右侧腋下小切口入路矫治法洛四联症的技术要点分析

The key surgical techniques for the complete correction of tetralogy of Fallot through the righ mini-lateral-thoracotomy

目的 总结右侧腋下小切口剖胸矫治法洛四联症（TOF）的技术要点.方法 回顾性分析1997年1月-2013年10月346例TOF患儿的临床资料.均采用右侧腋下小切口入路行根治术治疗,其中男159例,女187例;平均年龄（1.9±1.2）岁;平均体质量（9.7±2.4） kg.合并卵圆孔未闭43例、房间隔缺损22例、动脉导管未闭10例、永存左上腔静脉10例、主动脉瓣下隔膜7例、二尖瓣关闭不全1例.全组跨环补片205例,右室流出道补片141例.结果 全组手术死亡7例（2.02％）,术中体外循环（90±24） min,主动脉阻断（64±17） min,术后机械通气4～165 h,监护室停留（3.2±1.7）d,术后当日胸腔引流量（138 ±91） ml,平均带胸管（2.5±0.9）d.术后出现并发症36例（1.04％）：低心排血量综合征17例（死亡5例）,严重肺部感染2例（死亡1例）,灌注肺5例（死亡1例）,右肺损伤7例,膈神经损伤4例,室间隔缺损残余分流2例,乳糜胸2例.结论 右侧腋下小切口配合有效的牵引显露行TOF根治安全可靠.

Objective To summarize the key point of surgical techniques for the complete correction of pediatric tetralogy of Fallot （TOF） through right subaxillary minithoractomy.Methods Three hundred and forty-six TOF cases （159 males,187 females）,who underwent radical correction through right subaxillary minithoractomy from January 1997 to October 2013,were analyzed retrospectively.The mean age was （1.9 ± 1.2） years old and the mean body weight was （9.7 ± 2.4） kg,Associated cardiac lesions included patent foramen ovale （43 cases）,atrial septal defect （22 cases）,patent ductus arteriosus （10 cases）,persistent left superior vena cava （10 cases）,subaortic membrane （7 cases） and mitral valve insufficiency（1 cases）.Corrections with transannular patch were performed in 205 cases,right ventricular outflow tract patch in 141 cases.Results There were 7 early death.The mean time of CPB was （90 ± 24） min and the mean aorta clamping time was （64 ± 17） min,the postoperative average mechanical ventilation time was（4-165）h,the stay time in ICU was （3.2 ± 1.7） days.The volume of average postoperative drainage was （138 ± 91） ml,the average duration of chest tube was （2.5 ± 0.9） days.Postoperative complications were observed in 36 patients （1.04%）.Among them,low cardiac output syndrome in 17 cases （5 death cases）,severe pulmonary infection in 2 cases （1 death case）,perfusion lung in 5 cases（1 death case）,the right lung injury in 7 cases,phrenic nerve injury in 4 cases,the ventricular septal defect with residual shunt in 2 cases and chylothorax in 2 cases.Conclusions The right subaxillary minithoractomy with proper exposure is safe enough for the correction of TOF.