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Ministernotomy for correction of ventricular septal defect
© Vo et al. 2016
Received: 5 February 2016
Accepted: 18 April 2016
Published: 26 April 2016
The development of minimally invasive surgery in the adult has created motivation for similar approaches in the congenital heart domain. Over the past 20 years, this type of surgery has been advocated in an effort to reduce costs related to hospital stay, and to improve the cosmetic results. We report our experience with ventricular septal defect repair utilizing a ministernotomy incision.
From August 2014 to August 2015, 26 patients underwent ministernotomy for correction of ventricular septal defect at our center. All patients were between the ages of 14 months-old to 24 years-old with weight ranged from 7.5 to 54 kg (median weight 12 kg). Diagnoses were confirmed with echocardiography. We analysed in-hospital and 6 months follow-up outcomes of the group.
All defects were corrected successfully with satisfactory exposure. The median cardiopulmonary bypass time was 64 min, and median cross clamp time was 42 min. The intensive care unit stay ranged from 1 day to 3 days (median ICU stay, 1.5 days) and the hospital stay ranged from 4 to 13 days (median hospital stay, 5 days). There were no deaths during the operation or severe postoperative complications. No residual shunts were observed.
Our results demonstrated the safety and efficacy of ministernotomy for the correction of ventricular septal defect with improved cosmetic results in patients greater than 7.5 kg. This aprroach can be used in either the transatrial or transarterial approach, and in smaller weight infants.
The introduction of minimally invasive surgery in the adult population has stimulated similar approaches in the congenital heart domain. Over the past two decades, this type of surgery has been advocated for both adults and children in an effort to reduce costs related to hospital stay, and to improve the cosmetic results. Particularly in the pediatric population, awareness should be paid to the cosmetic and psychological consequences of a conventional full sternotomy, as this could have an important role in postoperative recovery . By using minimal skin incisions and a ministernotomy, surgical trauma can be reduced.
These techniques may necessitate costly equipment that can increase the cost of these procedures compared to that of conventional surgery. However, an inferior ministernotomy does not require any expensive equipment. This approach was first reported for correction of atrial septal defect . As experience with ministernotomy in atrial septal defect repair developed, this approach has been applied to other congenital heart diseases, especially the ventricular septal defect.
sShould one encounter difficulties in exposure or performing the procedure, it is always feasible to convert to a full sternotomy. At our center, along with safe application of peripheral and central cardiopulmonary bypass and adequate myocardial protection, adequate exposure was achieved using a self-retaining retractor for the upper part of the incision.
The goal of our experience was to assess the efficacy and safety of using minimally invasive surgery in repairing ventricular septal defects in small children down to 8 kg in three types of cardiac malformations: the perimembranous VSD; the infundibular VSD; and the doubly-committed VSD.
Type of ventricular septal defects treated with a ministernotomy
Type of defect
Number of patients
Doubly committed VSD
Before the ministernotomy, we expose the femoral vein, usually on the right side, using a small incision (1 cm) at the groin, and place a purse string on the vein. The femoral vein size is sufficient for inferior vena cava cannulation, and provides adequate venous return.
Demographic and postoperative data
14 month-old – 24 year-old (mean 5.6 ± 4.3)
7.5–54 (median, 12)
Operating time (min)
125–320 (median, 198)
ICU stay (days)
1–3 (median, 1.5)
Hospital stay (days)
4–13 (median, 5)
Pneumothorax requiring chest tube
Pericardial effusion needing drainage
Recently published results of minministernotomy VSD closure
Number of VSD
Shorter in-hospital stay
Luo et al. 
Da Silva et al. 
Sebastian et al. 
Vietes et al. 
There are two reasons to change the approach for congenital heart disease from a conventional sternotomy to a minimal access sternotomy. First is the cosmetic aspect affecting the incision, postoperative pain, and possible negative consequences on pulmonary function. Second is the development of cardiopulmonary bypass, thus allowing safer peripheral cannulation without decreasing the venous return in the presence of the vacuum system .
Several recent articles have addressed the safety of ministernotomy for the repair of congenital heart defects. Luo et al.  reported a randomized prospective series of 100 patients with septal defects undergoing repair via ministernotomy or full sternotomy. Three advantages of ministernotomy were noted. First, there was decreased postoperative chest tube drainage. Second, hospital stay was shortened. Third, the procedure provided a better cosmetic effect, especially in young women . However, apart from the cosmetic effect, the other benefits remained controversial. Laussen et al.  found no significant differences in terms of pain, emesis, pain drug requirements, respiratory rate, recovery or in-hospital stay in a group of 17 children undergoing ministernotomy for ASD repair, and compared with a group of 18 children undergoing full sternotomy. Nevertheless, with a larger series and several types of defects analyzed, Vieites et al.  reported ministernotomy had a higher early extubation rate and fewer complications than full sternotomy.
Sebastian et al.  found no differences in the number of blood transfusions but a prolonged cardiopulmonary bypass and cross-clamp times in the ministernotomy group. The issue of increased surgical time with minimally invasive surgery is encountered not only with ministernotomy, but also with other less invasive approaches [5, 8]. This has been explained by a smaller surgical field and a more complicated cannulation technique. However, the minimally invasive approach for VSD repair provides an excellent outcome with no increase in perioperative morbidity [4, 7].
Among the advantages of ministernotomy, the cosmetic effects remain the major benefit over the full sternotomy. Vietes et al.  found an improvement in cosmetic outcomes, as well as patient satisfaction after ministernotomy. In our study, with a smaller weight population, the limited skin incision could be retracted to provide improved exposure by losing or tightening the self-retaining retractor along with multiple pericardial traction sutures and the Army/Navy retractors. This gives the surgeon the flexibility to change from the upper half and the lower half of the operative field without extending the skin incision. Should difficulties in closing the VSD occur, transatrial approach and transarterial approach could be used at the same time to facilitate the operation. Furthermore, our results support the minimally invasive approach in lower weight patients.
Limitations of this study include the small number of patients and the lack of data regarding the level of pain, which is difficult and subjective to assess in pediatric patients.
In conclusion, we have demonstrated the efficacy and safety of the ministernotomy to repair ventricular septal defects. This can be used in either the transatrial or transarterial approach, and in smaller weight infants. The small incision also provides very good results in cosmetic. There has been no difficulties in technical repair and no conversion to full sternotomy. The ministernotomy has become our preferred approach for children with ventricular septal defects, and weight > 7.5 kg.
Ethics, consent and permissions
Written informed consent was obtained from all participants.
We would lielike to express our special thanks to Professor A. Thomas Pezzella for the great help and guidance in publishing this article.
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