FIG 16.5 Transverse thoracosternotomy The skin and subcutaneous tissues are divided with a combination of the knife and electrocautery along the solid line as indicated A subcutaneous flap beneath the breast tissue is developed until the fourth or fifth intercostal space is reached The intercostals are then divided at the desired interspace (dashed line) The internal mammary arteries are identified and ligated The sternum is then divided transversely at the interspace in which the thoracic cavities were entered The anterolateral thoracotomy is shown in Fig 16.6 The right anterolateral thoracotomy has been used for repair of a variety of congenital cardiac malformations, with good results.35–40 The anterolateral thoracotomy can be placed in the mammary crease and has been used as an alternate, more cosmetically appealing approach for simple intracardiac operations such as closure of atrial septal defects.41 There have been isolated reports, however, of compromised or asymmetric development of the breast with this incision,42,43 and of increased pain.44 The left anterolateral thoracotomy is often used on the hemodynamically unstable victim of thoracic trauma with suspected damage to the thoracic structures If sufficient access is not possible with this incision, it can be extended across the midline for further access to cardiac structures FIG 16.6 Anterolateral thoracotomy The skin and subcutaneous tissues are divided with a combination of the knife and electrocautery along the line indicated In some individuals, it is necessary to develop a flap beneath the subcutaneous tissue to reach the desired intercostal space The pectoralis major and the intercostal muscles in the desired space of entry are then divided In some individuals, the skin incision can be made more laterally, avoiding division of the pectoralis major Minimally Invasive Approaches In continued attempts to improve the cosmetic results after surgery, a variety of minimally invasive techniques have emerged Originally applied to adults, they are now frequently applied to children Among these techniques are partial upper and lower sternotomy, video-assisted thoracoscopic surgery, the minithoracotomy, the subxiphoid approach to the heart, and robotic techniques.45–48 Use of these techniques is controversial Opponents cite the potential for compromised exposure, and the accompanying increased risk of the procedure Proponents cite the psychosocial benefits of smaller incisions The potential for limited exposure must be balanced against the complexity of the case, and the likelihood of future reoperation Partial sternotomies can consist of a partial superior sternotomy or a partial inferior sternotomy The partial upper sternotomy has been used for such complex procedures as the arterial switch operation.49 The inferior partial sternotomy has been commonly used for many years for procedures such as placement of epicardial pacemaker leads, where access to the anterior portion of the heart or atrium is needed Atrial septal defects have been repaired through this incision.50 More recently, a broader range of cardiac operations have been performed through this incision including closure of ventricular septal defects, repair of tetralogy of Fallot and atrioventricular septal defect with common junction, and procedures on the mitral valve.49–53 In small children with more pliable sternums, a similar variety of procedures has been accomplished through a subxiphoid incision.54 The vertical infra-axillary thoracotomy has also been reported as a minimally invasive alternative to median sternotomy for closure of atrial septal defects In addition to the cosmetic result, the risk of injury to developing breast tissue in female patients is avoided with this approach.55 Video-assisted thoracic surgery has become a mainstay of general thoracic surgery during the last decade In this type of procedure, one large incision is replaced by two to four smaller incisions (Fig 16.7) A thoracoscope is placed through one incision Other ports are used to place stapling devices, thoracoscopic scissors, or instruments for dissection and retraction The technique has been used for ligation of the arterial duct, closure of interatrial communications, and division of vascular rings.55–59 In some series, pain and postoperative stay are significantly reduced.60–64 When used for closure of interatrial communications in adult patients, video-assisted thoracoscopic surgery has been shown to be safe, with a shorter length of intensive care unit stay compared to full open sternotomy.65 The majority of adult patients (more than 60%) undergoing this technique for interatrial communications closure are extubated in the operating room.65 In pediatrics, video-assisted thoracoscopic surgery has been predominantly employed for division of vascular rings In a large single institution series over 25 years, there seemed to be waning enthusiasm for this approach in the more contemporary surgical era.66 This lack of enthusiasm may be related to the risk of life-threatening, difficult-to-control bleeding in patients with a patent double aortic arch.67 ... than 60%) undergoing this technique for interatrial communications closure are extubated in the operating room.65 In pediatrics, video-assisted thoracoscopic surgery has been predominantly employed for division of vascular rings