Cardiac surgery is now more than a century old. The first successful surgery of the heart, performed without any complications, was by Dr. Ludwig Rehn of Frankfurt, Germany, who repaired a stab wound to the right ventricle on September 7, 1896. Invention of heart- lung machine in 1953 opened all new horizons in cardiac surgery.
Standard heart surgery typically requires exposure of the heart and its vessels through median sternotomy (dividing the breastbone), considered one of the most invasive and traumatic aspects of open-chest surgery. Pain due to rib fractures, atalectasis, more ICU and hospital stay are key disadvantages of this big incision. Considering all these, multiple alternative access incisions have been described and used for various procedures in cardiac surgeries and published as Minimally Invasive Cardiac Surgery (MICS).
Minimally Invasive Heart Surgery (also called keyhole surgery) is performed through small incisions, using specialized surgical instruments. The incision used for minimally invasive heart surgery is about 2 to 3 inches instead of the 8 to 10 inches incision required for traditional surgery. The spectrum of MICS includes all types of valve surgeries, ASD Closure, coronary artery bypass grafting and hybrid procedures. The approach to the heart is through minimsternotomy or small thoracotomy, using THOREXPO retractor arc, blade guide, manubrium hook, coupling rider system, OR-Table adapting clamp.
MICS ASD closure is one of the most common procedure performed through small incisions. ASD can be closed through small Ant. Thoracotomy, subxiphoid incision or small partial lower sternotomy.
Valve surgeries, including valve repairs and valve replacements, are the most common type of minimally invasive surgery, accounting for 40 percent of all minimally invasive cardiac surgeries performed at our center.
Minimally invasive direct coronary artery bypass graft (MIDCABG) surgery is an option for some patients who require a left internal mammary artery bypass graft to the left anterior descending artery.
Hybrid procedures are combination of surgical and catheter-based intervention to the heart. Hybrid coronary artery revascularization is a combination of surgical and catheter-based intervention to the diseased coronary arteries.
The benefits of minimally invasive surgery techniques are due to small incisions and scars. There is less incidence of infection, bleeding and blood transfusions. Less invasive procedure and less pain make hospital stay shorter than routine cardiac surgeries.
Faster recovery leads to early resumption of day to day activities. The average recovery time after minimally invasive surgery is 1 to 4 weeks, while the average recovery time after traditional heart surgery is 6 to 8 weeks. These incisions are better cosmetically and also known as bikini scar.
Certainly, MICS requires definite learning curve. The duration and techniques of anesthesia and surgery can be prolonged due to technical difficulty, and the risk of unsatisfactory anastomosis or incomplete revascularization can also be increased. The cardiopulmonary bypass circuit utilized for MICS requires a more complicated system including negative pressure venous drainage.
The detection of accidental trouble during surgery, which is related to the extracorporeal circulation or the MICS procedure itself, can be delayed due to the limited surgical view. MICS procedures carry additional risks related to the more complicated cardiopulmonary bypass system and small surgical wound.
We must be deliberate in determining the indications for MICS and obtain complete informed consent from patients when we perform MICS, including informing them of the additional risks related to the MICS procedure itself and the possibility of conversion to standard open-heart surgery.
MICS is truly subject of preference for both; surgeon and patient. Presence of multiple pathology and gross peripheral vascular disease make this procedure impossible. Occasionally, small thoracotomy exposure is difficult in grossly obese patients.
Minimally invasive cardiac surgery continues to evolve and expand with growths in technology and surgeon experience. Now that a significant amount of data has emerged on the safety and efficacy of MICS across a range of surgical operations, there is evidence to support the widespread adaptation of such techniques.
In the future, there will likely be a greater request for MICS approaches by patients seeking cardiac surgical options with reduced surgical trauma that allow for a faster return to normal activities and improved quality of life. In addition, MICS itself will continue to evolve in the future through growing use of percutaneous technology, hybrid operating rooms and ongoing collaborations with interventional cardiologists.