低侵襲弁膜症手術の今と昔

Minimally Invasive Cardiac Surgery for Valvular Heart Disease in Japan；Past and Present

本邦では1990年代から小切開による低侵襲心臓手術（MICS）が弁膜症に行われ始めた．当初は特別な手術器械を要しないことから胸骨部分切開や傍胸骨切開によるものが行われたが，2000年を過ぎてからは右小開胸によるMICSが行われるようになり，症例数が増加している．その後，小切開を追求することで直視下手術だけでなく，内視鏡補助下での僧帽弁形成術が行われるようになってきた．最近ではロボット支援下弁形成術もMICSの発展形として行われるようになった．MICSが普及しつつあるが，狭く深い視野や手術操作のストレス，手術時間が延長する危惧，必要な手術器械の調達，手術チームづくりなどでハードルの高さを感じる外科医もいる．胸骨部分切開からロボット支援下手術まで20年間のMICSについて，筆者の経験を中心に述べる．

Minimally invasive cardiac surgery （MICS） through partial sternotomy or parastenal incision was introduced for valvular heart disease in 1990s, it has gradually faded because it was somehow challenging without standardized manner or positive merits for the patients. Conversely, MICS via mini-thoracotomy has been started for mostly the patients undergoing mitral valve repair in 2000s, the number of MICS through mini-thoracotomy cases has increased progressively with the supports by academic societies and a national registry database system. Some enthusiasm for less invasiveness fashion oriented smaller skin incision and endoscopic procedures. Recently, robotically-assisted mitral valve surgery has taken place under strict regulation. Performing MICS requires not only surgeon’s skills but also heart team strength including anesthesiologists and perfusionists. MICS should give cosmetic benefit and patient satisfaction, and credibility for cardiologists and society. Past and current status of MICS in Japan is described based on over 20-year author’s experience from partial sternotomy MICS to robotically-assisted surgery for valvular heart disease.