右腋下小切口与胸骨正中切口治疗儿童先天性心脏病对比研究
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摘要
目前，采用胸骨正中切口，在体外循环下矫治先天性心脏病是安全、有效的外科治疗径路。随着近年来微创心脏外科技术的发展，许多经小切口入路越来越多地用于治疗先天性心脏病。其中，右腋下小切口是常用的手术入路之一。但是，这种小切口与常规胸骨正中切口相比，在临床上是否真正有更多的优点，尚缺乏这方面的报道。本项研究就是通过应用右腋下小切口治疗儿童先天性心脏病，与常规胸骨正中切口相比较，以探讨、评价两者的临床效果。
材料和方法：40例儿童先天性心脏病(房间隔缺损或室间隔缺损)病人，随机分为两组：右腋下小切口组(n_1=20)和胸骨正中切口组(n_2=20)。两组在年龄、体重、血红蛋白、
一
心胸比等临床资料无显著差异。所有病人术前均经心脏彩超证
实诊断。
胸骨正中切口组手术过程按常规手术步骤进行。右腋下小
切口组手术皮肤切曰长约 6——10cm，经右腋下开胸手术。两组
均在体外循环下，心肌保护采用经主动脉根部顺行微流量灌注
．
温血心肌停搏液。
0
术中记录手术时间、主动脉阻断时间、转流时间、术后记
录并发症、呼吸机辅助时间、术后监护时间、术后24h引流
量、术后输血例数、术后住院天数、切口愈合情况等临床资
料，并经统计学处理。术后1个月复查，行心脏彩超以观察有
无残余分流，术后随访3个月。
结果：全部病人术野暴露清晰，手术顺利，无手术死亡。
右腋下小切口组手术时间长于胸骨正中切口组
（P叱刀引。两组转流时间、主动脉阻断时间、术后监护时
间、呼吸机辅助时间无显著性差异（P＞O．05卜胸骨正中切口
组术后24小时引流量明显多于右腋下切口组（P划刀1）。胸
骨正中切口组术后输血例数多于右腋下小切曰组，有统计学意”
义沪＜0刀5卜 胸骨正中切口组术后住院天数亦多于右腋下小切
口组O功刀5卜 术后1个月右腋下小切口组病人反映切日疼痛
2
— —
例数多于胸骨正中切日组，但统计学上两组无显著差异
（P＞刀5卜术后1个月复查心脏彩超，均无残余分流。
结论：本研究结果提示，采用右腋下小切日矫治儿童先天
性心脏畸形，有三个忧点：①术后引流量明显减少，减少输
血；②术后住院大数缩短；③切口位于腋下，有美容效果，特
别对于年轻女性，这种切日可安全、有效地替代胸骨正中切日
】
纠治一些简单的先天性心脏畸形。
Objective: Surgical repair of congenital heart defects is both efficacious and safe using conventional median sternotomy and cardiopulmonary bypass, with the development of minimally invasive cardie surgical procedures in resent years, many minimal incisions have been used to perform operoations on patients with congenital heart defects. Among them, right subaxillary minithoracotomy is one of the most commonly used appoaches. But whether this small incision really has additional advantages over the conventional median sternotomy has not been
- (2002) i:^JkifeJC _ U
defined. This study was designed to evaluate the clinical effects of right subaxillary minithoracotomy in the repair of congenital heart defects in children with conventional median sternotomy.
Methods: We selected 40 patients with artrial septal defects (ASD)or ventricular septal defects (VSD). They were randomized into two group: right subaxillary minithoracotomy group
and conventional median sternotomy group. There were no significant differences with respect to age, sex,type of septal defects, weight, hemoglobin, heart ?chest ratio between the two group. The diagnoses were made in all patients using Doppler echocardiography.
In the median sternotomy group, the procedure were performed in the conventional manner. In the right subaxillary minithoracotomy group, the skin incision was 6 to 10cm. In both group, cardiopulmonary and micro-dose warm blood cardioplegia perfusion was used.
Morbidity ,duration of procedure (skin to skin), aotic cross-clamp time, bypass time, postoperative chest tube drainge for 24 hours,time of ventilation, length of intensive care unit and length of hospital stay were recorded. The condition of incisional pain
v (2002)
after discharge was also evaluated. Echocardiography was used to assess the effect of procedures 1 month after operation in all patients. Follow-up was at least 3 months postoperating .
