States of mind: #1 – less invasiveness (limited access cardiac surgery)

Cardiac surgery underwent a huge change since its beginnings. From an adventurous, dangerous but lifesaving endeavour carried out by real Mavericks to a surgery, which is perceived almost as routine and expected to be safe, with good and predictable results. While this latter is true (in the vast majority of cases), the change doesn’t end here: meanwhile, cardiac surgery is perceived as almost too invasive, mainly due to its standard surgical access, the median sternotomy (i.e. the longitudinal split of the long breast bone). The major invasiveness of the access to the heart is against the contemporary trend of minimal access to the internal organs, if possible through a catheter inserted in a peripheral vessel.

Cardiac surgery is transitioning slowly from “major access – major surgery” to “limited access – major surgery”. In other words the operation itself remains unchanged, what changes is the surgical access. The process is slow and it comes late compared to similar transitions in other major surgical disciplines, such as abdominal or orthopedic surgery. There are two main reasons for this.

One is safety. Incidents during surgery can happen, in cardiac surgery they can be life threatening. If the surgical access is a major obstacle in their prevention and more importantly in their correction if or when they happen, surgeons are not motivated to adopt this access. There are, however, ways to address this important issue (see below).

The other reason is the not perceived need for the transition. This specific need emerges when developments create pressure which threatens our vital space. Whole industries and leading companies had to re-invent themselves to avoid shrinkage, many of them with success, others without. Currently, cardiac surgery feels the pressure at various levels: the medical device industry seek new frontiers and markets and are inventing new devices destined to transcatheter treatments. Patients and their families are attracted by less invasive procedures requiring minimal hospitalization even if their results are less definitive or even suboptimal compared to those achieved by open heart surgery. The general practitioners feel these needs and try to find the best compromises to guide their patients. Those cardiac surgeons who are reluctant to leave their comfort zone do not perceive this changing environment.

The message is clear: cardiac surgeons must evolve. They have to invent ways to deliver the excellent functional results obtained by traditional open techniques less invasively.

The task could appear impossible. For many operations less invasiveness is not only feasible, it can yield even better results. This is where the “state of mind” comes into the equation.
To transform the own practice, less or minimal invasiveness must become a conviction, a true commitment. Only when minimal invasiveness is the default and not only an exceptional option, mindsets will start to change. To get there, the surgeon has first to get technically ready. Conferences, literature study, Internet (videos, forums etc.), personal communications and simulation studies (see Figure 1 for one), all this belongs to the technical preparation. Surgical techniques  have to evolve and be adapted during traditional surgeries with the aim to become applicable through minimal accesses. All scenarios, especially the potential incidents, have to be visualised, the surgeon has to go through them until he or she feels well prepared. This approach addresses the concerns regarding safety.

Fig. 1: Invented simulation setup for practicing proximal anastomosis in minimally invasive coronary bypass surgery through a left mini-thoracotomy.

Fig. 1: Invented simulation setup for practicing proximal anastomosis in minimally invasive coronary bypass surgery through a left mini-thoracotomy.


From the decision to realization it can / should take a long time. When the first cases and technical adjustments are done, then minimal access has to be the new default. Every patient has to be primarily considered as a candidate for minimally invasive surgery and only in case of contraindications the type of surgery should be shifted to a full sternotomy. Transitioning towards this new standard and performing an increasing number of limited access, technical adjustments and improvements according to the individual preferences will occur, which will increase the comfort of the surgical team.

This approach will transform also the attitude and mindset of the whole team, from the anesthesiologists to perfusionists and scrub nurses to the intensive care unit.

Less invasiveness should become the new standard, the new state of mind.


PS: a special thanks to Prof. Tristan Yan (Australia) for the permission to use the artwork published on his site