Hội phẫu thuật nhi Việt Nam

 

A Safe Technique of Thoracoscopic Clipping of Patent Ductus Arteriosus in Children

Nguyen Thanh Liem, MD, PhD, Tu Manh Tuan, MD, and Nguyen Van Linh, MD

Abstract

Aim: To present a modified and  safe technique of thoracoscopic clipping  of patent ductus

arteriosus (PDA) in children  and  its early outcomes.

 

Patients and  Methods:  Patients  are  anesthetized, ventilated via  single-lung ventilation, and 

placed  in a right lateral  position.  The surgeon and the assistant stand  at the patient’s  feet,

and a monitor is placed  at the patient’s head.  The ductus is pulled  forward with  a Vicryl®  

(Ethicon)  thread and  clipped  completely.

Results:  From May 2010 to February 2011, 58 patients with  PDA (27 boys and  31 girls) were

operated on using the same  technique. Patients’  ages  varied  from  8 days  to 36 months. Mean 

weight  of patients was  5.9 – 2.8 kg (range,   2.1–10 kg).  Mean   operative  time  was   33 – 12 

minutes  (range,   15–90  minutes).  There  were   no  in- traoperative  complications.

Postoperative complications occurred in  2 patients: 1 patient developed a pneu- mothorax, and 1

patient had pleural effusion. Mean postoperative stay was 4.1 – 2.1 days for patients > 3 months

old  and  11.9 – 8.4 days  for patients p3  months old.  No  injuries  of recurrent laryngeal nerve

 occurred in any patients, and  there  were  no residual shunts in any  patients 3–6 months after

discharge.

Conclusion: A modified technique of thoracoscopic closure is a safe and effective procedure for PDA

in children.

Introduction

horacoscopic clipping of patent ductus arteriosus (PDA)

was first reported by Laborde et al.1 in 1993 and to now has only been performed in a few centers.

Complications and rate of

conversion to open surgery remain high.2–6 Since 2010, we have performed a thoracoscopic clipping 

with some technical  modi- fications to reduce operative complications. The aim of this report

is to present our technique and its early outcomes.

Patients  and Methods

Patients

The  inclusion  criterion  was  patients with  PDA  p9 mm. Exclusion criteria were patient  with 

PDA  > 9 mm or patients who had had a previous thoracotomy.

Surgical technique

The patient is anesthetized with single-lung ventilation and then placed  in the right lateral 

position.  The surgeon and the assistant stand at the patient’s feet. A monitor is placed on the

patient’s  head.

The operation is performed using  four  trocars.  The initial trocar  (5 mm for the scope) is

introduced through the 8th in-

tercostal space in the midaxillary line, the second trocar (5 mm for instruments and  clip applier)

 through the 7th intercostal space  in the  postaxillary line, the  third  trocar  (3 mm  for in-

struments) through the 7th intercostal space in the ante- rioraxillary  line,   and   the   fourth 

 trocar   (3 mm   for   lung refractor)  through the third  intercostal space in the ante-

rioraxillary line (Fig. 1). CO2  pressure was maintained be- tween  4 and 6 mm Hg with  a flow rate

of 1–2 L/minute.

 

FIG. 1.   Patient  and  trocar  positions.

The pleura  are incised up to the base of the left subclavian artery.  A pleural flap is mobilized

medially to expose the ductus, the vagus  nerve,  and  the recurrent laryngeal nerve. The lower 

angle  between the  ductus and  aorta  is identified and  dissected. The dissection is continued

posteriorly to separate the ductus from surrounding tissue. The upper angle between the ductus and

aorta are also dissected. Any bands of fibrotic  tissue  are  divided to  separate the  aorta  

from  the ductus and  free the anterior of the ductus. A dissector  is in- troduced from the lower

angle of the ductus through the posterior space  to the  upper angle  between the  ductus and

aorta. A portion of Vicryl®  (Ethicon) 2-0 is grasped and pulled

from the upper angle to the lower angle, and then the ductus is gently pulled  forward with this

thread (Fig. 2). The recurrent laryngeal nerve  is  reidentified. A  clip  with  a  clip  applier

(Weck®   Hem-o-lok®;  Teleflex,  Inc.)  is  passed   through the lower  port,  and  the ductus is clipped  with  one or two  clips depending its length  (Fig. 3).

 

FIG.  2.   The  ductus 5s  pulled   forward with  a  thread  of Vicryl.

 

FIG.  3.   A  clip  is  passed   through the  lower  port  of  the ductus.