Result: There was no operative mortality.The duraiton of operation procedure in the right subaxillary minithoracotomy group was longer than that in the median sternotomy group(p<0.05),but there were no significant differences between the two groups with respect to the bypass time, aortic cross-clamping time, ventilation duration, and intensive care unit stay.The drainge for 24 hours in the right subaxillary minithoracotomy was less than in the median sternotomy group (p<0.01), and the mumber of patient requiring blood transfusion was less than in the median thoracotomy group . There was a shorter hospital stay in the right subaxillary minithoracotomy group than in the median sternotomy group(/'<0.05). Although the number of patients complaining about incisional pain 1 month after operation in the subaxillary minithoractomy group was more than the median thoracotomy group ,this did not reach significant difference compared with the median sternotomy group(/;>>0.05).
(2002)
Conclusion: Compared with median sternotomy, three advantages were found in the right subaxillary thoracotomy group:First, less postoperative chest tube drainge occurred. Second, there was a shorter stay time in the hospital. Third, the procedure provides a better cosmetic effect,especially in young women.The subaxillary minithoracotomy is as safe and effective as median sternotomy in the repair of simple congential heart defects in children.
材料和方法：40例儿童先天性心脏病(房间隔缺损或室间隔缺损)病人，随机分为两组：右腋下小切口组(n_1=20)和胸骨正中切口组(n_2=20)。两组在年龄、体重、血红蛋白、
一
心胸比等临床资料无显著差异。所有病人术前均经心脏彩超证
实诊断。
胸骨正中切口组手术过程按常规手术步骤进行。右腋下小
切口组手术皮肤切曰长约 6——10cm，经右腋下开胸手术。两组
均在体外循环下，心肌保护采用经主动脉根部顺行微流量灌注
．
温血心肌停搏液。
0
术中记录手术时间、主动脉阻断时间、转流时间、术后记
录并发症、呼吸机辅助时间、术后监护时间、术后24h引流
量、术后输血例数、术后住院天数、切口愈合情况等临床资
料，并经统计学处理。术后1个月复查，行心脏彩超以观察有
无残余分流，术后随访3个月。
结果：全部病人术野暴露清晰，手术顺利，无手术死亡。
右腋下小切口组手术时间长于胸骨正中切口组
（P叱刀引。两组转流时间、主动脉阻断时间、术后监护时
间、呼吸机辅助时间无显著性差异（P＞O．05卜胸骨正中切口
组术后24小时引流量明显多于右腋下切口组（P划刀1）。胸
骨正中切口组术后输血例数多于右腋下小切曰组，有统计学意”
义沪＜0刀5卜 胸骨正中切口组术后住院天数亦多于右腋下小切
口组O功刀5卜 术后1个月右腋下小切口组病人反映切日疼痛
2
— —
例数多于胸骨正中切日组，但统计学上两组无显著差异
（P＞刀5卜术后1个月复查心脏彩超，均无残余分流。
结论：本研究结果提示，采用右腋下小切日矫治儿童先天
性心脏畸形，有三个忧点：①术后引流量明显减少，减少输
血；②术后住院大数缩短；③切口位于腋下，有美容效果，特
别对于年轻女性，这种切日可安全、有效地替代胸骨正中切日
】
纠治一些简单的先天性心脏畸形。
Objective: Surgical repair of congenital heart defects is both efficacious and safe using conventional median sternotomy and cardiopulmonary bypass, with the development of minimally invasive cardie surgical procedures in resent years, many minimal incisions have been used to perform operoations on patients with congenital heart defects. Among them, right subaxillary minithoracotomy is one of the most commonly used appoaches. But whether this small incision really has additional advantages over the conventional median sternotomy has not been
- (2002) i:^JkifeJC _ U
defined. This study was designed to evaluate the clinical effects of right subaxillary minithoracotomy in the repair of congenital heart defects in children with conventional median sternotomy.
Methods: We selected 40 patients with artrial septal defects (ASD)or ventricular septal defects (VSD). They were randomized into two group: right subaxillary minithoracotomy group
and conventional median sternotomy group. There were no significant differences with respect to age, sex,type of septal defects, weight, hemoglobin, heart ?chest ratio between the two group. The diagnoses were made in all patients using Doppler echocardiography.
In the median sternotomy group, the procedure were performed in the conventional manner. In the right subaxillary minithoracotomy group, the skin incision was 6 to 10cm. In both group, cardiopulmonary and micro-dose warm blood cardioplegia perfusion was used.
Morbidity ,duration of procedure (skin to skin), aotic cross-clamp time, bypass time, postoperative chest tube drainge for 24 hours,time of ventilation, length of intensive care unit and length of hospital stay were recorded. The condition of incisional pain
v (2002)
after discharge was also evaluated. Echocardiography was used to assess the effect of procedures 1 month after operation in all patients. Follow-up was at least 3 months postoperating .
