الفهرس 
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Abstract
The standard incision for cardiac valve operations has been the median sternotomy, which has proved to be a versatile and reliable approach to the heart. However, it has a recognized incidence of non healing and does limited return to normal activity during the healing process. Because of these known difficulties, alternative “minimal-access” incisions have been proposed. Upper mini sternotomy with partial or complete transverse sternotomy allow central cannulation for cardiopulmonary bypass with standard equipment and, if necessary, rapid conversion to a full median sternotomy with minimal additional morbidity.
Early reports of minimally invasive aortic valve operations included the use of the upper mini sternotomy first recorded by Gundry et al. (1998). This incision is performed by locating the sternal notch and the fourth intercostal space. A skin incision is made that allows transection of the sternum from the sternal notch to the level of the forth intercostal space, which is inferior to the level of the aortic valve. At this point, either a partial transverse sternal extension to the right or a full transverse sternal transection can be done. The internal mammary arteries do not need to be ligated or mobilized. Exposure of the cardiac structures in this manner results in excellent viscualization of the aortic valve and permits central cannulation with standard equipment.
instruments to remove or cut calcified valves, the difference between traditional exposure and ministernotomy is that ministernotomy permits the surgeon access only to that portion of the heart of interest, rather than “seeing” the entire cardiac structure. The role that small incision play in patient well-being and comfort should not be underestimated nor questioned as a worthy goal.
The small skin incisions have been uniformly praised by patients, and to date there have been no wound complications nor sternal healing problems.
In this study:
60 cases with isolated mitral or aortic valve disease where studied at Hero DMC heart institute in india , they were divided into two groups according to the type of incision used for valve replacement. Both groups were assessed preoperatively, operatively and postoperatively to compare both groups and evaluate the advantages and disadvantages of minimally invasive incision.
Advantages of minimally invasive incision in this study:
Patients take short time on ventilator and need less time to extubation, some patients were extubated on table, blood loss in chest tube decrease than normal so most of the patients not in need to blood transfusion, patients can be tolerate chest discomfort so they are not request much analgesics and less affection of pulmonary function tests, decrease the I.C.U and hospital stay period which decrease the total cost, decrease the incidence of infection which with small incision give cosmetic scare and patient satisfaction.
Conclusion
from the results of the current study the following can be concluded:
1- Minimal access aortic valve replacement (upper ministernotomy) could be used alternatively with comparable safety to conventional aortic valve replacement (full sternotomy) for aortic valve replacement.
2- Minimal access aortic valve replacement (upper ministernotomy) approach demonstrated shorter operative time, less postoperative pain, less postoperative bleeding, shorter ICU and hospital stay, and better cosmetic appearance than conventional approach (full sternotomy).