What is Minimally Invasive Cardiac Surgery- keyhole heart surgery?
Dr Mohammed Rehan Sayeed
Vasanth nagar, Bengaluru Feb 9, 2017
Cardiac surgery has come a long way since the 1950’s when Rene Favolaro of the Cleveland Clinic Ohio my alma mater performed the first coronary artery bypass grafting surgery. We have gone from huge incision of a foot to small petite incisions of 3-4 inches.
Traditional open-heart surgery involves cutting the skin for a length of 8-10 inches and then cutting of the sternum or the chest bone into half to access the heart.
Keyhole heart surgeries came in the early nineties and were done sparingly by surgeons, as they demanded a lot of surgical expertise. With the advancements in technology and instrumentation it has now become a reality.
So what is keyhole heart surgery or minimally invasive cardiac surgery (MICS)?
These operations are done through small skin incisions of 5-7 cm in length without cutting the sternal bone. Through the god given space between our ribs known as intercostal spaces, we access the heart and perform the procedure either a bypass surgery or valve repair/replacement procedure.
The benefits of these procedures are
- Less pain
- Less bleeding
- Less infection or No infection
- Less time to recovery
What surgeries can be performed through these keyholes?
- Coronary artery bypass grafting surgery (CABG).
- Aortic valve repair/ replacement
- Mitral valve repair/ replacement
- Closure of atrial or ventricular septal defects (hole in the heart)
- PDA ligation
- Replacement of part of the aorta (hemi arch replacement)
How small is the keyhole? Is it really a keyhole?
The incision is all of 5-7cms in length. It is slightly larger than your door keyhole but the beauty of the incision is that it does not make us spread the bones apart thereby reducing the pain significantly.
The procedures at a glance
- Mini sternotomy CABG: this requires a small 6 cm incision in the middle of the chest bone and then a small portion of the chest bone may need to be cut to allow access to the heart. The importance of this approach is one can do quadruple or more bypass grafts effortlessly through this approach with utmost safety. It has a low incidence of wound infection and most patient leave the hospital in 4-5 days.
- MICAS: Minimally invasive coronary artery surgery is now a focus of most surgeons and is sold to the public at large as a cosmetically superior procedure. It is a good approach but has its limitations. It is best used to bypass all left sided arteries, as they are easily approachable from the side. The operation is done through a small 5 cm incision in the left chest just below the nipple with No cutting of the bones. It is important that we don’t open the incision wide as that results in a lot of postoperative pain for this reasons we use endoscopes to guide us. Patients are discharged in 3-4 days and can return to work easily in 10-14 days.
- Minimal access valve surgery: All the four valves in the heart can be accessed very easily through keyhole incisions and it is really not required to cut open the chest these days to do any valve related procedure. The mitral valve is approached through a small right anterior incision of 5 cms just below the nipple while the aortic valve is approached from the right 2nd intercostal space or through the center with a same size incision.
- Minimal access Pediatric cardiac surgery:
- The little kids got left out of this change in operative techniques until recently. Today one can close all Atrial septal defects easily through a total endoscopic approach which means a scar of 1cm. similarly one can also close some forms of VSD’s ( ventricular septal defects) through a 5 cm incision. A PDA can be clipped or ligated by a total endoscopic approach.