Results

From  May  2010 to February 2011, 58 patients with  PDA (27 boys  and  31 girls) received  surgery

using  this  modified technique. Patients’  ages  varied  from  8 days  to  36 months (Table 1).

Patients’  weights varied  from  2.1 to 10 kg (mean,

5.9 – 2.8 kg). Preoperative pneumonia occurred in 27 patients. Mean operative time was 33 – 12

minutes (range,  15–90 min- utes). Conversion to open operation was required in 1 patient because

of severe pleural adhesion and multiple lymph nodes surrounding the ductus. There were  no

intraoperative  com- plications.  Blood transfusion was not required in any patient. There  were 

no  operative or  postoperative  deaths. Pneu- mothorax occurred in 1 patient,  and pleural

effusion occurred

in  1  patient;   conservative management  was  successful   in both patients. Mean postoperative

stay was 4.1 – 2.1 days for patients > 3 months old and  11.9 – 8.4 days  for patients p3 months

old. No patient  suffered  from injury to the recurrent laryngeal nerve.  Follow-up of all patients

was  achieved be- tween 3 and 6 months post-discharge. Residual shunt was not detected in any

patients on cardiac  ultrasound.

Discussion

Since 1939, when Gross performed the first ligation of PDA by open  surgery, the ligation  or

division  of PDA via thora- cotomy  became  a standard technique for  PDA.7   However, long-term

musculoskeletal and  developmental morbidity as- sociated  with thoracotomy in infants  has been

reported.8

A  transcatheter  occlusive   technique  was   initially   per- formed  by Portsmann et al.9  in

1971 and  has become  a more and  more  popular technique used  by cardiologists.10,11  This

approach is a minimally invasive  procedure, and  the patient has a short hospital stay. However,

its efficacy is not as high as in  open  surgery, and  its  rates  of  complications remained

high.12,13

The first thoracoscopic clipping  of PDA was performed by Laborde  et al.1   in 1993. Thoracoscopic

closure  of PDA  has some important advantages. It is minimally traumatic, and its cost  is cheaper

 in comparison with  posterolateral thoracot- omy  or  transcatheter Amplatzer®  (AGA  Medical, 

now  St. Jude Medical) occlusion.14,15 This approach has been used  in some centers, but it has not

become a popular procedure. The primary concern in this approach is its safety, with three main

complications (bleeding,  injury  of recurrent laryngeal nerve, and residual shunt) 

reported.1,5,16

 

 

                                                                 

Our results  indicate  that  a modified technique of thoraco- scopic closure of PDA is a safe and

effective procedure. There were no intraoperative complications or deaths. Blood trans- fusion  was

 not required in any patient,  and  complete  occlu- sion of PDA was achieved in all patients. We

consider  that a careful dissection of the lower and upper angle between PDA and  the aorta  and 

the posterior space of PDA is an essential step in the thoracoscopic operation for PDA. Pulling the

PDA forward with  a portion of Vicryl allows  us to pass easily the clip applier through the ductus

and occlude it completely. We prefer the Hem-o-lok clip to the normal  titanium clip. We assume 

the Hem-o-lok clip to be better than a titanium clip to occlude  the  ductus because  it can 

occlude  the  ductus com- pletely  and  avoid  the  partial   reopening after  24 hours   as

mentioned by another report.1 No patient  in our series had a

postoperative residual shunt,  whereas others  have  reported this rate to be 1.4%.16 Inadequate

dissection and using normal titanium clips could be reasons for incomplete occlusion of the ductus

or reopening after the operation.

Careful  dissection and identification of the recurrent la- ryngeal nerve are also necessary to

avoid its injury. No patient in this study suffered  from injury  to the recurrent laryngeal nerve.

 This  complication occurred in 3–5.8% of patients in other reports.16,17

Postoperative stay in our series was longer than in patients treated by a transcatheter

technique.18 The postoperative stay in our series was associated with the patient’s  age.

There are some modifications in placement of surgical team and  trocars  in our technique. The

surgeon stands  on the pa- tient’s feet instead of in front of the patient.  With this position,

all  instruments can  approach the  ductus in  nearly  a  right angle. This facilitates the

dissection and especially clipping  of the PDA.

We can conclude  that  thoracoscopic closure  of PDA with our  surgical  modifications is a safe

and  effective for PDA in children.

Disclosure Statement

No competing financial interests  exist.

References

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Address  correspondence  to: Nguyen Thanh Liem, MD, PhD Department of Pediatric Surgery National

Hospital of Pediatrics

18/879 La Thanh  Road Dong Da District, Hanoi Vietnam

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