Three steps in MICS

Three steps to acquire competencies in TCRAT and minimally invasive cardiac surgical procedures

According to the three levels of expertise in minimally invasive cardiac surgical procedures

1) Get comfortable being uncomfortable

Median sternotomy is the standard approach in cardiac surgery and almost all cardiac surgical procedures are done through it. As a result, all instruments and techniques have been designed to be used in sternotomy settings. Same way surgeons developed their skill.  

With minimally invasive surgery surgeon meets new conditions, needs to operate with new instruments, with new methods, with limited operative view, with different tactile perception and often with minimal help from an assistant. 

So, the first step in acquiring competence in minimally invasive cardiac surgery is to admit that these conditions are a new background that couldn`t be changed and new surgical skills are required. 

New skills are needed to comfortably work with new incisions, limited operative view in limited operative field. Anastomotic techniques need to be revised as well.

2) Whole picture and plan of surgery

In minimally invasive surgery surgeons are faced with the different views of operative objects compared to the medium sternotomy. Moreover, surgeons see only one part at a time. Moreover, not all parts of the heart are reachable without cardiopulmonary bypass.

So, planning the procedure, the surgeon should keep in mind the whole view of the operative object, the whole plan of operation, including the sequence of surgical actions and the availability of the exposing maneuvers.

3) Know your limits

The cornerstone of modern cardiac surgery is safety. Safety is obtained when surgeon competencies are more than the complexity of procedures he performs. Complexity of the same surgical procedure can be different in different patients.

Understanding your own competency and the expected surgical complexity are the keys to safety. This guides surgeon throughout the surgical practice and allows expanding the indications to minimally invasive approaches. Competencies in isolated minimally invasive cardiac surgical procedures lead to the simultaneous minimally invasive cardiac surgical procedures, like TCRAT combined with aortic valve replacement (AVR) or mitral valve repair (MVR) done through the minithoracotomies.

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