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The Aortic Valve
Published in Theo Kofidis, Minimally Invasive Cardiac Surgery, 2021
A small pericardiotomy is then performed to allow direct finger palpation of the level of the aortic valve annulus, which localizes the aortic valve plane in relation to the lower rib. This step is crucial for subsequent optimal visualization. In this regard, the ideal exposure consists of the creation of an operative field that is quadrangular and has the aortic annular plane at its most caudal border and the distal ascending aorta at its cephalad border. This is called “the box principle”. Two scenarios are then possible after direct finger inspection. First, the valvular plane is at the level of or less than 1 cm from the inferior rib. So, the caudal border of the box field is appropriate. The operative field should expand cephalad, and the upper costochondral joint should be dislocated. Second, the valvular plane is significantly lower than the inferior rib. The lower rib is dislocated to extend the box field caudally. We use electrocautery to luxate the rib at the costochondral joint. Once the rib is dislocated, a rib spreader is inserted. The small pericardial hole is extended proximally and distally, anterior to the ascending aorta and root. At this stage, single-lung ventilation with an increased PEEP on the left lung may improve visualization as it shifts the mediastinum towards the right side. Many, up to ten, pericardial stay sutures are applied at the skin edges and the pericardium to adjust the box field (Figure 7.1.4).
Esophageal atresia: Open and thoracoscopic approaches
Published in Mark Davenport, James D. Geiger, Nigel J. Hall, Steven S. Rothenberg, Operative Pediatric Surgery, 2020
Shaun M. Kunisaki, Steven S. Rothenberg
Upon exposure of the pleura, separation of the pleura from the chest wall is best carried out by the gentle dissection with a peanut or cotton-tip applicator (Figure 9.6). Once the retropleural space has been developed, a small rib spreader can then be inserted and the ribs gently separated. Further posterior dissection of the pleura is achieved by using moist gauze or cotton-tip applicators.
Abdominal and right thoracic esophagectomy
Published in Larry R. Kaiser, Sarah K. Thompson, Glyn G. Jamieson, Operative Thoracic Surgery, 2017
S. Michael Griffin, Shajahan Wahed
The patient is secured in a left lateral decubitus position with the right arm rotated forward across an arm support. A posterolateral incision following the line of the ribs is made, skirting below the tip of the scapula, aimed toward the nipple, and terminating at the anterior axillary line. Diathermy and a bipolar electrosurgical tissue-sealing device are used to dissect through the tissues and divide the latissimus dorsi and serratus anterior muscles. The rib spaces are counted after insertion of the hand anterior to the scapula and pushed toward the apex. The 4th intercostal space should be used to allow for an anastomosis toward the apex of the thoracic cavity and permit a supra-azygos dissection if required. For middle-third squamous lesions, the 3rd rib space may be needed. Too low an incision makes this part of the operation difficult. The intercostal muscles are dissected off the top of the rib for the identified rib space with diathermy. A small incision is made to breach the pleura, ensuring the underlying lung is not damaged. At this stage, the anesthetist should be asked to deflate the right lung. The remainder of the pleura in the rib space is opened while a retractor is used to protect the underlying lung. One centimeter of the neck of the rib is excised to allow improved exposure and retraction while reducing the risk of uncontrolled rib fractures. The intercostal nerve is stripped along the rib, ligated, and excised. It is the authors’ experience that this reduces the incidence of postthoracotomy wound pain. The rib space is gradually opened using a rib spreader. A retraction device such as the Omni-Tract® or a Finochietto is used to gain exposure.
Less invasive aortic valve replacement using the trifecta bioprosthesis
Published in Scandinavian Cardiovascular Journal, 2022
Alfonso Agnino, Ascanio Graniero, Piersilvio Gerometta, Laura Giroletti, Giovanni Albano, Claudio Roscitano, Amedeo Anselmi
Interrupted, U-shaped, noneverting pledgetted sutures were employed for valve implantation. For the use of the Trifecta GT device, careful intra- and supra-annular sizing must be performed, in order to prevent upper stent deformation by narrow sinotubular junction anatomies. Facilitated suture gliding through the sewing ring allows early separation from the valve holder, and the parachuting of the valve can be completed with the aid of surgical forceps. Care must be paid to manipulate only the suture ring and avoid touching the leaflets (Video 1). This maneuver facilitates parachuting in narrow spaces. Knot tying was performed either manually or using a knot pusher in conditions of unfeasible or difficult manual knotting. For RAMT cases, a soft tissue retractor and a rib spreader were used; video assistance was employed to facilitate visualization of the aortic annulus, native valve excision, suture placement and tying.
Trans-thoracic versus retropleural approach for symptomatic thoracic disc herniations: comparative analysis of 94 consecutive cases
Published in British Journal of Neurosurgery, 2021
Christian Soda, Franco Faccioli, Nicolò Marchesini, Umberto M. Ricci, Marco Brollo, Luciano Annicchiarico, Cristiano Benato, Ivan Tomasi, Giampietro P. Pinna, Marco Teli
In TTA, a wide incision along the rib overlying the affected disc space was made; the rib was then resected 10–15 cm laterally to the tip of the transverse process. The parietal pleura was incised, the wound retracted using a Finochietto rib spreader and the lung collapsed and packed. Care was taken to preserve the intercostal nerve and vessels. To confirm the correct level a needle was inserted into the target disc space under fluoroscopy and the level counted in a cranio-caudal or caudo-cranial sequence. A wedge-trench osteotomy allowed access to the spinal canal above and below the area of cord compression. The osteotomy was limited to one quadrant of both adjacent vertebrae to reduce the risk of subsequent instability. Partial or complete drilling of the caudal pedicle was occasionally necessary. The posterior annulus and posterior longitudinal ligament were dissected off the dura under microscopic vision and the TDH removed to obtain a central decompression, up to the level of the contralateral pedicle.
Transthoracic Device Closure, Transcatheter Device Closure, and Surgical Repair via Right Submammary Thoracotomy for Restrictive Ventricular Septal Defect, a Respective Comparative Study
Published in Journal of Investigative Surgery, 2021
Qin Chen, Wei-Xiong Wu, Jiang-Shan Huang, Liang-Wan Chen, Guan-Hua Fang
This procedure has also been widely reported in previous studies.10 During the procedure, the undeveloped breasts and the pectoral muscles should be protected carefully. Right submammary thoracotomy (incision approximately 4–5 cm long) was performed as the approach. Then, the fourth intercostal space was opened to expose a better operative field using a small rib spreader. At approximately 2 cm anterior to the phrenic nerve, the pericardium was cut and suspended to expose the right atrium, superior and inferior vena cavae, and ascending aorta. Routine cardiopulmonary bypass was established, and a pericardial patch was used to repair the VSD. During the procedure, injury to the phrenic nerves and internal thoracic arteries should be avoided.