|Year : 2016 | Volume
| Issue : 2 | Page : 61-66
Submammary incision as right minithoracotomy approach with intercostal nerve exclusion and blockage technique: A comparative study in the young Indian female population undergoing mitral valve replacement
Sidartha Lukram, Mohit Sharma, Amit Sharan, Sunil Dixit, Anil Sharma
Department of Cardio-Vascular and Thoracic Surgery, Sawai Man Singh SMS Medical College, Jaipur, Rajasthan, India
|Date of Web Publication||6-Jun-2016|
Department of Cardio-Vascular and Thoracic Surgery, Sawai Man Singh (SMS) Medical College, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Objective: This study compares the quality of mitral valve (MV) replacement performed through a submammary right thoracotomy incision with nerve sparing opening and closure to the standard midline sternotomy procedure. Materials and Methods: Hundred young female patients underwent MV replacement with 50 patients in the thoracotomy group and the remaining 50 patients in the median sternotomy group between August 2013 and April 2014 with follow-up till August 2015. Demographics, procedures, operative techniques, and postoperative morbidity and mortality, along with follow-up, were recorded in both the patients and compared. Results: In our study, postoperative pain and postoperative drainage were significantly lower in the thoracotomy variant with 60% of the cases draining only 100-200 mL. Morbidity is quite less in the thoracotomy variant with 60% of the cases able to stand up without support postoperatively 12 h after extubation while the number is only 20% in the sternotomy variant and that too with sternal support. Most of the thoracotomy cases were discharged from the hospital within 1 week. On follow-up, there were only two cases, i.e., 4% of the total cases presenting with hypertrophied scar, which is significantly lower than 20% of the sternotomy cases where three cases developed into keloid while in the sternotomy cases, 10 (20%) cases reported with wound discharge and infection. Conclusions: This procedure provides the same quality of treatment through a less traumatic and better cosmetic incision, resulting in less hospital stay and a lower overall cost.
Keywords: Minimally invasive, minithoracotomy, mitral valve (MV) replacement, right minithoracotomy, sternotomy
|How to cite this article:|
Lukram S, Sharma M, Sharan A, Dixit S, Sharma A. Submammary incision as right minithoracotomy approach with intercostal nerve exclusion and blockage technique: A comparative study in the young Indian female population undergoing mitral valve replacement. Heart India 2016;4:61-6
|How to cite this URL:|
Lukram S, Sharma M, Sharan A, Dixit S, Sharma A. Submammary incision as right minithoracotomy approach with intercostal nerve exclusion and blockage technique: A comparative study in the young Indian female population undergoing mitral valve replacement. Heart India [serial online] 2016 [cited 2020 Jul 7];4:61-6. Available from: http://www.heartindia.net/text.asp?2016/4/2/61/183523
| Introduction|| |
Navia and Cosgrove  and Cohn et al.  performed the first minimally invasive valve operations (via the right parasternal and transsternal approaches). Remarkably, excellent exposure was achieved through smaller incisions, thereby making complex valve repair possible and safe. In 1996, Carpentier et al.  performed the first video-assisted mitral valve repair (MVR) through a minithoracotomy using ventricular fibrillation. Also, in 1998 Carpentier et al. performed the first completely robotic MVR using the Da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, California, USA). The most common minimally invasive approach to the aortic valve (AV) is the upper partial sternotomy, whereas with the mitral valve (MV), this includes a right minithoracotomy,  a robotically-assisted right thoracic approach  and a partial sternotomy.  An 8-cm anterolateral thoracotomy via the third intercostal space (ICS), direct aortic clamping, and cannulation have been described by Angouras and Michler.  In 2009, Wang et al.  in Nanjing, China presented a new approach for MV replacement through a right vertical infraaxillary thoracotomy with excellent results (0.5% mortality).
Our study compares the quality of the patient recovery during the postoperative period and the cosmetic acceptance in a young Indian female patient who is undergoing MV replacement by right minithoracotomy procedure as compared to the standard median sternotomy procedure. Although cardiac surgery is fast-evolving, in the Indian population a midline median sternotomy is still taboo and reflects an unsightly scar to the female patient, and if a hypertrophic scar or a keloid appears it becomes a big problem for the patient in marriage arrangements and to the spouse of the married lady. Despite taking all the necessary precautions, patients undergoing midline sternotomy usually have the following common complications, i.e., sternal wound dehiscence, sternal fracture, keloid, and hypertrophic scar.
