Total thoracoscopic approach
Patients in the thoracoscopic group (TT) were positioned supine in a 15 to 20 degrees left lateral decubitus position. Double lumen endotracheal tube intubation with a transient single lung ventilation strategy was performed under general anesthesia, and then venous cannulation consisted of a right percutaneous (16-Fr) superior vena cava (SVC) drainage catheter placed through the internal jugular vein, using ultrasonography guidance for placement. Three small ports were made on the right side of the chest. The first port (2.5–3 cm) was positioned in the fourth intercostal space outside the right midclavicular line. This port was used for the insertion of surgical instruments such as acutenaculums and scissors. The second port (1–1.5 cm) for the entry of instruments was handled by the left hand of the operator. The cross-clamp of aorta (ACC) occlusion forceps was made in the fourth intercostal space, anterior axillary line. The third port (1.0–2.0 cm) for the placement of the 5-mm thoracoscope was located in the fifth intercostal space between the mid-axillary line and the anterior axillary line (Fig. 1). A tissue retractor was inserted into the port immediately if each port was made. This could fix the incision open to protect the muscle and intercostal vessels, while facilitating access of the scope and instruments. The right common femoral vein was cannulated with a multiport (24- or 28-Fr) venous drainage catheter. The vena cava were isolated with separate tourniquet snares, similar to sternotomy-based surgery. The right common femoral artery was cannulated using a 17- or 19-Fr arterial cannula. The ascending aorta was cross-clamped with a transthoracic aortic cross-clamp and antegrade cardioplegia was delivered into the aortic root, while the body temperature dropped to 32 °C. A midbody right atriotomy was made after the superior and inferior vena cava were blocked. If the VSD could be exposed directly, it was closed with a patch of autologous pericardium or a bovine patch. If the VSD was inadequately exposed using the transatrial approach, detachment of the tricuspid valve was performed. The septal tricuspid valve was partially detached by a circumferential parallel incision 2 mm away from the annulus, and the septal leaflet was suspended by 3 or 4 sutures (Fig. 2). After the VSD was continuously sutured with a patch, the septal leaflet was reattached to the annulus with a continuous suture, with the patch sandwiched between the leaflet and the annulus. Finally, the tricuspid valve coaptation and competence were assessed by injecting the cold saline into the right ventricle. The right thoracic cavity was flooded with CO2 via the second port throughout the procedure to avoid gas embolisms. Transesophageal echocardiography was used in each patient immediately after the VSD repair.