Prof. Dr. Yavuz Beşoğul: Subaxillary Heart Surgery Description

The technique, popularly known as armpit heart surgery, is a heart operation performed through subaxillary or infra axillary minithoracotomy. Due to the complications of sternotomy, heart surgeries began to be performed with anterolateral thoracotomy in the world in the 1990s, and access incisions gradually became smaller. In 1997, we first started performing our surgeries by converting them to subaxillary incision in our country and contributed to the national and international literature in series. In fact, although there is no difference in the surgical technique, the entry technique has proven to be advantageous from bleeding to infection and early return to daily life. It reduces complications, especially in patients with diabetes, rib cage disorders, kidney failure and obesity. In addition, the small size of the incision and its location on the side are also important from a cosmetic perspective.

Advantages

On the other hand, the entrance site of the surgery provides excellent visibility and access, especially in terms of the exposure of the mitral, tricuspid and aortic valve. This is another factor that reduces complications. Since the rib spacing is different in terms of aortic and mitral valves, performing aortic and mitral valve, i.e. double valve, surgery may prolong the time and disrupt the chest structure and cause the ribs to break, which creates postoperative respiratory problems. Briefly; Aortic and mitral valve (double valve) surgery should not be performed with this technique. In such cases, a frontal incision, that is, ministernotomy, is more useful and there is no entry site complication.

SUBAXILLERY Surgery Technique

The patient is placed on the left side of the chest under double lumen intubation and general anesthesia; That is, an anterolateral thoracotomy position is given with the chest on the right side. A vertical 6 cm incision is made on the intersection of the subaxillary line and the right breast line. The pectoralis major and pectoralis minor muscles are dissected without cutting and a retractor is placed. The thorax is entered through the 3rd intercostal space for the aortic valve and the 4th intercostal space for the mitral valve, and right lung ventilation is provided. If it is turned off or not tolerated, the tidal volume is deducted. The pericardium opens and its leaves hang on the chest wall. Aorta, right and left atrium are clearly seen. After returning the aorta with the pedicle, it is suspended and the aorta, right auricle, and right atrium are easily cannulated. The patient is connected to the heart-lung pump, extra-corporeal circulation is transferred, ventilation is stopped and an x-clamp is placed on the aorta. Cardiac arrest is achieved by applying cold blood cardioplegia and topical cold saline. For the aortic valve, an incision is made at the aortic root and the aortic valve is clearly observed.

After Repair and Replacement

After axillary heart surgery repair or replacement is performed, the autotomy is closed. If the intervention is made through the 4th intercostal space, that is, for mitral valve surgery, the left atrium is opened and the image of the mitral valve is clear. After the repair or replacement is made, the left atrium is closed. The patient is warmed, the heart is defibrillated if necessary, and after starting, the pump flow is gradually reduced and stopped. The heart is easily decannulated. After bleeding control, a single chest drain is placed in the thorax (the location of the drain is important to avoid pain), the ribs are brought closer, and the muscles, subcutaneous and skin are closed properly. Postoperative follow-up is the same.

Although this intervention technique can be applied to every patient, it should not be preferred only in some cases. These :

Those with advanced lung problems
Those over 75 years of age,
Double valve replacement (Aortic and Mitral) required,
It should never be applied to patients requiring aortic valve surgery for the second time.
It is also an ideal method for second and third mitral valve surgeries and/or tricuspid valve surgeries.

Surgeries performed when the heart is arrested by connecting the heart to the lung pump are open heart surgeries. Surgeries performed while the heart is working and without connecting it to a heart-lung pump are closed heart or working heart surgery. However, among the public, surgeries that do not open from the front of the chest, that is, do not perform a sternotomy, are known as closed. In heart surgeries without sternotomy, various parts of the side walls of the chest may be preferred; The aim is to enter the chest and reach the heart through thoracotomy. The most useful of these techniques and the one that does not have any closure complications; It is a heart operation performed through subaxillary or infra-axillary minithoracotomy. Due to the complications of sternotomy, heart surgeries began to be performed with anterolateral thoracotomy in the world in the 1990s, and access incisions gradually became smaller.