A sternal wound once infected, becomes a challenge for the cardiac surgeon to treat it. It usually leaves a big scar and an awkward appearance. This dreaded complication is not acceptable for an unmarried woman cosmetically. The incidence of wound infections and septic complications is minimal with a thoracotomy than with a median sternotomy; this virtually eliminates mediastinitis, which is uncommon but possible after a partial sternotomy. , Again with sternotomy, the patient's recovery to his/her normal day-to-day activity becomes prolonged and a helper is needed for getting up from the bed and also for lying down in bed with the use of sternal binder. With the advent of minimally invasive approaches to cardiac surgery, it is now apparent that the standard cardiac valve operation can be performed through very small incisions in the right thorax in the submammary region and opening in the 4 th ICS. ,, Minimally invasive approaches appear to be associated with faster recovery, earlier discharge, and reduced use of rehabilitation facilities. ,, Our study emphasizes that the following benefits are common as compared to sternotomy. These are good cosmetic appearance, decrease in the chance of keloid and hypertrophic scar, easier management of wound infection, and early mobilization.
Despite the cosmetic benefits, thoracotomy incision is associated with less pain, discomfort, and postoperative analgesics.  Approximately one-half of the patients return to their routine work and full activity within 4 weeks after a right minithoracotomy.  Postoperative pain and quality of life were evaluated from 1996 to 1997 by the Leipzig group using different scoring systems.  Better stability of the bony thorax leads to earlier mobilization and return to daily activities. Yamada et al.  in 2003 compared early postoperative quality of life in minithoracotomy and conventional valve surgery but again the drawback was the postthoracotomy pain. To counteract the postthoracotomy pain we use three techniques combined with right minithoracotomy: Nerve sparing thoracotomy, intercostal nerve block, and nerve-sparing closure.
| Materials and methods|| |
During the period from August 2013 to April 2014, we selected 100 female patients who underwent MV replacement; out of these 100 cases, 50 were randomly allocated for right thoracotomy approach. This subset was compared to a subset of 50 patients which underwent MVR by median sternotomy. Comorbid conditions were ruled out. All patients were <40 years of age. Patients were selected after proper explanation. Pulmonary function tests were normal, i.e., forced expiratory volume (FEV)1 >80%, FEV1/FVC >0.70, diffusing capacity (DLCO) >80%. Lung pathologies were ruled out by clinical examination and chest x-ray. Two-dimensional (2D) echocardiogram (echo) was performed in all the patients with Wilkins's score. Follow-up was done till August 2015. We compared these following factors:
- Postoperative pain
- Postoperative mobility
- Discharge from hospital
- Hypertrophic scar and keloid scar on follow-up
- Wound infection.
We used the standard protocol of anesthesia in both the groups that is usually for a conventional MV replacement.
Positioning the patient
The patient is placed in a supine position and a sand sack is placed under the right scapulae to allow the patient's right chest to be elevated slightly (30-40°) according to the need of the surgeon for a better working field exposure. This is useful in patients with deep chest. The patient's right shoulder and arm should be slightly up and deviated from the body. The patient is draped so as to expose the anterior and right lateral chest wall and both the groin areas. An adhesive aseptic strip is then applied to the exposed areas, thus minimizing the possible risk of contamination. In our cases, we did not need femoral cannulation in any case.
