The clamshell approach for the surgical treatment of complex cardiopulmonary pathology in infants and children

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Abstract
BACKGROUND: The surgical approach to children with complexcardiovascular and pulmonary anomalies is still controversial. Stagedoperations through multiple incisions are often performed in this setting.OBJECTIVE: The different applications and clinical advantages of abilateral thoracosternotomy approach to complex cardiothoracic diseaserequiring surgical repair were reviewed retrospectively. METHODS: BetweenJanuary 1993 and June 1995, 33 patients, aged between 2 months and 17 years(mean 7.8 +/- 5.3) underwent surgical treatment of complex cardiovascularor pulmonary disease using a clamshell approach. Twenty-one patients (64%)had undergone 1-5 previous surgical procedures (mean 2.5 +/- 1.0/patient).The technique involved supine position placement, submammary incision,access to the pleural space bilaterally through the fourth intercostalspace and transverse division of the sternal body. RESULTS: Four groups ofpatients were operated on via this approach: (1) patients undergoing lobar,lung or heart-lung transplantation (40%); (2) patients undergoing repair oftetralogy of Fallot/pulmonary atresia (36%); (3) patients with previouslycorrected miscellaneous procedures (12%), including completion of Fontan,one-stage repair of left main bronchial stenosis and atrial septal defect,one-stage repair of partial anomalous pulmonary venous connection andaortic coarctation, and repair of congenital pulmonary venous stenosis.There were two early (< 30 days) deaths, giving a perioperativemortality of 6% for the entire series. Complications included postoperativehemorrhage in 4 patients (12%), prolonged ventilation time due tomechanical failure in 4 (12%). There were no wound infections. Analysis ofcomplications by group showed the lung transplant group to be more affected(18% of patients experienced complications). Except for 2 infantsundergoing complete unifocalization and presently awaiting completion ofrepair of tetralogy of Fallot/pulmonary atresia, in the remaining 31 (94%)a definitive surgical treatment could be performed in one-stage.CONCLUSIONS: The bilateral thoracosternotomy allows optimal exposure of allintrathoracic anatomic structures making one-stage surgical repair possiblein a variety of complex cardiovascular and pulmonary anomalies. Earlymortality and technique-related morbidity do not differ from those reportedwith the conventional approaches to the different disease conditions. Awider application of the clamshell approach for the management of complexintrathoracic pathology in infants and children is advocated.

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