Repair of this anomaly is usually performed through a left fourth interspace tho- racotomy. In rare cases, when the ductus is located in the right chest, a right fourth interspace incision is used. Division of the isolated ductus rather than ligation is used, except in premature infants or before cardiopulmonary bypass when working through a median sternotomy. Division is safer and should avoid ductal fracture or incomplete closure, which are risks of ligation.
vagus nerve
distal arch
left subclavian artery
ant caud<- ->ceph
post
ductus arteriosus
FIGURE
21-1. The parietal pleura is incised over the left subclavian artery and upper descending aorta to below the anticipated area of the ductus arteriosus. Loose adventitial tissue has also been incised over these structures. The vagus nerve is reflected anteriorly and stay sutures are inserted in the pleura and draped over the lung. The proximal left subclavian artery is dissected and followed caudad to identify the distal aortic arch.
Tissue immediately beneath the arch is incised and this readily allows identification of the cephalad portion of the ductus arteriosus.
444
ant caud<- ->ceph
post
pericardial lappet of Gross ductus arteriosus
FIGURE
21-2. The ductus is dissected along its caudad margin, taking care to avoid injury to the recurrent laryngeal nerve that courses around it. The posterior aspect of the ductus is dissected, and a right-angle clamp is passed around the ductus to identify the remain- ing posterior fibrous strands of tissue that are to be divided. The pericardial lappet of Gross, located over the anterior surface of the ductus, is dissected from the ductal struc- ture. The ductus can be seen entering the pulmonary artery, and this defines the extent of the dissection. Wide dissection is necessary to provide space on the ductus to apply vas- cular clamps.
ant caud^- -^•ceph
post
corner stitch
pulmonary artery end of ductus aortic end of ductus
FIGURE
21-3. Vascular clamps are applied to each end of the ductus, after which it is
divided, leaving an ample ductal stump near each vascular clamp. The pulmonary artery
end of the ductus is sutured first. Using a continuous monofilament stitch, a running
locking suture is placed as the first layer of the closure. The aortic stump of the ductus is
retracted.
ant caud<- -•ceph
post
pulmonary artery stump
FIGURE
21-4. After the first layer of the pulmonary artery stump closure is completed, the same continuous suture is placed as an over-and-over stitch, forming the second layer of the closure. The suture is tied to the original corner stitch that is placed at the time of the first layer closure.
pulmonary artery end of ductus
recurrent laryngeal nerve
aortic end of ductus
ant caud^- -^•ceph
post
FIGURE
21-5. The aortic stump of the ductus is closed with a similar two-layer closure
stitch. A sponge is packed between the two ductal stumps and the vascular clamps
removed. When needle-hole bleeding stops, the sponge is removed. For more significant
bleeding, adventitial figure-of-eight stitches are placed over the stump. The recurrent
laryngeal nerve is seen arising from the vagus nerve, after which it passes behind the ductus
stump and into the mediastinum posteriorly.
ant caud<- -^ceph
post
ductus arteriosus
FIGURE
21-6. In another infant who is small and premature, the thoracotomy incision is short and posterior in the fourth interspace. A limited parietal pleura incision is made over the patent ductus. The distal arch is identified, below which the ductus arteriosus is located.
Limited dissection is performed freeing only the ductus laterally, cephalad, and caudad, and medially behind the ductus.
ant caud^- -•ceph
post
FIGURE
21-7. A suture buttressed with Teflon® felt pledgets is placed around the ductus.
ant caud^- -•ceph
post
FIGURE
21-8. The ductus is ligated. The felt pledgets provide support for the ligature, which helps avoid laceration of the ductus.
caud^
ductus arteriosus
post
FIGURE
21-9. In another premature infant, limited dissection of the ductus is performed
anteriorly, cephalad, and caudad to that structure.
ant caud<- -•ceph
post
ductal closure clip
FIGURE
21-10. The ductus is then ligated with a single hemoclip. I currently prefer this technique in premature infants because the mediastinal surface of the ductus does not require dissection.
cept R « - - • L
caud
ductus arteriosus
main pulmonary artery
aorta
FIGURE
21-11. In another child, intracardiac repair of anomalies will be performed using
cardiopulmonary bypass while working through a median sternotomy. An associated
patent ductus arteriosus is dissected near the distal main pulmonary artery. It is identified
by locating the proximal right and left pulmonary arteries. The ductus is found between
these two vessels and is ligated with a hemoclip.
cept
R<- ->L
caud
repaired ductus
main pulmonary artery aorta
FIGURE
