1. Minimally Invasive Cardiac Surgery in Children Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery

2. Minimally Invasive Cardiac Surgery in Children Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery

3. Minimally Invasive Cardiac Surgery  Minimally invasive approaches, including limited lateral thoracotomies, partial longitudinal or transverse sternotomies & video-assisted thoracoscopic techniques 1. Limit the postoperative pain 2. Limit the respiratory dysfunction 3. Allow for the prompt recovery 4. Reduce the cosmetic impact of scar

4. Minimally Invasive Cardiac Surgery  Advantages 1. Excellent cosmetic healing 2. Reduced postoperative pain 3. Quick functional recuperation 4. Short hospital stay & cost savings 5. Expediency, safety, minimal discomfort

5. Limited Median Sternotomy  Advantages 1. Not allow excessive spreading of the sternum avoiding potential disruption of costovertebral junction or paravertebral hemorrhage 2. Upper abdominal discomfort associated with opening the linear alba is avoided 3. Avoids costal cartilage damage or removal, internal mammary artery damage & transverse sternotomy that are difficult to close securely 4. Extension of the incision into normal full sternotomy is easily done.

6. I-type Median Sternotomy  Advantages & disadvantages 1. Advantages 1) Increased sternal stability due to chest wall continuity 2) Decreased dissection of upper & lower end of sternum 3) Decreased trauma of cartilage, fascia, and muscles 2. Disadvantages 1) Chances of sternal deformity 2) Chances of the ITA injury

7. Selection of I-Sternotomy  In ASD, ASD & Simple CHD 1. Neonate, infancy : 1~5 ICS 2. Young children :2~5 ICS 3. More than 3~4 years :2~4 ICS 4. Subpulmonary VSD :Inverted-T, 3~4 ICS

8. Selection of I-Sternotomy  In Complex CHD 1. Neonate 1~5 ICS, or full sternotomy 2. TOF, or other complex Infant: 1~5 ICS Children: 2~5 ICS 3. Complicated cardiac anomaly 1~5 ICS, or full sternotomy

9. Limited Median Sternotomy  Problems 1. Poor operative field 2. Excessive skin traction 3. Difficult to defibrillate & deair 4. Difficult to maneuver the distal aorta & distal pulmonary artery

10. Parasternal or Partial Sternotomies  Disadvantages 1. Damage or removal of the costal cartilage 2. Damage or potential stretching or division of the IMA 3. Safety of operation can be compromised. 4. Transverse sternotomy is more difficult to close securely

11. Pediatric Chest Wall Incisions  Morbidity 1. Scoliosis 2. Sternal wall deformities 3. Post-thoracotomy pain syndromes 4. Breast & pectoral muscle maldevelopment

12. Right Axillary Approach  Alternative to other chest incisions The right anterolateral thoracotomy has led to less optimal than expected results, mainly because of subsequent deformation of the thoracic cage (caused by rib deformation and atrophy of the severed pectoral muscles) and asymmetric development of the breasts when used in prepubescent girls Right axillary approach allows the safe correction and results in a cosmetically acceptable and almost invisible scar and the breasts will develop harmoniously in female patients because of efforts never to cross the anterior axillary line and therefore never to violate the borders of the mammary gland.

13. Axillary Thoracotomy Incision Skin incision used in conjunction with a groin incision

14. Submammary Incision  Problems 1. Sensory & sympathetic denervation 2. Hypesthesia of the anterior chest wall (38.8%) 3 Decreased sensation & erection of nipples (12.5%) 4. Risks of infection and ischemic or necrotic damage to the skin flaps 5. Clinical complications such as hematoma, seroma, hypertrophic scar or keloid formation, galactorrhea, mastodynia, & hypoesthesia

15. Right Thoracotomy Incision  Contraindications in CHD 1. Pulmonary stenosis 2. Severe pulmonary hypertension 3. Age less than 2 years 4. Patent ductus arteriosus & Lt SVC

16. Pediatric Thoracotomy  Late complications 1. Winged scapulas 2. Chest wall deformities 3. Breast disfigurement 4. Rib fusion with respiratory compromise

17. Iliac Vessel Cannulation  For minimally invasive surgery External iliac vessels (which are at this point extremely superficial) were dissected and looped. The iliac vein was clamped and opened with a sharp incision. A simple thoracic drain (16F for children 20 kg) was inserted and pushed toward the right atrium. The artery was clamped, opened transversally with a scalpel, and gently dilated with a small mosquito clamp. And at the end of CPB, the artery was repaired with interrupted resorbable stitches, and the vein was repaired with a running suture. The heart-lung machine was brought close to the groin on the right side of the patient to have the shortest possible lines to reduce the loss of pressure and energy. A vacuum (10–25 mm Hg) was set on the venous return to improve return and reduce the risk of air blockage.

18. Video-assisted Thoracic Surgery  Advantages in pediatric use 1. Decrease in pain 2. Improved shoulder strength 3. Improved early pulmonary function 4. Decreased incidence of scoliosis Overall in 22 - 33 % of thoracotomy Severe in 7.8 %