Result: There was no operative mortality.The duraiton of operation procedure in the right subaxillary minithoracotomy group was longer than that in the median sternotomy group(p<0.05),but there were no significant differences between the two groups with respect to the bypass time, aortic cross-clamping time, ventilation duration, and intensive care unit stay.The drainge for 24 hours in the right subaxillary minithoracotomy was less than in the median sternotomy group (p<0.01), and the mumber of patient requiring blood transfusion was less than in the median thoracotomy group . There was a shorter hospital stay in the right subaxillary minithoracotomy group than in the median sternotomy group(/'<0.05). Although the number of patients complaining about incisional pain 1 month after operation in the subaxillary minithoractomy group was more than the median thoracotomy group ,this did not reach significant difference compared with the median sternotomy group(/;>>0.05).
(2002)
Conclusion: Compared with median sternotomy, three advantages were found in the right subaxillary thoracotomy group:First, less postoperative chest tube drainge occurred. Second, there was a shorter stay time in the hospital. Third, the procedure provides a better cosmetic effect,especially in young women.The subaxillary minithoracotomy is as safe and effective as median sternotomy in the repair of simple congential heart defects in children.
引文
1． Kirklin JW, Barratt-Boyes BG. Arial septal defect and partial anamalous pulmonary venous connection. In: Kirklin JW, Barrtatt-Boyes BG, eds. Cardiac Surgery. New York: Wiley, 1986,463-497．
2． Rosengart Tk, Stark JF. Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg, 1993, 55:1138-1140．
3． Bedard P , Keon WJ,Brais MP, Gold Stein W. Submammary skin incision as a cosmetic approach to median sternotomy. Ann Thorac Surg, 1986,41:339-341．
4． Cooly DA, Minimally invasive valve surgery versus the conventional approach. Ann Thorac Surg. 1998, 66:1101-1105．
5． 汪曾炜，刘维永，张宝仁主编．心血管外科卷．北京；人民军医出版社,1995, 348-349, 389-394．
6． Liewis FJ, Taufic M. Closure of atrial septal defects with the aid of hypothermia: Experimental accomplishment and the report of one successful case. Surgery, 1953, 33:52-59．
7． Gross RE , Watkins E Jr, Pomerane A A, et al. Method for Surgical closure of interauricular sepeal defects. Surg Gynecol Obstet, 1953,96:1-23．
8． Eugene A, Grossi, MD, Alfred T. Gulliford,MD, et al. Survey of 77 major infectious complications of median sternotomy:a review of 7,4949 consecutive operative procedures. Ann Thorac Surg, 1985,40(3) : 218-221．
9． Laks H, Hammond GL. A cosmetically acceptable incision for the median sternotomy. J Thorac Cardiovasc Surg, 1980, 79:146-149．
10． Wilson WR JR, Ilbw MN, Deleon SY, et al. Partial median sternotomy for repair of heart defects: a cometic approach. Ann Thorac Surg, 1992, 54(5) : 892-893．
11． Guilielmos V, Knaut M, Wagner FW ,et al. Minimally invasive surgical technique for the treatment of multivessel coronary artery disease. Ann Thorac Surg, 1998, 65(5) : 1331-1334．
12． Kirklin JW, Barrat-Boyes BG. Right anterolateral thoracotomy for cardioplumary bypass. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac Surgery. 1st ed. New York: Churchill Livingstone, 1988:29-82．
13． Prager PI, Pooley RW. Moggio RA, Somberg ED, MR, et al. Simplified method for reoperation on the mitral valve. Ann Thorac Surg 1989,48: 835-837．
14． Tribble CG, Killinger WA, Harman PK, Grosby IK, Nolan SP, Kron IL. Anterolateral thoracotomy as an alternative to repeat median sternotomy for replacement of the mirtral valve. Ann Thorac Surg 1989, 43: 380-382．
