title: How to set-up a program of minimally-invasive surgery for congenital heart defects.
abstract: BACKGROUND
  Mid-line sternotomy is the commonest incision for cardiac surgery. Alternative approaches are becoming fashionable in many centres, amidst some reluctance because of learning curves and overall complexity. Our recent experience in starting a new program on minimally invasive pediatric cardiac surgery is presented. The rationale for a stepwise onset and the short-medium term results for a three-year span are displayed.
  
  
  METHODS
  A three-step schedule is planned: First, an experienced surgeon (A) starts performing simple cases. Second, new surgeons (B, C, D, E) are introduced to the minimally invasive techniques according to their own proficiency and skills. Third, the new adopters are enhanced to suggest and develop further minimally invasive approaches. Two quality markers are defined: conversion rate and complications.
  
  
  RESULTS
  In part one, surgeon A performs sub-mammary, axillary and lower mini-sternotomy approaches for simple cardiac defects. In part two, surgeons B, C, D and E are customly introduced to such incisions. In part three, new approaches such as upper mini-sternotomy, postero-lateral thoracotomy and video-assisted mini-thoracotomy are introduced after being suggested and developed by surgeons B, C and E, as well as an algorithm to match cardiac conditions and age/weight to a given alternative approach. The conversion rate is one out of 148 patients. Two major complications were recorded, none of them related to our alternative approach. Four minor complications linked to the new incision were registered. The minimally invasive to mid-line sternotomy ratio rose from 20% in the first year to 40% in the third year.
  
  
  CONCLUSIONS
  Minimally invasive pediatric cardiac surgery is becoming a common procedure worldwide. Our schedule to set up a program proves beneficial. The three-step approach has been successful in our experience, allowing a tailored training for every new surgeon and enhancing the enthusiasm in developing further strategies on their own. Recording conversion-rates and complications stands for quality standards. A twofold increase in minimally invasive procedures was observed in two years. The short-medium term results after three years are excellent.
authors.affiliation: Department of Pediatric Cardiac Surgery, Hospital Gregorio Marañón, Madrid, Spain; ; Department of Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.
authors.forename: Juan-Miguel
authors.initials: JM
authors.lastname: Gil-Jaurena
authors.affiliation: Department of Pediatric Cardiac Surgery, Hospital Gregorio Marañón, Madrid, Spain; ; Department of Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.
authors.forename: Ramón
authors.initials: R
authors.lastname: Pérez-Caballero
authors.affiliation: Department of Pediatric Cardiac Surgery, Hospital Gregorio Marañón, Madrid, Spain; ; Department of Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.
authors.forename: Ana
authors.initials: A
authors.lastname: Pita-Fernández
authors.affiliation: Department of Pediatric Cardiac Surgery, Hospital Gregorio Marañón, Madrid, Spain; ; Department of Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.
authors.forename: María-Teresa
authors.initials: MT
authors.lastname: González-López
authors.affiliation: Department of Pediatric Cardiac Surgery, Instituto Cardiológico, Bucaramanga, Colombia.
authors.forename: Jairo
authors.initials: J
authors.lastname: Sánchez
authors.affiliation: Department of Pediatric Surgery, Hospital Gregorio Marañón, Madrid, Spain.
authors.forename: Juan-Carlos
authors.initials: JC
authors.lastname: De Agustín
keywords: Sternotomy; axillary; minimally invasive; sub-mammary; thoracoscopy; video-assisted