Ann Thorac Surg 2004;77:1105-1106
© 2004 The Society of Thoracic Surgeons
How to do it
Dorsal minithoracotomy for ductus arteriosus clip closure in premature neonates
Walter V. A. Vicente, MD, PhDa,b*,
Alfredo J. Rodrigues, MD, PhDa,
Paulo J. F. Ribeiro, MD, PhDb,
Paulo R. B. Évora, MD, PhDb,
Antonio C. Menardi, MDb,
Cesar A. Ferreira, MDa,
Lafaiete Alves, Jr, MDa,
Solange Bassetto, MDa
a Division of Thoracic and Cardiovascular Surgery, Ribeirão Preto Medical School of the University of São Paulo, São Paulo Brazil
b Centro Especializado do Coração e Pulmão, São Paulo, Brazil
Accepted for publication April 18, 2003.
* Address reprint requests to Dr Vicente, Departamento de Cirurgia, Hospital das Clinicas, Ribeirão Preto SP, Brazil, 14048-900
e-mail: wvvicent{at}fmrp.usp.br
 |
Abstract
|
|---|
We present a new surgical technique for patent ductus arteriosus (PDA) occlusion in premature neonates (PN). Through a dorsal minithoracotomy the PDA is dissected extrapleurally with q-tips and clipped. The short surgical time, avoidance of pleural drainage, and prevention of late breast deformity are the operation highlights.
|
Introduction
|
|---|
Although various operations have been used for PDA closure in PN [1, 2], we herein describe a new surgical approach that enhances exposure, reduces surgical trauma, and avoids late breast complications.
Fifty-two premature neonates (PN) who either remained ventilator dependent or in congestive heart failure after failed attempts to pharmacological closure of the PDA or presented contraindications to indomethacin use were operated on.
|
Technique
|
|---|
Under general anesthesia and endotracheal ventilation, the patient is prone positioned having the left hemithorax elevated 30° with a soft pad and the left arm alongside the head. A 2 cm incision is made between the tip of the scapula and the costovertebral bulge (Fig 1). With fine scissors, the subjacent avascular fascia or muscle is entered, the fourth intercostal space musculature transected, and the ribs forced apart (Figs 2, 3). One q-tip blunt extrapleural dissection (Fig 4) allows a rib spreader to be positioned (Fig 5). Bimanual q-tip dissection completes the extrapleural access. Exposure may be enhanced by manual ventilation and surgical retractors. Sometimes a vein overlapping the ductus needs attention or else a traction stitch helps to bring the PDA into view. The superior and inferior sides of the ductus aortic end are cleared up with scissors and one or two ligaclips are applied (Fig 6). The chest is closed with absorbable sutures and skin adhesive strips without pleural drainage. The whole operation takes usually less than 20 minutes.
Patient weight (grams) was 950 ± 201 (mean ± standard deviation). Surgical bleeding was minimal and the electrocautery was almost never employed. Hospital mortality was 3.8% (enterocolites and sepsis—1 patient each). There were four superficial wound infections. Parietal pleura lacerations were common but the visceral pleura always remained intact. Improper low placement of the thoracotomy occurred in 3 patients. Surgical exposure was improved by entering another higher intercostal space through the same skin incision.
|
Comment
|
|---|
The proximity between the dorsal chest wall and the posterior mediastinum, as well as the thoracic cage pliability, both explain the satisfactory exposure provided by the dorsal minithoracotomy. This incision shall avoid breast deformity, a feared late complication of some thoracic incisions, especially when done before puberty [3, 4]. Correct left arm positioning is essential to preventing caudal displacement of the scapula and inadvertent low placement of the skin incision. Notwithstanding previous concern [2] blunt extrapleural q-tip dissection proved easy, causing minimal surgical trauma, bleeding, and no visceral pleura laceration. Tube thoracostomy was safely avoided with all its possible advantages [2]. Taking into account that as the tubular shape of the PDA flattens out during clipping, the final width of the occluded vessel results bigger than its initial diameter. For this reason, one must be careful to clear up enough space around the ductus in order to position the clip forceps tips past it to ensure complete PDA occlusion and prevent bleeding from its back wall. Body weight and morbidity were similar to other series [1, 2, 5]. Considering videothoracoscopy present limitations [6], our technique represents a new and very attractive surgical option for this age group.
|
Acknowledgments
|
|---|
The authors wish to thank the FAEPA and Waldemar B. Pessoa Foundations.
|
References
|
|---|
- Kron I.L., Mentzer R.M., Rheuban K.S., Nolan S.P. A simple, rapid technique for operative closure of patent ductus arteriosus in the premature infant. Ann Thorac Surg 1984;37:422.[Abstract]
- Miles R.H., DeLeon S.Y., Muraskas J., et al. Safety of patent ductus arteriosus closure in premature infants without tube thoracostomy. Ann Thorac Surg 1995;59:668-670.[Abstract/Free Full Text]
- Somerville J. The Denolin Lecture: The woman with congenital heart disease. Eur Heart J 1998;19:1766-1775.[Free Full Text]
- Shelton J.E., Walburg J.R., Schneider E. Functional scoliosis as a long term complication of surgical ligation for patent ductus arteriosus in premature infant. J Pediatr Surg 1986;48A:855-857.
- Trus T., Winthrop A.L., Pipe S., Shah J., Langer J.C., Lau G.Y.P. Optimal management of patent ductus arteriosus in the neonate weighing less than 800 g. J Pediatr Surg 1993;28:1137-1139.[Medline]
- Le Bret E., Folliguet T.A., Laborde F. Videothoracoscopic surgical interruption of patent ductus arteriosus. Ann Thorac Surg 1997;64:1492-1494.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
C. R. Zamfir, M. Vernet, M. F. de la Vega, and E. Sapin
Patent Ductus Arteriosus Ligation: The LigaSure System May Be Unreliable
Ann. Thorac. Surg.,
June 1, 2007;
83(6):
2228 - 2230.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
B. Srinivasan, S. K. Thingnam, D. Das, and H. Singh
Approach to Patent Ductus Arteriosus
Ann. Thorac. Surg.,
August 1, 2006;
82(2):
769 - 769.
[Full Text]
[PDF]
|
|
|
|
|
|
|
V. L. Vida and A. R. Castaneda
Reply
Ann. Thorac. Surg.,
November 1, 2005;
80(5):
1976 - 1977.
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. V.A. Vicente
Patent Ductus Arteriosus in Neonates and New Approaches: Reply
Ann. Thorac. Surg.,
May 1, 2005;
79(5):
1828 - 1828.
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. Villa, E. Mazzera, D. Galetta, and R. M. Di Donato
Patent Ductus Arteriosus in Neonates and New Approaches
Ann. Thorac. Surg.,
May 1, 2005;
79(5):
1827 - 1828.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Leon-Wyss, V. L. Vida, O. Veras, I. Vides, G. Gaitan, M. O'Connell, and A. R. Castaneda
Modified Extrapleural Ligation of Patent Ductus Arteriosus: A Convenient Surgical Approach in a Developing Country
Ann. Thorac. Surg.,
February 1, 2005;
79(2):
632 - 635.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
