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Minimally Invasive Transthoracic Closure of Ventricular Septal Defect through Left Parasternal Approach: A Report of 15 Cases

目的总结左胸骨旁小切口微创封堵分流方向偏向流出道的室间隔缺损（VSD）的初步经验。 方法2014年2～8月广州医科大学附属第一医院对15例分流方向偏向流出道的VSD患者施行左胸骨旁小切口微创封堵手术，其中男7例，女8例；年龄10个月～19岁（4.5±4.6）岁；体重5.5～54.0（14.6±14.1）kg；其中干下型6例，嵴内型6例，膜周部型3例；缺损直径2.5～6.5（4.0±1.2）mm，距主动脉瓣环距离≤1 mm 9例，≤2 mm4例，>2 mm 2例；合并主动脉瓣右冠瓣轻度脱垂5例；采用左胸骨旁第2或第3肋间1.5～2.5 cm切口，在经食管超声心动图（TEE）监视下在右心室流出道表面选择适当的穿刺点，建立VSD输送轨道并置入封堵器，观察有无残余分流、主动脉瓣反流；术后3个月复查经胸超声心动图。 结果15例均成功封堵，无中转开胸，无残余分流和心律失常，新发主动脉瓣轻微反流2例，围手术期输血1例；手术时间30～120（58±28）min，术中出血量5～200（26±50）ml；术后住院时间3～13（4.3±2.6）d，无二次开胸止血、Ⅲ°房室传导阻滞、主动脉瓣反流加重、溶血、切口感染等并发症；术后3个月返院复查经胸超声心动图13例，无新发主动脉瓣反流和封堵器脱落；2例术中新发主动脉瓣反流加重，其中1例出现残余分流。 结论左胸骨旁小切口封堵分流方向偏向流出道VSD 手术安全、切口小、操作简单，近期效果尚满意；对合并主动脉瓣轻度脱垂VSD 需慎重施行外科微创封堵手术。

Application on The Approach of Transecting Anterior Cervical Muscle Group at Sternal End for Removal of Bilat-eral Huge Thyroid Neoplasm

Objective　To explore the advantage of transection the cervical muscles at sternal end and flip fixed in therapeutic bilateral huge thyroid surgery. Methods　The transection of the cervical muscles at sternal end and flip fixed in 53 cases was observation group， 44 cases of the neck white line incision thyroid surgery completed for the control group. The completion of the surgery by the same group of physicians. The operative time， operation field of exposing effect， amount of bleeding in operation， postoperative complications， and postoperative drainage volume were compared between two groups. Results　There was no statistically differences of sex， age， disease composition， and tumor size between two groups （P＞0.05）. Operative time， amount of bleeding， and postoperative drainage volume in observation group were shorter （less） than that in control group （P＜0.01）. The postoperative complication rate in observation group was lower than that in control group（P=0.04）. Surgical field exposure in observation group was better than that in control group （P＜0.01）. Conclusions　The huge bilateral thyroid surgery with the sternal end approach is feasible and simple. The operation field exposure is better than the white line neck incision， complications after operation is less. It is worthy of clinical application.

巨大外穿性畸胎瘤致胸骨、锁骨畸形一例

Bilateral Pectoralis Major Muscle Flaps for the Treatment of Sternal Dehiscence after Cardiac Surgery

Objective To investigate surgical strategies using bilateral pectoralis major muscle flaps for the treatment of sternal dehiscence after cardiac surgery. Methods From May 2005 to October 2010，21 patients with sternal dehiscence, sternal osteomyelitis and mediastinitis after cardiac surgery were admitted to Beijing An Zhen Hospital of　Capital Medical University. There were 13 male patients and 8 female patients with their age of 53-72 （64.5±7.8） years. There were 19 patients after coronary artery bypass grafting （CABG） and 2 patients after heart valve replacement. The non-viable　and necrotic bones were debrided and sternal wires partially or completely removed. The sternal origins of pectoralis major were released on both sides. The pectoralis major muscle flaps were tensionlessly sutured across medially over the sternal defect. Multiple suction drains were placed and removed in due time. The skin was intermittently closed. Results All the pectoralis major muscle flaps lived well after surgery，and all the patients were discharged in 2 weeks after surgery. Twenty patients were discharged with complete wound closure，and 1 patient had wound fistula and infection after removal of suction drains that was healed after another surgery to resect the wound fistula. During 6 month follow-up，sternal wound healed well in all the patients with normal thoracic appearance，and none of the patients had abnormal respiratory movement, infection recurrence or persistent infection. Conclusion Bilateral pectoralis major muscle flap technique is a positive and efficient surgical strategy for the treatment of refractory sternal dehiscence after cardiac surgery.

