Minithoracotomy and Ministernotomy: How to Compare and Choose

I often receive inquiries about the difference between a minithoracotomy and a ministernotomy approach. Most prospective patients want to know about the advantages and disadvantages related to these minimally invasive approaches. We discuss this issue every year among cardiac surgeons at our national conferences. I definitely recommend the minithoracotomy over the ministernotomy in the vast majority of my patients.

I’ll summarize why a minithoracotomy is a better choice in most patients in need of aortic, tricuspid, mitral, aortic valve surgery, atrial myxoma and atrial septal defect (ASD) repairs or other suitable coronary cases.

Minithoracotomy

The Minithoracotomy approach has the following advantages over a ministernotomy or a full sternotomy:

  • The biggest advantage stems from the fact that there is no need to break any bone with a minithoracotomy. The surgical incision is carried out through a thin muscle layer between the ribs. The avoidance of a split in the breast bone and ribs gives less pain, less chances of wound infection, less bleeding and a much more reliable healing of the surgical wound.
  • It is easier to have an excellent pain control by injecting local anesthetic in the nerves between the ribs (intercostal nerve block).
  • It affords a superior cosmetic result by placing the small scar way below the neck and away from the midline towards the side of the chest. In women the scar can often be hidden in the skin fold underneath the breast.
  • Patients can resume their normal activities much faster because there are no restrictions in driving a car or carrying weights other than the patient’s own comfort level. These restrictions are routinely imposed on patients with sternotomies or ministernotomies to allow the broken sternum to heal for about six weeks before allowing any mechanical stress. If mechanical stress is applied before that time the breast bone is fully healed, the two halves of this bone might not “stick” well to each other.
  • More cannulation options (choices in how to connect the heart lung machine) are available through a minithoracomy.

So…Why are so many surgeons offering a ministernotomy rather than a minithotracotomy?

A minithoracotomy carried out by an expert minimally invasive heart surgeon is clearly a better option in most patients. Here is the straightforward answer to this question: most surgeons out there did not have the time, willingness or expertise to learn a minithoracotomy approach.

This approach is radically different from a routine sternotomy approach and implies learning a new set of skills. It cannot be learned overnight and requires serious dedication and commitment to get the best results. On the other hand a ministernotomy constitutes an easy way out for a traditional surgeon who wants to be able to claim some minimally invasive expertise by simply modifying the traditional approach he or she knows and is comfortable with.

The problem is that I do not see what advantages a ministernotomy could possiby offer when compared to a full traditional sternotomy. Consider the following aspects and you’ll see why I do not consider ministernotomy a minimally invasive approach with any merit other than allowing the surgeon who uses it to call it “minimally invasive”:

  • The breast bone is split lengthwise and across. The wound complication rates, bleeding, pain, chance of infection are pretty much the same as a full sternotomy. As a matter of fact it might actually take a little longer to heal because it has been split in two different directions
  • Local anesthetic injections do not work as well for local pain control.
  • There is definitely very little, if any, cosmetic advantage since the surgical scar is right in the midline in the upper part of the chest. If you wear a shirt or a blouse, it is still the part of the scar you see whether you had a ministernotomy or a full sternotomy.
  • You still need downtime to recover and heal the split breast bone. You have to refrain from driving and moderate physical activity for a length of time to allow proper bone healing, same as it happens with a full traditional sternotomy

I hope this gives you some food for thought and I encourage you to contact me if you are interested in more information about different surgical options. Talking to an expert minimally invasive heart surgeon might help you learn the real pros and cons of these techniques and make a truly informed decision about the best care for you or your loved ones.