The clinical pathway for fast track recovery of school activities in children after minimally invasive cardiac surgery
Masamichi OnoNorihide FukushimaShigeaki OhtakeHajime IchikawaKoji KagisakiTohru MatsushitaHikaru Matsuda
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Abstract:
Minimally invasive cardiac surgery is now becoming standard in the correction of simple congenital cardiac malfbrmations. We introduced a clinical pathway for fast track recovery of school activities in children after minimally invasive cardiac surgery, and assessed the function of the pathway in children with atrial or ventricular septal defects, comparing minimally invasive surgery to repair through a conventional full sternotomy.We studied 15 children of school age who underwent repair of an atrial or ventricular septal defect through a lower midline sternotomy, and 10 children undergoing repair through a full sternotomy. The clinical pathway was for extubation to take place in the operating room, echocardiographic evaluation on the 5th postoperative day, and discharge home on the 7th postoperative day, with return to school within 2 weeks, and resumption of all gymnastic activity within 6 weeks of the minimally invasive surgery.In those having a lower midline sternotomy, postoperative hospital stay was 7.4 +/- 0.8 days, with return to school 8.0 +/- 2.4 days after discharge. They resumed gymnastics 41 +/- 11 days after the minimally invasive surgery. In those having a full sternotomy, in contrast, these parameters were 13.5 +/- 2.7, 23.1 +/- 8.4, and 95 +/- 43 days, respectively. Of the 15 children undergoing a minimally invasive approach, 12 (80%) fulfilled the criterions of our clinical pathway.We conclude that minimally invasive cardiac surgery can safely be performed in children. In addition to its cosmetic role, the technique has added value in promoting early return to normal school life, including gymnastics.Keywords:
Invasive surgery
Median sternotomy
Fast track
Objective: Cardiac surgery has been traditionally performed via a median sternotomy incision where a large exposure of the mediastinum assured most of the cardiac procedures. Recently, the concepts of less-invasive surgery, well affirmed in many surgical specialties, led cardiac surgeons to develop limited accesses in coronary, valves and congenital operations. Methods: Between January and May 1997, 30 patients were operated on with a less-invasive approach. A short (6–9 cm) median incision followed by a subcomplete sternotomy permitted a limited opening of the chest without compromising the surgical exposure; a conventional central CPB was instituted and valve surgery and most of intracardiac procedures were performed without modification of the standard technique. Results: No mortality was observed; morbidity was minimal. Cardiopulmonary bypass time and aortic cross-clamp time averaged 84±9 and 61±11 min, respectively. The majority of patients were extubated and discharged from the ICU early. Chest drainage lost on average 290±180 ml/m2. Conclusions: Despite our limited initial experience, this technique seems to provide several potential and practical advantages: there is less trauma and pain reported by patients; the small wound reduces the potential for wound infection and blood loss. Patients are extubated and discharged from the hospital earlier with lower overall costs.
Median sternotomy
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Minimally invasive surgery is an attractive choice for patients undergoing major cardiac procedures. This paper focuses on minimally invasive mitral valve repair and robotic surgery using the da Vinci Surgical System. Minimally invasive mitral valve repair is usually performed through a right minithoracotomy with direct vision. The techniques used in this procedure are similar to those in open surgery. The outcome of minimally invasive mitral valve repair is also equivalent to that of open surgery, with high levels of patient satisfaction. On the other hand, minimally invasive cardiac surgery using the da Vinci Surgical System has not been approved in Japan except for internal mammary artery harvesting. A Japanese clinical trial of da Vinci surgery for mitral valve repair and atrial septal defect closure has been completed and approval is awaited. Although da Vinci surgery is technically demanding, this less-invasive technique may provide another choice for patients in the near future.
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Invasive surgery
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Fast track
Vascular surgery
Cardiothoracic surgery
Regional anaesthesia
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Median sternotomy
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Background/IntroductionMany risk factors have been shown to be independently predictive of the success of fast-track for post cardiac surgery patients.While a safe fast-track protocol is important, patient selection is crucial too in determining the success of fast-tracking patients. Aims/ObjectivesWe aim to improve on our fast-track protocol by identifying risk factors affecting extubation time in our institution.
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We present a case of surgical implantation of biventricular epicardial pacing leads and a defibrillating patch via lower half mini sternotomy. Although median sternotomy is routinely used for this purpose, lower half mini sternotomy could provide the surgeon with the same surgical field exposure and a faster post operative recovery.
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