Application of Lower Sternal Incision with On-pump， Beating Heart Intracardiac Procedures in Mitral Valve Replacement

Abstract：　Objective　To explore the application of lower sternal incision with on-pump， beating heart intracardiac procedures in mitral valve replacement （MVR）. Methods We retrospectively analyzed clinical data of 42 patients （minimal incision group） with valvular heart diseases who underwent MVR via lower sternal incision under the beating heart condition in Xinqiao Hospital of the Third Military Medical University from January 2011 to December 2011. There were 16 male and 26 female patients with their average age of 42.3±12.7 years in the minimal incision group. We also randomly selected 42 patients with valvular heart diseases who underwent MVR via routine midline sternotomy during the same period in our department as the control group. There were 18 male and 24 female patients with their average age of 43.8±13.1 years in the control group. Operation time， cardiopulmonary bypass time， major complications， chest drainage　 in postoperative 24 hours， skin incision length and average postoperative hospital stay were observed and compared　 between the two groups. Results There was no major perioperative complication such as in-hospital death. There was no reexploration for postoperative bleeding， complete atrioventricular block， embolism or perivalvular leakage in the minimal incision group. There was no statistical difference in cardiopulmonary bypass time， operation time， or the incidence of　 reexploration for postoperative bleeding， wound infection and perivalvular leakage between the two groups（P＞0.05）. The skin incision length in the minimal incision group was shortened by 5.2 cm compared to that in the control group （7.9±1.4 cm vs. 13.1±3.3 cm， P=0.000）. Chest drainage in postoperative 24 hours in the minimal incision group was significantly less than that of the control group （183.6±40.2 ml vs. 273.4±59.9 ml， P=0.000）. Postoperative hospital stay in the minimal incision group was significantly shorter than that of the control group （8.1±1.3 d vs. 10.6±2.1 d， P=0.000）. Forty patients in the minimal incision group were followed up for 3-15 months and 2 patients were lost during follow-up. Four patients had postoperative wound pain， and the majority of patients didn’t have significant wound scar formation but a satisfactory quality of life. Thirty-eight patients in the control group were followed up for 3-15 months， 4 patients were lost during follow-up， and 17 patients had postoperative wound pain. Conclusion Lower sternal incision with beating heart can reduce the surgical injury， simplify the operation procedure and improve the therapeutic efficacy. It is a safe， effective and esthetic surgical approach for MVR.

Minimally Invasive Sternal Lowering Operation for the Correction of Pectus Carinatum

Objective To investigate surgical indications，techniques，safety and clinical outcomes of minimallyinvasive sternal lowering operation for the treatment of pectus carinatum （PC）. Methods Clinical data of 40 PC patientswho underwent minimal invasive sternal lowering operation in Xinhua Hospital，School of Medicine，Shanghai Jiao Tong University from July 2009 to August 2012 were retrospectively analyzed. There were 39 male patients and 1 female patientwith their average age of 14.5 （12-22）years. All the patients underwent their surgical correction for the first time，and their chest deformity were characterized by a significant protrusion of the sternum and ribs including 21 symmetric and 19 asymmetric protrusions. Preoperative evaluation included electrocardiogram，CT scan of the chest，echocardiogram and pulmonary function test. Preoperative mean Haller index was 1.91±0.23. Sixteen patients had mild restrictive ventilatory disorder. Allthe patients received minimally invasive sternal lowering operation with a curved Nuss steel bar. Aggravating activities wererestricted within 3 months postoperatively，and the steel bar was removed 2 years later. Results All the operations were completed successfully，and thoracic appearance was significantly improved after correction. All the patients and their relativeswere very satisfied with the corrective outcomes. The operation time was 65-115 （82.0±15.6）minutes and average intraop-erative blood loss was less than 10 ml. Postoperative hospital stay was 3-5 （3.5±0.8） days. Postoperative Haller index was2.39±0.17，which was significantly higher than preoperative Haller index （P＜0.01） . Postoperative complications included wound infection in 2 patients，pneumothorax in 1 patient （cured by closed thoracostomy），subcutaneous effusion in 3 patients，and persistent pain （longer than 14 days） in 2 patients. There was no other serious postoperative complication. All the 40 patients were followed up for 3-36 months after discharge. A steel bars was removed ahead of schedule because of wound infection in one patient. Other steel bars were in normal position in 39 patients and there was no displacement of the steel bars or the stabilizers. Eight patients received removal of the steel bars without PC recurrence. Conclusion Juveniles with PC who have good chest wall compliance are the best candidates for minimally invasive sternal lowering operation which is an easy，safe，reliable，minimally invasive and esthetic procedure with satisfactory corrective outcomes.