15． Dietl CA, Torres AR, Favaloro RG. Right submammary thoracotomy in female patients with artrial septal defect and anomalous pulmonary venous connections. J Thorac Cardiovasc Surg. 1992, 104:723-727．
16． Lancaster LL, Mavroudis C, Rees AH, et al. Surgical approach to atrial septal defect in the female: right thoracotomy versus sternotomy. Ann Surg, 1990, 56:218-221．
17． Cherup LL, Siewers RD. Futrell JW. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg. 1986, 41: 492-497．
18． Daebritz S, Sachweh J, Walter M, Messmer BJ. Closure of atrial septal defects via limited right anterolateral thoracotomy as a
minmal invasive approach in female patienes. Eur J Cardiothorac Surg, 1999, 15:18-22．
19． Black MD, Freedom RM. Minimally invasive respair of artrial Septal defects. Ann Thorac Surg, 1998, 65(3) : 765-767．
20． Massetti M, Babratasi G, Rossi A, et al. Operation for artrial septal defect through a right anterolateral thorcotomy: current outcome. Ann Thorac Surg, 1996, 62:1100-1103．
21． Furnary AP, Magovern JA, Simpson KA, et al. Prolonged open sternotomy and delayed sternal closure after cardiac operations. Ann Thorac Surg, 1992, 54(2) :233-239．
22． Tatebe Shoh, Eguchi Shoji, Miyamura Haruo. Et al. Limited vertical skin incision for median sternotomy. Ann Thorac Surg, 1992,54:787-788．
23． 李守军，吴清玉，吕锋，等．胸骨下端小切口行先天性心脏病纠治术116例．中国循环杂志, 2000, 15 (4) : 206-207．
24． Doty DB, Dirusso GB, Doty JR. Full spectrum cardiac surgery through a minimal incision: mini-sternotomy (lower half technique. Ann Thorac Surg, 1998, 65: 573-577．
25． Christian Hagl, Ulrich Stock, Axel Haverich, et al. Evaluation of different minimally invasive technique in pediatric cardiac
26.Dothenberg SS, Pokony WJ. Experiences with a total muscle-sparing approach thoracotomy in neonates, infants and children. J Pediatr Surg 1992, 27:1157-1159.
27.Rodeny DL, Peter FT, Robert JK, et al. Acute and chronic morbidity differences between muscle sparing and standard sternotomy. 76th annual meeting of AATS, 1996, 118.
28．刘迎龙，张宏家，孙寒松，等．右胸外侧切口小儿先天性心脏畸形矫治术 793 例体会．中国循环杂志，2000，15(4)：201—203．
29．马捷，李家成，李新华，等．右腋下直切口在心内直视手术中的应用．中华胸心血管外科杂志，2001，(3)：171-172．
30．王东进，吴清玉，杨秀滨，等．风湿性心脏病右腋下小切口二尖瓣置换术 37 例．中华胸心血管外科杂志，2000，16(5)：298—299．
31.Liu YL, Zhang HJ, Sun HS, et al. Correction of Cardiac defects through a right thoracotomy in children, J Thorac Cardiovasc Surg, 1998, 116: 359-361.
32．贾清仁，姚建民，成杞润，等．胸部小切口心脏不停跳心内直视手术．中华外科杂志，1998，36：358-359，
33．刘建林，隋东虎，郑建杰，等．微创心脏不停跳修补先天性心间隔缺损 20 例．中华胸心血管外科杂志,2000，16(4)：235
34．辛永祥，王建东，杨志雄，等．微创技术在心脏手术中的应用 13 例报告．武警医学，2001，11(1)：21—22．
35．贾清仁，姚建民，卢宁，等．微创伤腋下切口心内直视手术．中华胸心血管外科杂志，1999，15(1)：36．
36．贾清仁，姚建民，成杞润，等．右腋下小切口在先天性心脏病手术中的应用．中国胸心血管外科临床杂志，1998，5(1)：25-26．
2． Rosengart Tk, Stark JF. Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg, 1993, 55:1138-1140．
3． Bedard P , Keon WJ,Brais MP, Gold Stein W. Submammary skin incision as a cosmetic approach to median sternotomy. Ann Thorac Surg, 1986,41:339-341．
4． Cooly DA, Minimally invasive valve surgery versus the conventional approach. Ann Thorac Surg. 1998, 66:1101-1105．
5． 汪曾炜，刘维永，张宝仁主编．心血管外科卷．北京；人民军医出版社,1995, 348-349, 389-394．
6． Liewis FJ, Taufic M. Closure of atrial septal defects with the aid of hypothermia: Experimental accomplishment and the report of one successful case. Surgery, 1953, 33:52-59．
7． Gross RE , Watkins E Jr, Pomerane A A, et al. Method for Surgical closure of interauricular sepeal defects. Surg Gynecol Obstet, 1953,96:1-23．
8． Eugene A, Grossi, MD, Alfred T. Gulliford,MD, et al. Survey of 77 major infectious complications of median sternotomy:a review of 7,4949 consecutive operative procedures. Ann Thorac Surg, 1985,40(3) : 218-221．
