Total thoracoscopic approach
Patients in the thoracoscopic group (TT) were positioned supine in a 15
to 20 degrees left lateral decubitus position. Double lumen endotracheal
tube intubation with a transient single lung ventilation strategy was
performed under general anesthesia, and then venous cannulation
consisted of a right percutaneous (16-Fr) superior vena cava (SVC)
drainage catheter placed through the internal jugular vein, using
ultrasonography guidance for placement. Three small ports were made on
the right side of the chest. The first port (2.5–3 cm) was positioned
in the fourth intercostal space outside the right midclavicular line.
This port was used for the insertion of surgical instruments such as
acutenaculums and scissors. The second port (1–1.5 cm) for the entry of
instruments was handled by the left hand of the operator. The
cross-clamp of aorta (ACC) occlusion forceps was made in the fourth
intercostal space, anterior axillary line. The third port (1.0–2.0 cm)
for the placement of the 5-mm thoracoscope was located in the fifth
intercostal space between the mid-axillary line and the anterior
axillary line (Fig. 1). A tissue retractor was inserted into the port
immediately if each port was made. This could fix the incision open to
protect the muscle and intercostal vessels, while facilitating access of
the scope and instruments. The right common femoral vein was cannulated
with a multiport (24- or 28-Fr) venous drainage catheter. The vena cava
were isolated with separate tourniquet snares, similar to
sternotomy-based surgery. The right common femoral artery was cannulated
using a 17- or 19-Fr arterial cannula. The ascending aorta was
cross-clamped with a transthoracic aortic cross-clamp and antegrade
cardioplegia was delivered into the aortic root, while the body
temperature dropped to 32 °C. A midbody right atriotomy was made after
the superior and inferior vena cava were blocked. If the VSD could be
exposed directly, it was closed with a patch of autologous pericardium
or a bovine patch. If the VSD was inadequately exposed using the
transatrial approach, detachment of the tricuspid valve was performed.
The septal tricuspid valve was partially detached by a circumferential
parallel incision 2 mm away from the annulus, and the septal leaflet was
suspended by 3 or 4 sutures (Fig. 2). After the VSD was continuously
sutured with a patch, the septal leaflet was reattached to the annulus
with a continuous suture, with the patch sandwiched between the leaflet
and the annulus. Finally, the tricuspid valve coaptation and competence
were assessed by injecting the cold saline into the right ventricle. The
right thoracic cavity was flooded with CO2 via the
second port throughout the procedure to avoid gas embolisms.
Transesophageal echocardiography was used in each patient immediately
after the VSD repair.