A small incision makes a big difference - Dr. Natig Mirzeyev

A small incision makes a big difference - Dr. Natig Mirzeyev

- What is the main point of minimally invasive heart surgery?

- Minimally invasive heart surgery is similar to traditional open heart surgery performed by incising the sternum, performed with a smaller incision, no sternal incision, and causes fewer traumas to the patient. During these surgeries, incisions of less than 7 cm are used. Good cosmetic results are not the only reason minimally invasive surgery is emerging and becoming more common. It's not unimportant either, but the main driving force behind the development of this method was patient complaints.

    Since the end of the last century, surgeons began to look for alternative ways to access the heart, and to perform heart surgery in response to patient complaints because of the incision in the sternum area. At that time, they saw that it was possible to perform heart surgery using intercostal incisions. In this case, there was a need for new ways to connect to the cardiopulmonary apparatus. This situation required technical development. Thanks to the development of the medical industry, it was possible to connect the heart to the cardiopulmonary apparatus not from the center, but peripherally, i.e. from the arteries and veins of the leg and arm. As a result, it became possible to preserve the heart and cool the body without cutting into the sternum. All these processes accelerated the development of minimally invasive heart surgery.

- Since when did the use of these techniques in cardiac surgery begin?

- Minimally invasive cardiac surgery techniques began to develop around 1995-2000. Initially, operations were performed to repair heart valve defects and congenital heart defects. As surgeons gained experience, from 2010-2012, they began to perform bypass surgery.

    Although at first the number of such surgeries in our center was small, now we can apply minimally invasive surgery technique for almost all patients. In fact, this method satisfies the patient more than the physician. That's why we approach each patient individually and try to help them with the most modern methods.

- What incisions are used in cardiac pathologies?

- Minimally invasive cardiac surgery techniques can be used for some congenital, most often acquired heart defects, i.e., heart valve defects, heart tumors and almost most bypass surgeries. However, due to the location of these structures in the chest, the incision sites vary. For aortic valve malformations, it is more convenient for the surgeon to perform the operation through the right 2nd intercostal space, elimination of mitral and tricuspid valve malformation, removal of benign myxomatous heart tumor through the right 4th intercostal space. Mini bypass surgery is performed from the left 4th intercostal space.

    Before these surgeries, a three-dimensional tomographic study of the corresponding areas of the body is performed, looking at the correlation of the heart and major vessels with the thoracic organs, as well as the distance to the skin. In short, a dozen parameters are used to decide from which incisions the operation will be performed.

- How is bypass surgery performed using minimally invasive surgery?

- The most commonly performed heart surgery is aorta-coronary bypass surgery. At this time, a narrowed or completely occluded vein is replaced with a new vein removed from the patient's own body, and blood flow is thereby restored. But in the last 10-12 years, these operations have been performed using minimally invasive methods. At first they started with operations on 1 or 2 vessels, and then it became possible to perform these operations on all vessels of the heart.

    In Baku Cardiology Center where I work we conduct such surgeries in patients for whom minimally invasive methods are suitable, that is without opening of sternum, with 6-7 cm incision in the region of 4th intercostal space. Because we use an incision under the breast in women, they do not have a scar in the front.

- Could you also provide information on hybrid bypass surgery. In what cases is this method of surgery used?

- At our center, we also widely use hybrid surgeries, which are a new stage in the development of minimally invasive surgery. These operations, as the name implies, combine two methods: open surgery and stenting, i.e. intravascular stent placement. In this procedure, the main artery of the heart, called the LAD, bypasses the internal thoracic artery (LIMA), which has a 20-year 98% patency rate. In the next step, stents are implanted in the other vessels a few days or weeks later. This allows a minimally invasive operation in patients, in whom it is not possible to operate on all vessels, thereby protecting the sternum.

- Is it possible to perform minimally invasive heart surgery on every patient?

- This method can be used for most cardiac pathologies. In particular, minimally invasive surgery is more widely used in patients who want to quickly return to an active lifestyle and work. However, this method is a unique option not only for young active patients, but also for elderly patients who need a faster recovery, due to comorbidities. In patients who underwent cardiac surgery several years ago, this method is considered indispensable if the new heart pathology requires reoperation.

    However, like all methods, it has contraindications. The risk group includes patients with excessive body weight, those who have previously undergone chest surgery, and those who have undergone trauma. At the same time, this method is considered risky for patients with anatomic or atherosclerotic vascular lesions, aneurysm of large vessels, because we cannot connect to the peripheral cardiopulmonary apparatus.

    As our experience increases and our technical equipment are updated, the obstacles in front of us are decreasing. We can use minimally invasive surgery in almost all patients.

- What are the advantages for patients of this new method of surgery?

- After surgeries performed by dissecting the sternum, a long scar remains in the patient's chest area. The pain and the sight of the incision sometimes have such a psychological impact that some patients become depressed. However, minimally invasive surgery leaves a small incision of 6-7 cm in length.

    These days, people can't stay out of work for long. The comfort provided by these surgeries and the possibility of early activation become the main motivating factors for most patients choosing this method. The patient is discharged home 6-7 days after the operation with sternal incision and 2-3 days after the operation with minimally invasive method. In the first case, the full recovery period takes 3 months, and with the minimally invasive method, the patient can go to work (even with heavy physical exertion) after 3-4 weeks. Most patients are disconnected from the ventilator in the operating room. Early activation leads to rapid recovery of lung function and increased patient's wakefulness. When patients are discharged home after minimally invasive surgery, they can comfortably buckle up and drive.

    The sternum is one of the major organs of hematopoiesis in adults. Not cutting this bone greatly reduces blood loss. As a result, the need for blood transfusions is reduced. Because the sternum is not cut, but only the intercostal muscles are cut, there is less pain. Because the incision is small, there is less contact with air, which minimizes the risk of infection. As a result, the need for antibiotics is reduced. This is especially important for elderly patients with liver and kidney problems.

I have already mentioned the aesthetic aspects, as they have become a hallmark of minimally invasive surgery.

- Is there any difference between minimally invasive surgery you conducted in Baku and the same surgery you conducted in Europe, for example, in Germany?

- Robotic surgery is considered the pinnacle of minimally invasive surgery, but it is not performed in every hospital, even in Western Europe and the United States. The minimally invasive surgeon is inevitably moving towards robotic surgery. Our work does not lag behind our colleagues in the West in terms of technical, qualitative and performance indicators.


Kenul Jafarli