Aortic Hemiarch Replacement through a J-Shaped Lower Partial Sternotomy.

Minimally invasive cardiac surgical techniques include the use of partial sternotomy for aortic valve and mitral valve replacement. Partial sternotomy is associated with less pain, better chest and upper-sternal stability, shorter hospital stays, and faster recoveries. However, aortic arch operations are still typically performed through median sternotomies. We describe the case of a 77-year-old woman who underwent elective hemiarch replacement because of an asymptomatic ascending aortic aneurysm. She requested a minimal incision. Our J-shaped partial lower sternotomy adequately exposed the proximal aorta and enabled all cannulations to be performed through the sternotomy. The patient had an uncomplicated postoperative course. We think that a partial sternotomy for ascending aortic and hemiarch replacement can be considered in selected patients for whom the procedure's benefits are important.

The use of soft silicone solid implant molded intraoperatively for pectus excavatum surgical repair / Utilização de silicone sólido de baixo índice de dureza moldado no período intraoperatório para a correção de pectus excavatum

Objective To describe a new surgical technique to treat pectus excavatum utilizing low hardness solid silicone block that can be carved during the intraoperative period promoting a better aesthetic result. Methods Between May 1994 and February 2013, 34 male patients presenting pectus excavatum were submitted to surgical repair with the use of low hardness solid silicone block, 10 to 30 Shore A. A block-shaped parallelepiped was used with height and base size coinciding with those of the bone defect. The block was carved intraoperatively according to the shape of the dissected space. The patients were followed for a minimum of 120 days postoperatively. The results and the complications were recorded. Results From the 34 patients operated on, 28 were primary surgeries and 6 were secondary treatment, using other surgical techniques, bone or implant procedures. Postoperative complications included two case of hematomas and eight of seromas. It was necessary to remove the implant in one patient due to pain, and review surgery was performed in another to check prothesis dimensions. Two patients were submitted to fat grafting to improve the chest wall contour. The result was considered satisfactory in 33 patients. Conclusion The procedure proved to be fast and effective. The results of carved silicone block were more effective for allowing a more refined contour as compared to custom made implants. .

Objetivo Descrever a técnica para reparação de pectus excavatum com o uso de bloco de silicone sólido de baixa dureza, que possibilita a adequação de suas dimensões no intraoperatório para melhor resultado estético. Métodos Entre maio de 1994 e fevereiro de 2013, pacientes do gênero masculino, portadores de pectus excavatum, foram submetidos à correção cirúrgica com bloco de silicone sólido de baixa dureza, de 10 a 30 Shore A, pré-fabricado em forma de paralelepípedo, com as dimensões da altura e da base coincidentes com as da falha óssea. Durante o ato cirúrgico, esse bloco foi esculpido até adequar-se ao formato do espaço dissecado. Os pacientes foram acompanhados por um mínimo de 120 dias de pós-operatório. Resultados Trinta e quatro pacientes foram operados. Destes, 28 foram de tratamento primário e 6 secundário a outras técnicas cirúrgicas, ósseas ou de uso de implantes. As complicações foram dois casos de hematoma e oito de seroma. Foi necessária a retirada do implante em um dos casos devido à dor. Em outro caso, foi a realizada revisão cirúrgica das dimensões da prótese. Dois pacientes foram submetidos a enxerto de gordura, para melhorar o contorno da parede torácica. Não ocorreu nenhum caso de infecção. O resultado foi considerado satisfatório em 33 pacientes. Conclusão O procedimento mostrou-se rápido e efetivo. Os resultados dos contornos obtidos foram considerados mais efetivos quando comparados aos obtidos com a utilização de próteses pré-moldadas. .

Novel longitudinal plate-fixation technique after gross resection of the sternum.

Herein, we describe a plate-fixation technique as an alternative method to close a fragile or fractured sternum. A 69-year-old obese woman with diabetes mellitus and chronic obstructive pulmonary disease underwent coronary artery bypass grafting. One week postoperatively, sternal instability was detected, and traditional rewiring was performed. A week later, because of multiple sternal fractures, we performed sternal resection, with use of longitudinally affixed titanium plates and figure-8 steel wires for the anterior chest wall. The procedure was uneventful, and, on short-term follow-up, the anterior chest wall was stable. This longitudinal plate-fixation technique can be tailored to each patient. We think that the technique is safe, effective, economical, and easy to implement, and it is readily reproducible. To evaluate any associated risks, long-term follow-up in additional patients is warranted.

Video assisted thoracoscopic plication of the left hemidiaphragm in symptomatic eventration in adulthood.

Diaphragmatic eventration is a rare congenital developmental defect of the muscular portion of the diaphragm, which appears attenuated and membranous, maintaining its normal attachments and its anatomical continuity. It has been attributed to abnormal myoblast migration to the septum transversum and the pleuroperitoneal membrane. Eventration can be unilateral or bilateral, partial or complete. It is more common in males, and involves more often the left hemidiaphragm. Eventration results in diaphragmatic elevation (cephalad displacement). Most adults are asymptomatic and the diagnosis is incidentally made by chest radiography. The commonest symptom in the adults is dyspnoea, while orthopnoea, mild hypoxemia, tachypnoea, respiratory alkalosis, palpitations, and non specific gastrointestinal symptoms may be present. Surgery is indicated only in the presence of symptoms. The established surgical treatment is diaphragmatic plication. Various techniques and approaches have been employed. We present a simple surgical technique of a 3-port video assisted thoracoscopic plication of the left hemidiaphragm in the adult.

Pedicled latissimus dorsi muscle flap: routine use in high-risk thoracic surgery.

Bronchopleural fistula and empyema are serious complications after thoracic surgical procedures, and their prevention is paramount. Herein, we review our experience with routine prophylactic use of the pedicled ipsilateral latissimus dorsi muscle flap. From January 2004 through February 2006, 10 surgically high-risk patients underwent intrathoracic transposition of this muscle flap for reinforcement of bronchial-stump closure or obliteration of empyema cavities. Seven of the patients were chronically immunosuppressed, 5 were severely malnourished (median preoperative serum albumin level, 2.4 g/dL), and 5 had severe underlying obstructive pulmonary disease (median forced expiratory volume in 1 second, 44% of predicted level). Three upper lobectomies and 1 completion pneumonectomy were performed in order to treat massive hemoptysis that was secondary to complex aspergilloma. One patient underwent left pneumonectomy due to ruptured-cavitary primary lung lymphoma. One upper lobectomy was performed because of necrotizing, localized Mycobacterium avium-intracellulare infection. One patient underwent right upper lobectomy and main-stem bronchoplasty for carcinoma after chemoradiation therapy. In 3 patients, the pedicled latissimus dorsi muscle was used to obliterate chronic empyema cavities and to buttress the closure of underlying bronchopleural fistulas. No operative deaths or recurrent empyemas resulted. Two patients retained peri-flap air that required no surgical intervention. We conclude that the use of transposed pedicled latissimus dorsi muscle flap effectively and reliably prevents clinically overt bronchopleural fistula and recurrent empyema. We advocate its routine use in first-time and selected reoperative thoracotomies in patients who are undergoing high-risk lung resection or reparative procedures.