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J Thorac Cardiovasc Surg 1998;115:258
© 1998 Mosby, Inc.

LETTERS TO THE EDITOR

Minimal-access or minimally invasive surgery?

To the Editor:

The concept that the trauma of access is often worse than that of the surgical correction per se has become widely accepted in various surgical disciplines. The latest extension of this principle has been into the treatment of heart disease, where "minimally invasive" cardiac surgery is currently undergoing rapid progress. ¹ The inherent complexities of cardiac operative procedures, coupled with the need for cardiopulmonary bypass and the various myocardial protection methods, initially presented significant technical challenges but then led to the evolution of different minimally invasive approaches. ^2,3

In the April issue of the Journal, two reports presented two distinct incisions for "minimally invasive" cardiac surgery. Benetti and his colleagues, ⁴ whose pioneering work has helped establish the MIDCAB technique, described a right minithoracotomy approach to aortic valve replacement. To achieve this, they used a specially adapted rib spreader that deforms the ribs in such a way that the aorta is accessed without the need for excision of costal cartilages. Moreno-Cabral, ⁵ on the other hand, described a lower mini-T sternotomy that can be used for both coronary bypass and valve replacement surgery. However, lifting the manubrium with a special retractor and spreading the sternum were necessary to achieve good exposure. Only preliminary clinical results were presented in the first report, and none in the second. Although we applaud both groups for their creativity, we would like to express our concerns regarding the conclusions of both reports.

Experience to date in minimally invasive cardiac surgery suggests that small incisions are likely to be associated with less morbidity than median sternotomy, but this remains to be scientifically substantiated. ^1,2 Many of us, however, believe that lessened morbidity is unlikely to remain true when "specially designed" rib spreaders or "manubrium lifters" and sternal retractors are used to achieve exposure at the expense of buckling ribs and a substantial trauma to the chest wall. One should not disregard the fact that the main source of postoperative pain is spreading the ribs or sternum, and not the size of the skin incision. ^2,6

Bearing this in mind, one is obliged to enquire whether patients managed with either of these new approaches fared better than those undergoing conventional surgery. The article by Benetti's group ⁴ offers no data to suggest this, because the postoperative progress of their patients was no different from that which is expected of patients treated through a median sternotomy; furthermore, they do not demonstrate any other advantage of such an approach. Moreno-Cabral ⁵ does not present any clinical data whatsoever! Still, in the discussions of their reports, both authors propose less trauma and pain as advantages of these approaches. Clearly, such an overly ambitious leap of logic lacks firm foundations.

We propose that a more appropriate conclusion for the first article would be that "aortic valve replacement through a right minithoracotomy is feasible, although more clinical experience is required to clarify the benefits of such approach." As for the second report, we believe that all that can be concluded is that "it is not necessary to divide the sternum fully to perform many cardiac surgical operations."

Considerable clinical experience coupled with documented clinical benefits are fundamental before a small-sized incision is labelled as "minimally invasive."

Division of Cardiothoracic Surgery
Department of SurgeryThe Chinese University of Hong Kong, Hong Kong References

1. Izzat MB, Yim APC. Minimally invasive cardiac surgery: A fleeting fancy or a lasting prospect? [editorial]. Int J Cardiol 1997;59:223-5.[Medline]
   
2. Izzat MB, Yim APC. Minimally invasive intracardiac surgery. In: Mack M, Landreneau R, Cohen R, editors. Minimally invasive cardiac surgery. St. Louis: QMP. In press.
   
3. Izzat MB, Yim ACP. Minimally invasive direct atrial septal defect closure [letter]. Ann Thorac Surg 1997;63:1831-4.[Free Full Text]
   
4. Benetti FJ, Mariani MA, Rizzardi JL, Benetti I. Minimally invasive aortic valve replacement. J Thorac Cardiovasc Surg 1997;113:806-7.[Free Full Text]
   
5. Moreno-Cabral RJ. Mini-T sternotomy for cardiac operations [letter]. J Thorac Cardiovasc Surg 1997;113:810-1.[Free Full Text]
   
6. Yim APC. Minimizing chest wall trauma in video-assisted thoracic surgery. J Thorac Cardiovasc Surg 1995;109:1255-6.
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mohammad Bashar Izzat Anthony P. C. Yim Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Izzat, M. B. Articles by Yim, A. P. C. Search for Related Content PubMed Articles by Izzat, M. B. Articles by Yim, A. P. C.