The Evolution of Cardiac Surgery Incisions: From Sternotomy to the Bikini Cut

Valve replacement is done the same way as conventional surgery, except through a robotic-assisted approach: instead of a large incision, four ports are used, and robotic arms carry out the same cross-clamping, cautery, scissors, needle holders and sutures used in open surgery. The only real difference is the approach, long instruments are operated through the robotic arms rather than by hand, giving the surgeon four arms instead of two, with the ability to switch between them.

For valve repairs such as tricuspid valve surgery, cardiopulmonary bypass is established through peripheral cannulation, one line into the aorta feeding the heart, and the SVC and IVC snugged with cannulas for venous return, so blood bypasses the heart via the bypass machine while the heart itself keeps beating. The body is cooled to around 30 degrees so the heart beats at a slower rate, allowing precise stitching while it is still beating, which is generally better for outcomes than arresting the heart, since some hearts do not come off bypass well after being arrested. Aortic and mitral valve work, heart transplants and acute dissections still require arresting the heart, but tricuspid repair is done on a beating heart specifically because the results are better that way.

There is no absolute contraindication as such, complex cases including acute dissections and acute coronary syndromes have been safely transported, and some patients are shifted on ECMO. The determining factor is haemodynamic stability: patients on high inotropic support, requiring more than 5 litres of oxygen per minute, or with an unstable rhythm need to be stabilised where they are rather than shifted immediately. It is a dynamic, case-by-case decision made jointly by the shifting team and the receiving hospital based on a video call reviewing the patient's arterial blood gas and clinical parameters.

This reflects a training distinction rather than a hard rule: cardiac surgeons handle coronary and aortic work, while vascular surgeons handle the thoracic and abdominal aorta and peripheral vascular disease, with some grey zones between the two. These are micro-specialisations within cardiothoracic and vascular surgery training rather than entirely separate fields, and which areas a given surgeon focuses on often comes down to personal interest, coronary, valvular and aortic work in one case, or peripheral and femoral vascular work in another, both trained under the same cardiothoracic and vascular surgery programme.

The most important symptoms are valvular: classic breathlessness, dyspnoea on exertion, and paroxysmal nocturnal dyspnoea, where patients cough at night and cannot lie flat, along with chest pain. On evaluation, echocardiograms and electrocardiograms combined with coronary angiography establish the diagnosis. On examination, a murmur, a raised jugular venous pressure, or an irregular rhythm suggestive of atrial fibrillation with an ejection systolic or diastolic murmur in the mitral area points toward rheumatic heart disease with mitral stenosis and regurgitation. In short, the heart has only a few ways of signalling distress, tachycardia or bradycardia, changes in blood pressure, breathlessness or pain, and any of these symptoms warrants evaluation by a physician.

A high burden of rheumatic heart disease in young women at marriageable age, for whom a visible chest scar carried social consequences, drove the development of the inframammary, groin and 'bikini' incisions that could be concealed by clothing.

A periareolar incision of around 2 cm, used for select cases such as combined atrial septal defect closure with mitral valve repair, allowing discharge as early as day three with minimal pain and no visible trauma.