医学相关说明文字—解说词

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Primaryrepairoftotalanomalouspulmonaryvenousconnectionwithsuturelessstrategy
1.Thisisa6dayoldboy,whowasdiagnosedwithinfracardiactotalanomalouspulmonaryvenousconnection(TAPVC)withpulmonaryvenousobstruction,patentductusarteriosusandpatentforemanovale.2.HeunderwentemergentTAPVCrepairbecauseoflowbloodpressureandextremelylowarterialsaturation.3.Standardmediansternotomy,andcardiopulmonarybypasswithaorticcannulaandsinglerightatrialcannula.Thepatentductusarteriosuswasligated.4.Cooleddownthepatient’scoretemperatureto18˚C.Afteraorticcrossclampandantegradeinfusionofcardioplegia,thecirculationwasarrested.5.Arightatrialincisionwasmade,andthepatentforemanovalewasclosedwithprimaryclosure.6.Thestaysutureswereremovedandtherightthoraciccavitywasopenedsothattheheartcouldberotatedandputintotherightthoraciccavity.Thepulmonaryveinsandtheverticalveinposteriortothepericardiumwereexposed.7.Thetipoftheleftatrialappendagewasligatedtemporarilyandretractedtotherights>Twostaysuturesweremade.Thepericardiumandtheverticalveinwerecutopenatonce.Makesurethatthelooseconnectionbetweenthepulmonaryveinsandthepericardiumwasnotdissected.9.Togetacleanoperatingfield,thelungswereinflatedanddeflatedseveraltimestosqueezeoutthebloodinlungs.10.Thisincisionwasextendedontoeachindiv>Theincisionwascontinuedtothepleuralpericardialreflectionlaterally.12.Anincisionwasmadeontheposteriorwalloftheleftatrium.Therightendofthisincisionshouldreachtheinteratrialseptum.13.Theleftatrialincisionandthepericardialincisionwereanastomosedtogetherwithrunningsutures.14.Formostpatients,wepreferto7-0prolene,butforpatientsunder2kilograms,weuse8-0prolene.15.Mostofthesutureswillnottouchthevenouswallbecausewebelievethiskindofinjurytothepulmonaryvenousintimamaytriggerfibrousproliferativeresponseandfurtherleadtonew-onsetobstruction.16.However,attheapexofthetrianglezonebetweentwoindiv>Theanastomosiswascontinuedwiththeanotherarmoftheprolene.18.Sincetheleftatrialincisionwasnotbigenough,itwasextendedsufficientlytoguaranteethattheatrialincisionwasbiggerthanthepulmonaryvenousincision.19.Whentheanastomosiswasfinished,lungswereinflatedandholdtocheckanypossiblebleeding.20.Andweprefertousefibringluetopreventneedleholesfrombleeding.21.Therightatrialincisionwasoversewedandthevenouscannulawasinsertedtorestartthecardiopulmonarybypass,andtheheartrestartedperfusion.22.Theboywaseasilyweanedoffthecardiopulmonarybypass,andtheoperationwassuccessfullyterminated.23.Therearethreekeypointsforthesuturelessstrategy.24.First,fullyrelieveanypreoperativepulmonaryvenousobstruction.Thepulmonaryvenousincisionsshouldbeextendedoutwardsontoeachindiv>Second,anastomosetheleftatriumwiththepericardiumratherthanthepulmonaryvenouswall.Thepulmonaryvenousincisionsareradialandirregularwithlongcircumference,atriopericardialanastomosiscanshortenandsimplifythisstep.Inthemeantime,thepericardiumcouldactasabuffertoalleviatetheanastomosingdistortioncausedbynonparallelaxisesofthepulmonaryvenousandtheleftatrialincisions.26.Third,"notouch"technique.Webelieveinjuryfromsutureneedlesmayleadtopulmonaryvenousintimalfibrousproliferativeresponse.,The“notouch”techniquemayalleviatethepossibilityofnew-onsetpulmonaryvenousobstructioncausedbythisresponse.27.Thankyou.

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