A submammary incision is made in the right thorax [Figure 1]. A 7-8 cm curvilinear incision along the Langer's line in the submammary region is given over the right thoracic wall in the anterolateral space starting from the medial side of the sternum [Figure 1]. The breast and skin are dissected above the pectoralis major superiorly and the 4th ICS is exposed [Figure 1]. The pectoralis major muscle is cut and the 4th ICS, along with the rib, is exposed. The serratus anterior and the pectoralis minor can also be cut if needed. The 4 th and 5 th ribs are stripped subperiosteally and the 4 th ICS is opened just above the 5 th rib, taking care not to injure the intercostal vessels and nerves. The 4 th rib is also stripped periosteally, making an intercostal muscle flap. Once the opening is complete, thoracotomy rib retractor is used to spread open the thorax without the retractor pressing on the nerve. If the chest is deep and the opening is not enough, the 4 th rib can be electively transected. The described procedure is a modification of a technique proposed by Cerfolio et al. , who harvested the intercostal muscle flap at the beginning of surgery, retracted the flap outside the thoracotomy field using a soft Penrose drain, and at closure, drilled holes in the lower rib to avoid compressing the nerve. This approach is theoretically a more attractive concept as it avoids nerve entrapment both by the chest retractor during surgery and the intercostal sutures after closure. The right lung is decompressed and the pericardium is exposed 3-4 cm above the phrenic nerve. Multiple stay sutures are applied to the pericardium to expose the left atrium and the aorta. Maximum pericardium is preserved on the right side to help in de-airing while closure of the left atrium so blood can pool over the pericardium.
Cannulation and bypass
Aortic and venous cannulations in this group is the same as in standard sternotomy. We use long snares [Figure 2] so that the snares and artery forceps attached with snares do not come in the operating field and exposure is good. Aortic cannulation is the difficult part as the aorta is a little away. For aortic cannulation, we hold the epiaortic tissue by artery forcep for gentle traction and we hold the aortic cannula by another artery forcep for smooth insertion. After cannulation going on, bypass is the same as in standard protocol of MVR.
Opening of left atrium and mitral valve replacement
A dissection is performed in the Sondergaard's plane and the left atrium is opened, retractor is applied, and the MV is exposed, then the required MV replacement is performed as per standard procedures. In our cases, we are discussing only replacement and no repair was done in our series. Weaning off from bypass, de-airing and hemostasis are the same in our series as in standard MVR. Two drains are put in thoracic cavity, draining the apex and the base of the cavity. They are put laterally in the posterior axillary line in the 6 th ICS. After confirming hemostasis, the pericardium is closed with interrupted sutures to avoid tamponade.
Intercostal nerve blockage
Intercostal nerve blockage is given in the 3 rd ICS, 4 th ICS, and 5 th ICS near the nerve root, taking proper care not to injure any vessel and ganglion, i.e., one space above and below the thoracotomy incision.
Thoracotomy closure with intercostal nerve sparing technique
We reviewed the recent article by Bayram et al. on modified thoracotomy closure technique to reduce compression of the intercostal nerve and thereby reduce postthoracotomy pain.  In our cases, thoracotomy is closed with 1-0 Vicryl using the nerve sparing technique. The needle of the suture is passed along the upper border of the upper rib and lower border of the lower rib so that the neurovascular bundle is safe [Figure 3].
Hundred young female patients,<40 years of age without any comorbid condition were selected. The hepatic and renal parameters were within normal range. With adequate blood biochemistry, out of these 100 cases 50 cases were randomly selected for the right minithoracotomy approach and the remaining 50 cases were performed with the standard midline approach [Table 1].
|Table 1: Baseline demographic and clinical characteristics of the combined 100 patients|
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The mean of the values of the bypass data shows that all the cases had been completed without much complication without any significant deviation in any of the data. All the 100 cases did not have any intraoperative complication [Table 2] and [Table 3]. There was not much difference in the bypass time and the total operation timing in the miniright thoracotomy cases and the standard midline sternotomy cases [Table 3]. In the thoracotomy, much time was required in opening and cannulation due to difficult anatomy and meticulous preparation. On the other hand, in the midline sternotomy cases most of the time was required in proper hemostasis and closure of the sternum. But the time required to go on bypass is less in the sternotomy cases, making it more suitable for emergency and sick patients. The total operating time is a little bit higher for the thoracotomy cases [Table 3].
|Table 3: Duration of bypass time and total operating time required in patients undergoing thoracotomy and sternotomy|
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Postoperative pain was much less in the thoracotomy cases [Table 4], as nerve exclusion and block technique were used; 10 out of the 50 patients did not need analgesics within 12 h after surgery while in the sternotomy cases most of them were complaining about pain. The time spent in postoperative ventilation was not much significant in both the cases.