慢性缩窄性心包炎手术径路的选择

目的 探讨慢性缩窄性心包炎的外科最佳手术径路选择，总结临床经验。方法 回顾性分析 1970年9月至 2009年 9月中国医科大学附属第一医院收治 538例慢性缩窄性心包炎患者的临床资料，按手术径路不同将其分为两组，胸骨正中切口组： 324例，男 204例，女 120例，年龄（ 44.5±10.0）岁；左胸前外侧切口组： 214例，男 130例，女 84例，年龄（ 46.5±6.8）岁。比较两组患者术后心功能和并发症发生情况。结果 胸骨正中切口组死亡 1例，术后 2 d死于顽固性室性心律失常。左胸前外侧切口组死亡 9例，其中死于多器官功能衰竭 1例，呼吸衰竭 2例，低心排血量综合征 2例，严重肺部感染 3例；1例于第 3次复发手术中发生左心室破裂死亡。胸骨正中切口组心功能较左胸前外侧切口组明显改善，中心静脉压较左胸前外侧切口组降低，胸腔积液、肺炎和脓胸发生率均低于左胸前外侧切口组（ P＜ 0.05）。随访 385例（胸骨正中切口组 231例、左胸前外侧切口组 154例），随访时间 3个月～ 15年，心功能明显改善，均恢复正常工作和学习。胸骨正中切口组缩窄性心包炎复发 4例，左胸前外侧切口组复发 17例，均经相应的治疗治愈或好转。结论 心包剥脱术是治疗慢性缩窄性心包炎的有效手段，胸骨正中切口径路是外科治疗慢性缩窄性心包炎最佳的手术径路。

同种异体胸骨移植重建胸骨三例

目的 探讨胸骨切除后同种异体胸骨移植，一期重建胸骨手术的可行性、手术方法与技巧。 方法 2008年 1月至2009年12月青岛大学医学院附属医院收治胸骨肿瘤患者3例，其中男2例，女1例；年龄分别为19岁、44岁和52岁；病程2个月~2年。3例患者均行胸骨部分切除，同期以同种异体胸骨重建。异体胸骨预先冻存；手术切除范围距病变边缘至少2 cm，包括病变胸骨、相应部分肋软骨、软组织；异体胸骨植入后用钢丝固定，残腔以大网膜填充。 结果 3例手术均获成功，手术效果满意；3例分别随访6个月～2年，无肿瘤复发，无明显排斥反应，患者生活良好。 结论 以同种异体胸骨重建胸骨临床效果满意，有良好的可行性。

心脏大血管手术后胸骨感染的外科治疗

目的 总结心脏大血管手术后胸骨感染的外科治疗经验。 方法 回顾性分析2003年2月至2010年7月8例心脏大血管手术后发生胸骨感染患者的临床资料，男7例，女1例；年龄30～60岁（44.8±10.9）。8例患者均采用彻底清创，包括清除坏死皮缘和增生组织、彻底止血、搔刮胸骨、咬除感染胸骨、清除胸骨后的感染脓腔、用1%碘伏纱布浸泡，抗生素液反复冲洗，留置滴液入管和胸骨后引流管等处理；对胸骨后感染严重（有脓腔）者，彻底清创后经膈肌切口将带蒂（胃网膜有动脉分支的）大网膜上引放置在胸骨后，同时留置滴液入管和胸骨后引流管。 结果 胸骨伤口Ⅰ期愈合5例，Ⅱ期愈合2例，感染未控制1例。Ⅱ期愈合者合并糖尿病，均使用双侧乳内动脉行冠状动脉旁路移植术；分别经局部换药或再次清创2周后愈合。随访8例，随访时间1~3个月，1例主动脉夹层全弓置换术患者因胸骨感染未控制术后3个月死于人工血管继发感染、破裂大出血，其余患者胸骨感染无复发，恢复正常生活或工作。 结论 对心脏大血管手术后发生胸骨感染患者应积极行外科手术清创，采用放置滴液入管，并持续用碘伏冲洗以及带蒂大网膜或肌瓣充填，可尽快控制感染，促进伤口愈合。

经胸骨正中切口心脏手术后并发乳糜胸的治疗

摘要： 目的 探讨经胸骨正中切口心脏直视手术后发生乳糜胸的可能机制和治疗经验，以减少术后乳糜胸的发生。 方法 回顾分析1996年10月至2006年1月收治的18例经胸骨正中切口径路行心脏直视手术后发生乳糜胸患者的临床资料，其中男12例，女6例；年龄2个月~79岁，平均年龄144岁。所有患者均采用在禁食基础上的保守治疗，包括胸腔闭式引流、静脉高营养、强心、利尿等综合措施。 结果 住院时间7~130 d，胸腔引流时间4~35 d。全组死亡2例，其中死于心律失常、心搏骤停1例；因肺部感染、再次插管，死于多器官功能衰竭1例。随访14例，随访时间2~10年，失访2例。随访期间无乳糜胸复发或需二次手术者。 结论 经胸骨正中切口径路行心脏直视手术后发生乳糜胸可能与手术时损伤较小的淋巴侧枝有关，采用禁食、胸腔闭式引流、静脉高营养等保守治疗效果满意。