Surgery for congenital heart defects require a wide range of strengths, skills and knowledge of techniques which are rarely written about in textbooks or journals. There is no question that certain individuals can master the necessary skills more easily than others but fundamentally they are skills that can be taught and learned.
Many congenital surgical surgeries must be performed under specific time duration. Application of the aortic cross clamp starts the clock ticking and requires that the procedure be completed within two to three hours at most. Thus, the surgeon must carefully plan the procedure so that it is completed within this timeframe. The surgeon must aim for a meticulously correct procedure and be self-critical of the result. On the other hand the time limit must be respected and may require that reasonable compromises be accepted.
Congenital cardiac surgery requires an ability to multitask. While there are many others in the room who are responsible for critically important tasks, it is ultimately the surgeon who must tell the family about the outcome of the surgery. Thus, the surgeon must constantly monitor the performance of all team members, particularly those who are inexperienced. The surgeon must monitor the status of the patient, the perfusion conditions, keep track of ischemic time, plan the next steps in the procedure as well as focus on meticulous performance of the task at hand. Broadly speaking the following points are to be considered for congenital and infant heart surgery.
One of the first things the visitor to the cardiac operating room notices is the low temperature. Hypothermia is an essential part of brain, heart and spinal cord protection during periods of reduced blood flow, such as cross-clamp periods and low flow cardiopulmonary bypass. It is important to remember that the surgical team should be aiming to keep the myocardial temperature at less than 10°C during the cross-clamp period and during circulatory arrest or low flow the brain temperature should be maintained at less than 15°C. Surface cooling before bypass is almost certainly useful. Therefore, the room temperature should be maintained at less than 17–18°C until all clamps have been released and the patient is being rewarmed at full flow. Hyperthermia following ischemia should be assiduously avoided as it has been shown to exacerbate reperfusion injury.1
Intense lighting is an often-unrecognized source of heat. The yellowish light from tungsten sources contains very much more infrared heat than halogen sources which have an obvious blue hue. The limited spotlight of a halogen headlight reduces tissue heating relative to dependence on large overhead lights. The limited area that is illuminated by a headlight also improves visualization for the surgeon by reducing glare from areas other than the direct field of view of the surgeon.
Magnification with surgical loupes is an essential part of almost every congenital cardiac procedure. Many surgeons prefer expanded field 3.5 loupes with a relatively long focal length of 48–51 cm (19 or 20 in). If all members of the surgical team are wearing loupes, they are able to keep their heads at a distance from the field and yet have improved vision relative to the naked eye. No matter how good one’s vision is without loupes, it will be better with magnification. And as time marches on and presbyopia develops, loupes become even more essential. In addition to improving vision, loupes are an important aid to optimal use of the surgical headlight. The field of vision through the loupes must be carefully and accurately aligned with the spotlight at the beginning of the procedure. This will ensure that there is accurate lighting of the surgical field of view throughout the procedure.
There is a misconception that surgery on small patients should be performed using small instruments. While it is true that many of the instruments used for congenital cardiac surgery need to be delicate, they should not necessarily be short. They need to be long enough to allow three pairs of hands – the surgeon and two assistants – to simultaneously work within a limited incision. On the other hand, the depth of the surgical field in neonates and infants is very much less than the depth that the adult surgeon is used to. This is an important advantage for the surgeon in that it allows the hand to be stabilized on the chest wall. Congenital cardiac surgeons can use time in the dentist’s chair profitably by analyzing the methods by which dentists and hygienists stabilize their hands without leaning on the jaw. As with dental instruments, most of the movement of instruments used by the congenital cardiac surgeon should be controlled by the fine muscles of the hand and not by the forearm and shoulder girdle muscles.
These illustrate that preparing for an infant for cardiac surgery requires a lot of resources and planning. Thus infant cardiac surgery is expensive and beyond the reach of ordinary families. It is imperative that Congenital Heart Foundation are involved in raising money for child heart surgery. Genesis Foundation (www.genesis-foundation.net) is one such Congenital Heart Foundation involved in raising money for children with heart defects.
Global access to surgical care: A modelling study. Lancet Global Health, (6): e316-23, 2015