the forth costal cartilages had a satisfactory exposing result. Conclusions: The MIPA is an approach with satisfactory cosmetic result and little trauma. The approaches of removing single costal cartilage could permit some cardiac operations, but they were not very easy. The operations on arterial septum, mitral valve, and aortic valve could be carried out through the approach of removing the second and the third costal cartilages. The operation on arterial septum, aortic valve, mitral valve, and tricuspid valve could be carried out through the approach of removing the third and the forth costal cartilages. The removing of the second to the forth costal cartilages have a satisfactory exposing result since it has relative more trauma, we do not recoment it. MIPA need cardiopulmonary bypass being established outside the surgical field. Defect on chest wall and thoracic complications after the operation are the main shortcomings of MIPA.