**3. Minimally invasive surgical approaches**

#### **3.1 Mini-sternotomy**

As previously described [45], a 4-cm skin incision in the midline of the chest, with its superior margin at or approximately 1–2 cm below the nipple level, is employed (**Figure 4**). The sternum is longitudinally divided in its lower third, up to its body and retracted to expose the great vessels. When central cannulation is employed, the inferior vena cava cannula is passed through a separate 5-mm skin incision (which is later utilized for the chest drainage insertion).

The MS approach is usually used for surgical repair of simple CHD lesions as ASD, VSD, PAPVD, and p-AVSD in infants and children. Whenever the child is older than 5 years, the sternal bone is more rigid, and the simple MS may not allow a safe exposure of ascending aorta. For this reason, we usually utilize a T-incision (**Figure 5**) which consists in an extension of the midline sternal incision about 5–10 mm laterally (right and left) at the level of the third intercostal space, without reaching the external border of the sternal body and the mammary artery. This incision can be safely performed with an oscillatory saw. The application of a reverse T mini-sternotomy has also been applied to young adults for aortic valve repair or replacement, with or without associated ascending aorta vascular graft replacement. The right pleura is routinely opened, and the pericardium is incised laterally down to 1 cm from the right phrenic nerve to create a sort of pericardial window, to avoid possible cardiac tamponade in case of severe postoperative pericardial effusion.

**77**

**Figure 5.**

**Figure 6.**

**3.2 Right anterior mini-thoracotomy**

*Right anterior mini-thoracotomy approach.*

We use this technique mainly in female patients (some children but mostly teenagers and adults) for ostium secundum type ASD closure, as an alternative to an MS. In RAMT, a 4-cm semilunar incision in the sulcus of the right breast is entering the chest in the fourth intercostal space (**Figure 6**). In the prepuberty age, the incision is kept very low under the right nipple (at about 5–8 cm away from the nipple area [7, 16]), particularly in female patients, to avoid any possible future interference with breast development [45]. Subcutaneous fat and mammary gland are gently dissected from the fascia up to the fourth intercostal space, where the chest cavity is entered. The incision of the intercostal space is approximately 1 cm longer

*T-sternal incision mini-sternotomy (T-MT) is useful in older children to expose the great vessels adequately.*

*Minimally Invasive Approach in Surgery for Congenital Heart Disease*

*DOI: http://dx.doi.org/10.5772/intechopen.87136*

*Minimally Invasive Approach in Surgery for Congenital Heart Disease DOI: http://dx.doi.org/10.5772/intechopen.87136*

#### **Figure 5.**

*Cardiac Surgery Procedures*

before discharge.

**3.1 Mini-sternotomy**

inserted and the thorax closed in layers.

**3. Minimally invasive surgical approaches**

At the end of CPB, systemic heparinization is reverted, and the femoral cannulas are then removed. After chest closure, the SVC cannula is removed by the anesthesiologist. As a routine, the femoral vessel patency is checked by 2D-echo and Doppler,

After completion of the procedure, decannulation and hemostasis are performed. The opened pericardium is partially approximated with interrupted stitches; this is suggested to avoid rare but potentially lethal complications such as cardiac herniation [49]. A subperiosteal epidural catheter is placed in the posterior intercostal groove created extrapleurally for bupivacaine infusion. A thorax drain is

As previously described [45], a 4-cm skin incision in the midline of the chest, with its superior margin at or approximately 1–2 cm below the nipple level, is employed (**Figure 4**). The sternum is longitudinally divided in its lower third, up to its body and retracted to expose the great vessels. When central cannulation is employed, the inferior vena cava cannula is passed through a separate 5-mm skin

The MS approach is usually used for surgical repair of simple CHD lesions as ASD, VSD, PAPVD, and p-AVSD in infants and children. Whenever the child is older than 5 years, the sternal bone is more rigid, and the simple MS may not allow a safe exposure of ascending aorta. For this reason, we usually utilize a T-incision (**Figure 5**) which consists in an extension of the midline sternal incision about 5–10 mm laterally (right and left) at the level of the third intercostal space, without reaching the external border of the sternal body and the mammary artery. This incision can be safely performed with an oscillatory saw. The application of a reverse T mini-sternotomy has also been applied to young adults for aortic valve repair or replacement, with or without associated ascending aorta vascular graft replacement. The right pleura is routinely opened, and the pericardium is incised laterally down to 1 cm from the right phrenic nerve to create a sort of pericardial window, to avoid possible cardiac tamponade in case of severe postoperative pericardial effusion.

*Mini-sternotomy approach: The cutaneous incision (3–5 cm long) is done below the line between the two nipples.*

incision (which is later utilized for the chest drainage insertion).

**76**

**Figure 4.**

*T-sternal incision mini-sternotomy (T-MT) is useful in older children to expose the great vessels adequately.*

**Figure 6.** *Right anterior mini-thoracotomy approach.*

#### **3.2 Right anterior mini-thoracotomy**

We use this technique mainly in female patients (some children but mostly teenagers and adults) for ostium secundum type ASD closure, as an alternative to an MS. In RAMT, a 4-cm semilunar incision in the sulcus of the right breast is entering the chest in the fourth intercostal space (**Figure 6**). In the prepuberty age, the incision is kept very low under the right nipple (at about 5–8 cm away from the nipple area [7, 16]), particularly in female patients, to avoid any possible future interference with breast development [45]. Subcutaneous fat and mammary gland are gently dissected from the fascia up to the fourth intercostal space, where the chest cavity is entered. The incision of the intercostal space is approximately 1 cm longer

than the skin incision at each side. A video-assisted optical technology using a 5 mm 0° optical scope, which is inserted through a separate 5 mm incision, in the fourth intercostal space, may be helpful to implement the surgical vision [45], but with increased experience we have realized that this aid is rarely necessary for infants and children. In patients >15 kg who undergo peripheral cannulation, the SVC is usually occluded with a cross-clamp that is inserted through a separate lateral 5-mm incision that is later utilized for inserting chest drainage.
