To improve the cosmetic results of minimally invasive cardiac surgery (MICS) for aortic valve replacement (AVR), we use a small right infraaxillary incision. A disadvantage of AVR via right infraaxillary thoracotomy is the distance between the thoracotomy incision and the ascending aorta. Therefore, we devised a technique to perform all manipulations using the fingertips without the aid of a knot pusher or long-shafted surgical instruments. This was achieved by particular placement of several retracted sutures to the right chest wall. We named placement of these sutures the "Stonehenge technique" (Figs. 1A and 1B)
Surgical TechniqueWe successfully performed AVR through a small right infraaxillary thoracotomy with our Stonehenge technique in 10 patients between July 2015 and August 2016. The patients were six women and four men with a mean age of 69.3 years (range: 56-81 years). Patients with severe aortic calcification, peripheral arterial stenosis, or poor left ventricular function were not included. The preoperative diagnosis was aortic stenosis in nine patients and aortic regurgitation in one patient.Using general anesthesia with differential lung ventilation, the patients were placed in a 70° left lateral position with a pillow beneath the left chest. The right upper arm was abducted anteriorly and the elbow flexed to 90°. The forearm of the patients was set in front of the face and held by a padded positioner bar. An 8-cm skin incision along the edge of the pectoralis major muscle was made at the right anterior axillary line (Fig. 1E). After dissecting a space beneath the pectoralis major muscle anteriorly, a thoracotomy incision was made through the third or fourth intercostal space. Cardiopulmonary bypass was established through the right femoral artery and vein or right atrium. Although the right atrial Ann
An 83-year-old woman was referred to our hospital under a diagnosis of acute aortic dissection. Contrast-enhanced computed tomography revealed no intimal flap in the mid-ascending aorta, and the intimal flap was found from the distal ascending aorta to the aortic arch. Operative findings showed that the intima of the mid-ascending aorta was circumferentially dissected and was inverted into the aortic arch. An emergent replacement of the ascending aorta was successfully performed; however, she died of a global intestinal ischemia on the fourth operative day.
A 71-year-old man was referred to our hospital under a diagnosis of abdominal aortic aneurysm (AAA). The past history of the patient included a sigmoid colectomy at 64 years old for an ischemic colitis. The maximum diameter of AAA was still 45 mm, and the inferior mesenteric artery (IMA) was aneurysmal and was 30 mm in diameter and thrombosed. The growth rate in the diameter of IMA aneurysm was 5 mm per year for the last 3 years. The patient successfully underwent endovascular aneurysm repair (EVAR), and the postoperative course was good. At 5 years after EVAR, computed tomography revealed a decrease in the diameter of both aneurysms.
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