Minimal incision and less invasive techniques in congenital cardiac surgery: a narrative review

Background and Objective: Minimal incision and less invasive techniques derive from adult cardiothoracic surgery and they gradually find their application in congenital cardiac surgery. Diffusion of these techniques into congenital cardiac surgery has so far been limited due to case complexity, widespread range of ages and patient dimensions, a need to access multiple segments in a constrained operative field and lack of proper instrumentation. This review endeavors snapshot on techniques currently available with a view of possible future trends. Methods: Literature and international database search was carried out with the relevant key terms. Findings are presented in correspondence with bi-institutional practices of the authors. Key Content and Findings: A minimally invasive approach offers an alternative to conventional open surgery in an environment where not only survival matters but also quality-of-life and avoidance of complications. The final aim extends beyond a more appealing scar, it targets reduction of collateral trauma, and morbidity. The actual surgical method is dictated by the extent of anomalies: solitary defects [e.g., atrial septal defect (ASD), ventricular septal defect (VSD), valvar anomalies] can be addressed by direct access via lateral approach, whereas multicompartment complexes [e.g., tetralogy of Fallot (TOF), simultaneous intracardiac/extracardiac anomalies) often necessitate a limited midline approach. Success relies on detailed personalized preoperative planning that involves multimodality advanced imaging, 3D modelling and emulation on physical models or in augmented reality. Precise execution of the surgical plan requires an uncompromised view, mastering new skillsets, proper instrumentation and detailed briefing of the participants. Throughout the entire continuum-of-care, full multidisciplinary team participation and adherence is essential. On a programmatic level it also includes coaching by experts, strict auditing of results, and dedicated institutional support. Conclusions: Indication for minimally invasive congenital cardiac surgery gradually broadens, however, it is yet to reach complex neonatal/infant procedures involving multiple operative compartments. Progress is documented by the adoption of endoscopy and other visualization modalities, manipulation techniques of robotics and by the emergence of new hybrid procedures.