Totally Endoscopic Bentall Procedure via Right-Lateral Minithorcotomy with 3-D Viisualization

S. Salamate¹, M. Hamiko², F. Bakhtiary^2
1Cardiac Surgery University Hospital Bonn, Bonn, Nordrhein-Westfalen ²Cardiac Surgery University Hospital Bonn, Germany, Bonn, Nordrhein-Westfalen

Please explain the educational or technical point that this video addresses.: In this case we performed a minimally invasive totally endoscopic aortic valve and aortic root replacement with re-implantation of the right and left coronary arteries (Bentall procedure) via a right-lateral minithoracotomy. With the help of 3D visualization, a very small thoracotomy and a soft tissue retractor without resection or the use of a rip spreader in order to preserve chest wall stability while preserving the right internal thoracic vessels, the aortic valve and the aortic root with re-implantation of the left and right coronary arteries can be easily and safely accessed for replacement. The other main features of these techniques are extracorporeal circulation achieved through peripheral percutaneous cannulation of the femoral vessels, as well as the CorKnot Mini device. Additionally, an automated vascular closure device (MANAT device) has been used for closing the femoral artery following decannulation. The use of a totally endoscopic approach enables even smaller incisions, preserving the integrity and stability of the chest wall while ensuring excellent visualization of the surgical field and access to the aortic valve.

Please provide a 250 word summary of the surgical video being submitted.: Percutaneous arterial and venous femoral cannulation is the standard procedure used to establish cardiopulmonary bypass. A 3-4cm skin incision 2cm to the right of the sternal border, at the level of the third intercostal space was performed. Soft-tissue retractor and 3D-camera were used for optimal exposure without resection of the ribs and without the use of a spreader. After pericadiotomy and cross-clamping the aorta, the complete aneurysm, including the aortic root, was resected. The coronary buttons were cut out and retracted, and the remaining portion of aortic sinuses was removed. Afterwards, the aortic valve leaflets were removed. After sizing the annulus, a suitable biological conduit (size of vascular graft = 5 mm > size of aortic valve prosthesis) was constructed. Then, annular sutures were placed manually using interrupted non-everted pledgeted mattress sutures, starting at the base of the right coronary cusp and proceeding in a clockwise fashion. After completing the annular sutures, the sutures stitched through the sewing cuff of the biological conduit. After parachuting the conduit down into the annulus, The automatically knot tie device (Cor-Knot®) was used to tie the sutures with the constructed conduit. Further sutures were placed from aortic side and are also tied with the conduit. Thereafter, the left coronary button was anastomosed on the vascular graft. Then, the distal anastomosis between the graft and the remaining aorta was completed. Finally, the right coronary button was anastomosed on the vascular graft.