Surgical treatment of patent ductus arteriosus

Surgical approach and exposure of the operative field

The surgery is always performed under deep endotracheal anesthesia. To ensure an adequate view, surgeons use a left-sided lateral thoracotomy, entering the thoracic cavity through the fourth intercostal space.

The first step within the wound itself is accessing the vascular bundle:

• The mediastinal pleura is incised directly above the aorta and the left branch of the pulmonary artery.
• The pleural incision must run strictly between two important landmarks: the phrenic and vagus nerves.
• The created pleural flaps are gently retracted, allowing visualization of the anterior surface of the ductus arteriosus.

Identification and isolation of the ductus arteriosus

A reliable diagnostic criterion confirming that the surgeon has reached the functioning duct is a characteristic palpation sign—a continuous systolic-diastolic thrill is felt over the pulmonary artery.

The isolation process requires extreme caution:

1. The vagus nerve is gently encircled with a special tape and retracted dorsally (posteriorly) to avoid damaging it during further manipulations.
2. The tissues around the duct are separated using a combined method: both blunt and sharp dissection.
3. The greatest challenge is the mobilization of the posterior wall of the duct. In this area, very dense connective tissue adhesions between the vessel and the left main bronchus are frequently encountered.

Classic ligation technique

If the anatomy permits, the duct is obliterated by placing silk ligatures.

Two threads are passed beneath the isolated vessel. Before tying them, a trial clamping must be performed. If the duct is clamped correctly, the systolic-diastolic thrill should completely disappear.

There is a strict algorithm for knot tying:

• First, the ligature on the aortic side is tied.
• Then, the thread at the pulmonary end is secured.

To prevent fatal slippage of the threads (as shown in the surgical diagrams), the tissue between the two placed ligatures is additionally transfixed, after which the thread is securely tied on both sides.

Technique of duct division

In some cases, simple ligation is insufficient, and complete anatomical division of the vessel is required.

This step carries a high risk of hemorrhage and therefore requires careful preparation:

• Extensive mobilization of the aorta is performed both above and below the level of the duct origin.
• The aorta is encircled and secured with rubber vessel loops. This is a critically important step to ensure control: if bleeding from the duct stump begins, the surgeon will be able to instantaneously clamp the aorta.
• Exactly two clamps are applied to the ductus arteriosus itself.
• The vessel is divided with a scalpel or scissors strictly between the instruments.
• The resulting ends (stumps) are carefully sutured.

The intrathoracic stage of the operation concludes with the closure of the mediastinal pleura using interrupted sutures along its edges. There are also modifications of the procedure in which isolation and ligation of the duct are performed intrapericardially.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Topography of the vagus and phrenic nerves in the projection of the aortic arch
• Anatomy of the left main bronchus and its relationship with the great vessels
• Rationale for choosing a transfixation ligature for slippage prevention
• Intrapericardial approach: indications and surgical technique

Other topics in the section "Operations on the Chest Wall and Thoracic Organs"

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