Minimally Invasive Cardiovascular and Thoracic Surgeries

What is minimally invasive surgery?

Minimally invasive surgery is performed through a small incision, often using specialized surgical instruments. The incision is about 3 to 4 inches instead of the 6- to 8-inch incision required for traditional surgery. Keyhole approaches or port-access techniques are also available for some types of surgery.

The benefits of minimally invasive surgery include:

• A smaller incision
• A smaller scar

Other possible benefits of minimally invasive surgery may include:

• Reduced risk of infection
• Less bleeding
• Less pain and trauma
• Decreased length of stay in hospital after the procedure: the average stay is 3 to 5 days after minimally invasive surgery, while the average stay after traditional heart surgery is 5 days
• Decreased recovery time: the average recovery time after minimally invasive surgery is 2 to 4 weeks, while the average recovery time after traditional heart surgery is 6 to 8 weeks

• Valve surgery
• Coronary artery bypass graft (CABG) surgery
• Epicardial lead placement: placement of leads for biventricular pacemakers (cardiac resynchronization therapy)
• Atrial fibrillation

Valve surgeries, including valve repairs and valve replacements, are the most common minimally invasive procedures. Minimally invasive valve surgeries account for 87 percent of the minimally invasive cardiac surgeries performed at The Cleveland Clinic. A small, 3- to 4-inch incision is made down the center of the sternum (breastbone), whereas the incision made during traditional valve surgery is about 6 to 8 inches long.

Traditional incision The incision is larger (about 6 - 8 inches), made down the sternum, through bone and muscle	Minimally invasive valve incision The small incision (about 3 - 4 inches) is made down the center of the breastbone	Alternative minimally invasive incision for some mitral valve surgeries	Minimally invasive CABG incision The small thoracotomy incision (about 2 - 3 inches) is made in between the ribs

Minimally invasive direct coronary artery bypass graft (MID CABG) surgery is an option for some patients who require a left internal mammary artery bypass graft to the left anterior descending artery. A small, 2-3 inch incision is made in the chest wall between the ribs, whereas the incision made during traditional CABG surgery is about 6 to 8 inches long and is made down the center of the sternum (breastbone).

Saphenous (leg) vein harvest may also be performed using small incisions.

Several techniques for minimally invasive bypass surgery are being explored at the Cleveland Clinic, including surgeries performed on a beating or nonbeating heart.

Off-pump or beating heart bypass surgery allows surgeons to perform surgery on the heart while it is still beating. A medication may be given to slow the heart during surgery, but the heart keeps beating during the procedure. This type of surgery may be an option for patients with single-vessel disease (such as disease of the left anterior descending artery or right coronary artery).

beating heart bypass surgery

Traditionally, CABG surgery is performed with the assistance of cardiopulmonary bypass (heart-lung machine). The heart-lung machine allows the heart’s beating to be stopped, so the surgeon can operate on a surface which is blood-free and still. The heart-lung machine maintains life despite the lack of a heartbeat, removing carbon dioxide from the blood and replacing it with oxygen before pumping it around the body.

During off-pump or beating heart surgery, the heart-lung machine is not used. The surgeon uses advanced operating equipment to stabilize (hold) portions of the heart and bypass the blocked artery in a highly controlled operative environment. Meanwhile, the rest of the heart keeps pumping and circulating blood to the body.

Keyhole Approaches

For some surgical procedures, an endoscopic or “keyhole” approach may be performed. This approach may also be referred to as port access surgery or video-assisted surgery.

The port access surgery technique allows surgeons to use one to four small (5- 10 mm) incisions or “ports” in the chest wall between the ribs. An endoscope or thoracoscope (thin video instrument that has a small camera at the tip) and surgical instruments are placed through the incisions. The scope transmits a picture of the internal organs on a video monitor so the surgeon can get a closer view of the surgical area while performing the procedure.

Types of surgeries that may be performed using the innovative port-access or “keyhole” approach include:

• CABG surgery
• Valve surgery
• Biventricular pacemaker lead placement on the surface of the left ventricle

Minimally invasive surgery for atrial fibrillation. The surgeon views the epicardial (outer) surface of the heart using an endoscope. Specialized instruments are used to create new pathways for the electrical impulses that trigger the heartbeat. Unlike traditional surgery for atrial fibrillation, there is no large chest wall incision, and the heart is not stopped during the procedure.

Some types of thoracic surgery. Video-assisted thoracoscopy (VATS), also called thoracoscopy or pleuroscopy, is a minimally invasive surgical technique that may be used during some types of thoracic surgeries, such as partial resection of the lung, lung biopsy, lobectomy, drainage of pleural effusions, or pericardial and mediastinal biopsies.