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The future of treating heart disease is now.
 
Limited-Access Heart Surgery
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Thousands of heart surgeries are performed every day in the United States. In fact, in 2009 alone, surgeons performed a total of 416,000 coronary artery bypass procedures.

Many years ago, most doctors thought that heart surgery would be impossible. Surgeons during World War II had learned how to repair some injuries to the heart, but major repairs were still a challenge, because surgeons had to work on a beating, moving heart. All surgeons knew that stopping the heart for more than a few minutes would lead to brain damage.

Two major advances in medicine made heart surgery possible:

  • The heart-lung machine, which is a device that adds oxygen to the blood and pumps it through the body, just like the lungs and heart usually do. With the heart-lung machine performing these jobs during surgery, the heart can be stopped, and surgeons can do their repairs.
  • Heart protection techniques, which allow the heart to be stopped for several hours, if needed. These techniques allow surgeons to make more extensive repairs of the heart. Before these techniques, surgeons could not perform procedures that took more than 30 to 40 minutes, because the risk of damaging the heart muscle was too high.

Now surgeons are looking into newer, minimally invasive heart surgery techniques.

What is minimally invasive heart surgery?

In minimally invasive heart surgery, surgeons take steps to decrease trauma to the body and speed up recovery, often by using smaller incisions during the surgery. You may have heard the words "limited access," "keyhole," or "port access" to describe these minimally invasive operations. We will use the term "limited access" when talking about these procedures.

Surgeons perform limited-access operations through a small incision, often using special surgical instruments designed just for this kind of surgery. The incision is usually about 2 to 4 inches long and is made between the ribs, on the side of the chest. With traditional open heart surgery, the incision is usually 6 to 8 inches long and is made down the middle of the chest. Also, with limited-access operations, surgeons usually do not need to saw the breastbone open to gain access to the heart.

Some of the benefits of limited-access surgery may include

  • A smaller incision
  • A smaller scar
  • Decreased chance of infection
  • Less bleeding during surgery
  • Less pain after surgery
  • A shorter hospital stay after surgery (usually 3 to 5 days after limited-access surgery, instead of 5 days or longer after traditional heart surgery)
  • A shorter recovery time (around 2 to 4 weeks, instead of the 6 to 8 weeks it takes to recover from traditional heart surgery) 

What are the types of limited-access heart surgery?

Most Surgeons can perform a number of procedures using limited access.

  • Minimally invasive direct coronary artery bypass (MIDCAB). Surgeons are able to perform coronary artery bypass surgery through only a small, 2- to 3-inch incision between the ribs. This is called minimally invasive direct coronary artery bypass, or MIDCAB. The MIDCAB technique is most often used when there are only 1 or 2 bypasses needed, and the arteries needing bypasses are located on the front of the heart. MIDCAB is not the best technique to use when arteries at the back of the heart need bypassing, because surgeons cannot gain good access to the back of the heart through the smaller incision.
  • Off-pump coronary artery bypass (OPCAB). Sometimes, coronary artery bypass surgery, usually MIDCAB, may be done without stopping the heart. This is called off-pump coronary artery bypass (OPCAB) or beating heart surgery. During off-pump or beating heart surgery, the heart-lung machine is not used. Instead, surgeons use special equipment to hold parts of the beating heart still while they are constructing the bypass grafts. Meanwhile, the rest of the heart keeps pumping blood to the body.
  • Valve repair and replacement. With limited-access techniques for valve repair or replacement, the breastbone does not need to be split open to gain access to the heart. Instead, surgeons can replace the aortic valve through a small incision between the ribs on the side of the chest or through a 3-inch incision made in the middle of the chest. The mitral valve can be repaired or replaced through a 3-inch incision between the ribs, on the side of the chest.
  • Lead placement. When patients need biventricular pacemakers for cardiac resynchronization therapy, the pacemaker leads can usually be placed using limited-access techniques.

Who can have limited-access heart surgery?

Surgeons look at a number of factors when deciding if patients are good candidates for limited-access surgery, including

  • The patient's weight and build.
  • The patient's age.
  • The presence of other illnesses, such as lung disease or hardened arteries.
  • The type of surgery being performed.

Surprisingly, in many patients, it may actually be safer to use traditional heart surgery techniques, where the breastbone is split open.

What is videoscopic surgery?

In certain patients, surgeons may perform coronary artery bypass surgery or valve operations using a long thin telescope, or endoscope, attached to a video camera, to see inside the chest. This is another form of limited-access surgery called videoscopic surgery.

With videoscopic heart surgery, surgeons make several half-inch incisions or "ports" in the chest, between the ribs. In most cases, surgeons do not even need to spread the ribs to gain access to the heart through the ports. The endoscope with the video camera is then placed through one of the ports, and long, thin surgical instruments specially designed for the procedure are placed through the other ports. Surgeons can then perform the procedure through the ports, using the video camera to see. The video camera provides a well-lit, magnified image of the area where surgeons are operating and allows them to clearly see the ends of their instruments.

During videoscopic surgery, patients usually need to be attached to a heart-lung machine. In traditional open heart surgery, patients would be connected to the heart-lung machine after surgeons open the chest. But, for videoscopic surgery, patients are connected to the machine in a different way. Instead, special tubes are threaded through the arteries and veins in the groin and up into the heart, so that the chest does not have to be split open.

What is robotic-assisted heart surgery?

In yet another kind of limited-access surgery, the procedure is performed with the help of a surgical robot. Essentially, the surgical robot allows surgeons to perform videoscopic surgery with even greater precision.

In robotic-assisted surgery, surgeons make several small incisions in the chest wall, between the ribs, like they would if they were performing videoscopic surgery. But, instead of using conventional surgical instruments held in their hands, surgeons use specialized instruments attached to the surgical robot. Surgeons sit at a console and control the robot through their hand movements. The robotic instruments are still under full control of surgeons, but the robot allows them to make finer movements than they could if they were actually holding the instruments in their hands.

Surgeons can perform the following types of heart surgeries using a surgical robot:

As with other kinds of limited-access surgery, robotic-assisted surgery can mean shorter hospital stays and recovery times for patients. But, not all patients are candidates for robotic-assisted surgery. Again, it will be up to your surgeon to decide if this type of surgery is the right treatment option for you. 

See also on this site:

See on other sites:

American Heart Association
www.heart.org/HEARTORG/Conditions/HeartAttack/
PreventionTreatmentofHeartAttack/Cardiac-Procedures-and-Surgeries_UCM_303939_Article.jsp
 
Cardiac Procedures and Surgeries

www.medmovie.com/mmdatabase/mediaplayer.aspx?Message=VG9waWNpZD01Nzc7Q2xpZW50SUQ9NjU7Vm
VybmFjdWxhcklEPTE%3D-NU4mO0obQE4%3D&SrchVisible=True&SrchID=577
  
Minimally Invasive Heart Surgery Illustration  

MedlinePlus
www.nlm.nih.gov/medlineplus/ency/article/007012.htm
Heart Bypass Surgery – Minimally Invasive 


Updated December 2013
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Texas Heart Institute Heart Information Center
Through this community outreach program, staff members of the Texas Heart Institute (THI) provide educational information related to the prevention, diagnosis, and treatment of cardiovascular disease. It is not the intention of THI to provide specific medical advice, but rather to provide users with information to better understand their health and their diagnosed disorders. Specific medical advice will not be provided and THI urges you to visit a qualified physician for diagnosis and for answers to your questions.
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