Setting Up A Minimal Access Mitral Service
ishtiaq ahmed, Andrew Hill, Ashok Narayanasamy, Mauricio Vieira, Jonathan Sheppard, Jennifer Santos, Jocelyn Baluyot, Victoria Parish, Joon Lee, Uday Trivedi.
Royal Sussex County Hospital, Brighton, United Kingdom.
OBJECTIVE: Minimal Access Mitral Surgery is established practice in many high volume centres across the world. However only <5% of mitral surgery in the UK is performed via this route. Reasons for this are varied and include learning curves, governance and financial implications of setting up such a service. We aimed to set up a new service and demonstrate the steps taken so this can be reproduced in other units to help facilitate the growth of this procedure.
METHODS: The approach involved a specific 'team approach' for surgeon, anaesthetist, perfusion and scrub nurses. A stakeholder analysis was important to get support from management, cardiologists and radiology. Multiple meetings established the importance, challenges and benefits of setting up such a program. Cost benefit analysis demonstrated that this was feasible even in the difficult economic climate in the National Health Service. A separate multidisciplinary meeting was set up to plan technical aspects and review 3D echo and CT imaging preoperatively. Multiple aspects were initially adopted during the usual sternotomy cases including use of endoscope, specialized peripheral cannulation, organization of the ergonomics of theatre and increased use of automatic suturing devices. This was to increase the familiarity of the whole team to the procedure. Multiple dry lab simulations were also carried out.
RESULTS: By utilizing a step by step process and maintaining a close 'team environment' all the equipment was used initially very successfully during the sternotomy cases and also during re-do cases. The team progressed to moving from simulation, to using long shafted instruments and endoscopes routinely during sternotomy. Finally the team moved onto minimal access mitral surgery via a limited working port in the right chest. The team has now completed 8 cases. All cases had successful mitral repair, with no intra operative complications.
CONCLUSIONS: Although much of the literature around starting a minimal access program hinges around the surgeons and their technical ability, we demonstrate a step by step way to engage with the wider members of the theatre, cardiovascular, management and radiology teams to ensure a smooth and safe adoption of this technically challenging procedure.
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