The String Puppet Technique to Improve Exposure in Totally Endoscopic Mitral Valve Surgery

Aim To determine the feasibility of the string puppet technique as a flexible, dynamic alternative to atrial retractors in totally endoscopic non-robotic mitral and tricuspid valve surgeries.Method Fifty-one (51) consecutive patients were operated on for totally endoscopic mitral valve repair from July 2017 to February 2018. A 3 cm peri-areolar (males) or submammary (females) incision was placed on the right chest. The thoracic cavity was accessed via the fourth intercostal space. A temporary pacing wire was placed transcutaneously as a puppeteering sling in the thoracic cavity under endoscopic vision. Multicoloured sutures were used to expose the right atrium and interatrial septum by weaving and suspending the sutures on the sling. The sling was tightened to pull up the walls of the cardia and manipulate them externally, like a puppet on a string, to improve selective exposure.Results We were able to obtain adequate exposure of the mitral and tricuspid valves in all patients without the use of atrial retractors. No patient required conversion to sternotomy due to lack of exposure. None of our patients had postoperative mitral regurgitation of more than 1+ over a mean follow-up of 2 years.Conclusions The string puppet technique improves exposure of mitral and tricuspid valves in totally endoscopic cardiac surgery. It is safe, effective, easy to perform, and inexpensive.