9． Laks H, Hammond GL. A cosmetically acceptable incision for the median sternotomy. J Thorac Cardiovasc Surg, 1980, 79:146-149．
10． Wilson WR JR, Ilbw MN, Deleon SY, et al. Partial median sternotomy for repair of heart defects: a cometic approach. Ann Thorac Surg, 1992, 54(5) : 892-893．
11． Guilielmos V, Knaut M, Wagner FW ,et al. Minimally invasive surgical technique for the treatment of multivessel coronary artery disease. Ann Thorac Surg, 1998, 65(5) : 1331-1334．
12． Kirklin JW, Barrat-Boyes BG. Right anterolateral thoracotomy for cardioplumary bypass. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac Surgery. 1st ed. New York: Churchill Livingstone, 1988:29-82．
13． Prager PI, Pooley RW. Moggio RA, Somberg ED, MR, et al. Simplified method for reoperation on the mitral valve. Ann Thorac Surg 1989,48: 835-837．
14． Tribble CG, Killinger WA, Harman PK, Grosby IK, Nolan SP, Kron IL. Anterolateral thoracotomy as an alternative to repeat median sternotomy for replacement of the mirtral valve. Ann Thorac Surg 1989, 43: 380-382．
15． Dietl CA, Torres AR, Favaloro RG. Right submammary thoracotomy in female patients with artrial septal defect and anomalous pulmonary venous connections. J Thorac Cardiovasc Surg. 1992, 104:723-727．
16． Lancaster LL, Mavroudis C, Rees AH, et al. Surgical approach to atrial septal defect in the female: right thoracotomy versus sternotomy. Ann Surg, 1990, 56:218-221．
17． Cherup LL, Siewers RD. Futrell JW. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg. 1986, 41: 492-497．
18． Daebritz S, Sachweh J, Walter M, Messmer BJ. Closure of atrial septal defects via limited right anterolateral thoracotomy as a
minmal invasive approach in female patienes. Eur J Cardiothorac Surg, 1999, 15:18-22．
19． Black MD, Freedom RM. Minimally invasive respair of artrial Septal defects. Ann Thorac Surg, 1998, 65(3) : 765-767．
20． Massetti M, Babratasi G, Rossi A, et al. Operation for artrial septal defect through a right anterolateral thorcotomy: current outcome. Ann Thorac Surg, 1996, 62:1100-1103．
21． Furnary AP, Magovern JA, Simpson KA, et al. Prolonged open sternotomy and delayed sternal closure after cardiac operations. Ann Thorac Surg, 1992, 54(2) :233-239．
22． Tatebe Shoh, Eguchi Shoji, Miyamura Haruo. Et al. Limited vertical skin incision for median sternotomy. Ann Thorac Surg, 1992,54:787-788．
23． 李守军，吴清玉，吕锋，等．胸骨下端小切口行先天性心脏病纠治术116例．中国循环杂志, 2000, 15 (4) : 206-207．
24． Doty DB, Dirusso GB, Doty JR. Full spectrum cardiac surgery through a minimal incision: mini-sternotomy (lower half technique. Ann Thorac Surg, 1998, 65: 573-577．
25． Christian Hagl, Ulrich Stock, Axel Haverich, et al. Evaluation of different minimally invasive technique in pediatric cardiac
26.Dothenberg SS, Pokony WJ. Experiences with a total muscle-sparing approach thoracotomy in neonates, infants and children. J Pediatr Surg 1992, 27:1157-1159.
27.Rodeny DL, Peter FT, Robert JK, et al. Acute and chronic morbidity differences between muscle sparing and standard sternotomy. 76th annual meeting of AATS, 1996, 118.
28．刘迎龙，张宏家，孙寒松，等．右胸外侧切口小儿先天性心脏畸形矫治术 793 例体会．中国循环杂志，2000，15(4)：201—203．
29．马捷，李家成，李新华，等．右腋下直切口在心内直视手术中的应用．中华胸心血管外科杂志，2001，(3)：171-172．
30．王东进，吴清玉，杨秀滨，等．风湿性心脏病右腋下小切口二尖瓣置换术 37 例．中华胸心血管外科杂志，2000，16(5)：298—299．
31.Liu YL, Zhang HJ, Sun HS, et al. Correction of Cardiac defects through a right thoracotomy in children, J Thorac Cardiovasc Surg, 1998, 116: 359-361.
32．贾清仁，姚建民，成杞润，等．胸部小切口心脏不停跳心内直视手术．中华外科杂志，1998，36：358-359，
33．刘建林，隋东虎，郑建杰，等．微创心脏不停跳修补先天性心间隔缺损 20 例．中华胸心血管外科杂志,2000，16(4)：235
34．辛永祥，王建东，杨志雄，等．微创技术在心脏手术中的应用 13 例报告．武警医学，2001，11(1)：21—22．
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