The postoperative drain was significantly lower in the thoracotomy variant with 60% of the cases draining only 100-200 mL while most of the sternotomy variants (60%) had drain between 200 mL and 400 mL, most probably due to bleeding from the sternal edges and marrow after wiring [Table 5]. Morbidity was quite less in the thoracotomy variant with 60% of the cases able to stand up without support postoperatively 12 h after extubation while it was only 20% in the sternotomy variant with sternal support/chest binder. Most of the thoracotomy cases (80%) were recovered and able to mobilize independently within 24 h of surgery while sternotomy variant cases were unable to do so without support. Most of the thoracotomy cases were discharged from the hospital within 1 week while the sternotomy cases required more than 1 week to go home [Table 6].
On follow-up, there were two cases (4%) of the total cases presenting with hypertrophied scar, which is significantly lower than the sternotomy variant where three (20%) cases developed into keloid. There was one case in thoracotomy variant where the wound got infected on follow-up after discharge. It was also complicated by rupture of a big branch of internal mammary artery, which was subsequently repaired by shifting to the operation theater while in the sternotomy cases, 10 (20%) cases reported with wound discharge and infection that more common in the obese cases with fat necrosis [Table 7] and [Table 8].
Postoperative rehabilitation was significantly better in the thoracotomy cases even in the complicated wound cases. Out of the 10 infected cases in the sternotomy variant, six developed sternal infection and exposure, along with infected wiring, and needed prolonged dressing more than 1 month for the fresh granulation to grow up till secondary suturing was possible while in the thoracotomy case, the patient was discharged in 10 days with proper healing. Extensive antibiotic coverage increases the cost in such complicated cases [Table 8] and [Table 9].
| Discussion|| |
Minimally invasive cardiac valve surgery represents a recent significant paradigm shift. Traditionalists were initially resistant to such techniques, claiming that smaller incisions lead to poor exposure and inferior outcomes. The rapid development and refinement of techniques over the past decade have led to the realization that a minimally invasive approach enables complex valve surgery to be performed with results, at the very least, equivalent to those of conventional (open) valve surgery performed in experienced centers. Several reports of minimal invasive valve operations have been published during the last decade. Until this past year, these operations have been performed through the standard complete median sternotomy and cardiopulmonary bypass with intrathoracic cannulation.
This described surgical technique via the right minithoracotomy gives an excellent MV exposure and working field with less invasiveness and better cosmetic results. Patients have less postoperative pain and shorter hospital stay. Certainly, trauma is considerably less with the minimal invasive incisions. Sternal infections are avoided and for the most part, there is less blood loss from the incision and the operative site. In addition, there are improved cosmetic results with this incision under the right breast fold. In a study of patients having a right thoracotomy, Casselman et al.  reported that approximately 99% of the patients thought that their scar was aesthetically pleasing, which agrees with our findings.
With the use of the nerve sparing technique of thoracotomy and closure, the pain in this procedure is considerably less than in median sternotomy. There are fewer requirements for pain medication both in the hospital and after surgery, and a faster return to normal activity. The disadvantage of femoral dissection has been ruled out in our cases. Our findings were in agreement to the four studies measuring postoperative pain, and all found a reduction of pain compared with a sternotomy.
MVR or MV replacement through the right minithoracotomy is still in its developmental stage. Surgeons have the possibility to select devices and instruments and surgical techniques for their own preferences and comfort. Our approach becomes more reproducible for all surgeons, being based on their conventional hand skills. In our department, we are currently performing all isolated MV cases in right minithoracotomy approach. Our experience with MV replacement through right minithoracotomy demonstrates that minimally invasive MV surgery is a feasible method that can be performed safely and effectively. Pleural adhesions in case of reoperation, chest profile, and unfavorable intrathoracic working plane that can cause poor visualization of the ascending aorta could be a reason for double lumen tube insertion. In our study, there was no redo case. We believe that the quality of the valve surgery has not been mitigated in any way as compared to the standard midline sternotomy procedure. The ischemia time and the bypass time are somewhat longer than the standard operation and do balance out a certain amount of cost reduction realized from the reduced length of stay but overall changes were down much less than the standard operation. This procedure provides the same quality of treatment through a less traumatic and better cosmetic incision, resulting in less hospital stay and a lower overall cost. It is estimated that posthospital care now exceeds tens of billions of rupees per year in India and the cost is still rising.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]