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
1. Laborde F, Noirhomme P, Karam J, et al. A new video as- sisted thoracoscopic surgical
technique for interruption of patent ductus arteriosus in infants and children. J Thorac
Cardiovasc Surg 1993;87:870–875.
2. Laborde F, Folliguet TA, Etienne PY, et al. Video-thoracoscopic
surgical interruption of patent ductus arteriosus. Routine experience in 332 pediatric
cases. Eu J Cardiothorac Surg
1997;11:1052–1055.
3. Hines MH, Raines KH, Payne MP, et al. Video-assisted ductal ligation in premature
infants. Ann Thorac Surg
2003,76:1417–1420.
4. Nezafati, M.H, Soltani G, Vedadian A, et al. Video-assisted ductal closure with new
modifications: Minimally invasive, maximally effective, 1,300 cases. Ann Thorac Surg 2007;84:
1343–1348.
5. Vanamo K, Berg E, Kokki H, et al. Video-assisted thoraco- scopic versus open surgery for
persist ductus arteriosus. J Pediatr Surg 2006;41:1226–1229.
6. Rothenberg S, Chang JHT, Toews WH, et al. Thoracoscopic closure of patent ductus arteriosus: A
less traumatic and more cost-effective technique. J Pediatr Surg 1995,30:1057–1060.
7. Gross R, Hubbard J. Surgical ligation of patent ductus arteri- osus. Report of a first
successful case. JAMA 1939;112:729–731.
8. Westfelt JN, Nordwall A. Thoracotomy and scoliosis. Spine
1991;16:1124–1125.
9. Portsmann W, Wierny L, Warnake H, et al. Catheter closure of patent ductus arteriosus. 62 cases
treated without thora- cotomy. Radiol Clin North Am 1971;9:203–218.
10. Rashkind WJ, Mullins CE, Hellenbrand WE, et al. Non- surgical closure of patent
ductus arteriosus: Clinical appli- cation of the Rashkin PDA Occluder System. Circulation
1987;75:583–592.
11. Khan A, al Yousef S, Mullins CE, et al. Experience with 205 procedures of transcatheter
closure arteriosus in 182 patients, with special reference to residual shunts and long-term
fol- low-up. J Thorac Cardiovasc Surg 1992;104:1721–1727.
12. Gray DT, Fyler DC, Walker AM, et al. Clinical outcomes and costs of transcatheter as compared
with surgical closure of patent ductus arteriosus. The Patent Ductus Arteriosus Closure
Comparative Study Group. N Engl J Med
1993,329:1517–1523.
13. Shrivastara S, Marwah A, Radhakrishnan S. Transcatheter closure of patent ductus arteriosus.
Indian Pediatr 2000,37:
1307–1313.
14. Chen H, Weng G, Chen Z, et al. Comparison of posterolat- eral thoracotomy and
video-assisted thoracoscopic clipping for the treatment of patent ductus arteriosus in neonates and
infants. Pediatr Cardiol 2011,32:386–390.
15. Chen H, Weng G, Chen Z, et al. Comparison of long-term clinical outcomes and cost between
video-assisted thoraco- scopic surgery and transcatheter Amplatzer occlusion of the patent ductus
arteriosus. Pediatr Cardiol 2012;33:316–321.
16. Villa E, Vanden Eyden F, Le Bret E, et al. Paediatric video- assisted thoracoscopic clipping
of patent ductus arteriosus: Experience in more than 700 cases. Eur J Cardiothorac Surg
2004,25:387–393.
17. Das MB, Kapoor L, Moulick A, et al. Video-assisted thor- acoscopic surgery for closure of
patent ductus arteriosus in children. Indian Heart J 1997;49:300–302.
18. Chen ZY, Wu LM, Luo YK, et al. Comparison of long-term clinical outcome between transcatheter
Amplazer occlusion and surgical closure of isolated patent ductus arteriosus. Chin Med J
(Engl) 2009;122:1123–1127.
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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