Discussion

As the substantial reduction in mortality and even morbidity for the treatment of certain congenital heart defects has become the expected norm, patient parents, the media, and society at large have challenged the surgical community to become “minimally invasive”, avoiding a median sternotomy for surgical repairs not amenable to catheter intervention, without compromising the quality of repair. To offer valid alternatives to less invasive transcatheter interventional techniques, various types of surgical incisions have been introduced to avoid a median sternotomy including the anterior, anterolateral (or sub-mammary), posterolateral, and muscle-sparing right axillary thoracotomy. ^{Reference Mihalyi, Kiraly, Prodan, Bodor, Tamas and Hartyanszky1–Reference Heinisch, Bartkevics and Beck27} With the anterolateral or sub-mammary approach, rib deformation and atrophy of severed pectoral muscles, and asymmetrical breast development in females have been reported, resulting in suboptimal cosmetic results. ^{Reference Schreiber, Bleiziffer and Kostolny3,Reference Mishaly, Ghosh and Preisman4,Reference Palma, Giordano and Russolillo6,Reference Ding, Wang and Dong7,Reference Hu, Tan, Chen, Ding and Xu10–Reference Yaliniz, Topcuoglu and Gocen12,Reference Gil-Jaurena, Pérez-Caballero, Pita-Fernández, González-López, Sánchez and De Agustín16,Reference Hong, Chen and Lin20,Reference Liu, Rui, Zhang, Lin, Li and Hua24–Reference Luo, Chen, Yu, Chen and Huang26,Reference Mavroudis, Backer, Stewart and Heraty28} The suggested advantages of the mini right axillary incision include: (a) a muscle-sparing approach with resultant shorter recovery time and return to full capacity of the right arm and shoulder function, as only longitudinal muscle fibres of the serratus anterior are split parallel to the ribs; (b) avoidance of breast tissue, which is especially important in young female infants given the absence of any visible landmark at the time of surgery, thus avoiding future asymmetrical breast growth; (c) a completely hidden scar underneath the resting arm, resulting in a superior cosmetic appearance in comparison with any other thoracic incision. ^{Reference Mihalyi, Kiraly, Prodan, Bodor, Tamas and Hartyanszky1–Reference Dave, Comber, Solinger, Bettex, Dodge-Khatami and Prêtre5,Reference Gil-Jaurena, Castillo and Gonzalez8–Reference Hu, Tan, Chen, Ding and Xu10,Reference An, Zhang, Zheng, Wang, Wu and Xing14–Reference An, Zhang, Zheng, Wang and Ma17,Reference Heinisch, Wildbolz and Beck19–Reference Lee, Weiss, Williams, Kiblawi, Dong and Nguyen21,Reference Wang, Ye, Ge and Wang23–Reference Heinisch, Bartkevics and Beck27}

As with introducing any new technique, during the early development of the minimally invasive right axillary approach, our goal was to demonstrate its safety, and reproducibly match standard hospital outcomes or even improve upon them, compared to surgery through a conventional median sternotomy. Several reports from groups who perform variations of our minimally invasive technique have presented similar if not better data related to the length of tracheal intubation, duration of need for chest drains, requirement for blood transfusion, duration of ICU and hospital length of stay, ^{Reference Mihalyi, Kiraly, Prodan, Bodor, Tamas and Hartyanszky1–Reference Dave, Comber, Solinger, Bettex, Dodge-Khatami and Prêtre5,Reference Gil-Jaurena, Castillo and Gonzalez8–Reference Hu, Tan, Chen, Ding and Xu10,Reference An, Zhang, Zheng, Wang, Wu and Xing14–Reference An, Zhang, Zheng, Wang and Ma17,Reference Heinisch, Wildbolz and Beck19–Reference Lee, Weiss, Williams, Kiblawi, Dong and Nguyen21,Reference Wang, Ye, Ge and Wang23–Reference Heinisch, Bartkevics and Beck27} as confirmed in our current study. The two patients requiring reoperations during the same hospital stay merit a discussion regarding optimal pre-operative imaging, considerations with regards to cannulation, and sufficient exposure required for an optimal repair. It has been an integral part of the pre-operative imaging protocol to use low-dose CT scanning for lesions involving anomalous pulmonary vein connections and either very high or very low sinus venosus atrial septal defects. ^{Reference Dodge-Khatami and Adebo30} In patients with anomalous pulmonary venous connections, documenting a high insertion of upper and middle lobe pulmonary veins may allow a planned Warden operation and very high venous cannulation of the innominate vein or even internal jugular vein. With very low sinus venosus defects, pre-operative CT imaging may point to the need for peripheral venous cannulation of the femoral vein, so as to leave the area of repair free from cluttering cannulae. In our two patients, despite adequate pre-operative advanced imaging and satisfactory exposure after peripheral venous cannulation, imperfect technique resulted in low sinus venosus atrial septal baffle leaks requiring revision during the same hospital stay, through the same mini right axillary incision.

With regard to the quality-of-life metrics, we identified only one prior study comparing patients operated on through an anterolateral thoracotomy with those who underwent median sternotomy, which evaluated pain score systems on two occasions in the immediate post-operative period. ^{Reference Kara and Caner29} After initial slightly higher pain scores in patients undergoing surgery through the anterolateral thoracotomy, a general state of well-being, comfortable mobilisation, and greater success in post-operative exercises were observed, starting from the first post-operative day. Additionally, discharge occurred earlier, lower subsequent pain scores were reported, along with improved signs of well-being during the first post-operative week. ^{Reference Kara and Caner29}

For our study, an abbreviated questionnaire derived from the Child Health and Infant/Toddler Health Questionnaires system was used, focusing primarily on the patient’s global health, physical activity, and pain/discomfort. The results of the questionnaires (Table 3) didn’t show any statistical difference in perceived quality of life between the two groups at last follow-up when beyond a month. During the early post-operative period up to 1 month after hospital discharge, the amount and duration of discomfort or bodily pain were significantly less in the right axillary thoracotomy group, compared to patients undergoing a conventional median sternotomy (p = 0.033 and p = 0.014, respectively). All data in this study were obtained within 2 years of the patient’s surgical procedure, and two out of six QOL questions (question 4 and question 5) include a specific time frame of 1 month post-operatively, which limits or could influence answers should the time frame be left open and/or asked at an earlier or later date. Although conjecture, it is uncertain whether this time frame after surgery is enough to capture potential differences in a patient’s global health and physical limitations, or highlights psychological benefits pertaining to self-perception with a hidden scar. It is possible that with increased follow-up time after surgery, physical limitations, symptoms, or simply perceived psychological status and body perception could be different between the two incisions, which begs for longer follow-up studies of similar design.