右小開胸弁膜症手術の標準化

Standadizing Right Minithoracotomy Valvular Surgery

1970年代に胸骨正中切開が心臓手術の標準アプローチとして確立された後，1990年代から整容性の向上と入院期間の短縮を目的に，単弁置換術，1枝冠状動脈バイパス術など簡易な手術を対象に小切開心臓手術（MICS）の報告が散見されるようになった．当初は，胸骨部分切開と肋間開胸という二つのアプローチが共存していたが，内視鏡器具の改良，手術支援ロボットの開発など，テクノロジーの進歩により，肋間開胸アプローチが主流になってきた．特に，胸骨を切開しないことで早期社会復帰を可能にする，整容性において胸骨部分切開に優るなどの利点がある．本稿では右小開胸によるMICSにつき，僧帽弁手術に主眼をあて，当施設での経験を中心に解説する．

Minimally invasive cardiac surgery （MICS） via mini-right thoracotomy approach has been developed and standardized in the last 30 years, aiming to facilitate postoperative recovery and to minimize surgery-related complications. Mitral regurgitation is the major target of this MICS approach. In our institute, MICS mitral valve repair by direct vision under thoracoscopy guidance has been performed in 139 cases between 2011 and March 2018. Subsequently, robot-assisted surgery program was launched to perform mitral valve repair for 130 patients in the last 2 years. In-hospital and mid-term outcome post-mitral valve repair was not significantly different among sternotomy, MICS direct vision and MICS robot-assist approaches, though there were several pitfalls through the launch of the MICS program. Standardization of the MICS approach of mitral valve repair and other cardiac surgeries was herein summarized and associated pitfalls were explained from surgeons’ view.