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Lean Management Systems in Health Care: A Review of the Literature

Winner, Laura E. DrPH, MBA, BSN, LSSBB; Reinhardt, Erica MS, RD, LSSBB; Benishek, Lauren PhD; Marsteller, Jill A. PhD, MPP

Johns Hopkins University School of Nursing, University in Baltimore, Maryland (Dr Winner); Lean Sigma Deployment, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland (Dr Winner and Ms Reinhardt); Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland (Dr Benishek); and Center for Health Services and Outcomes Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Dr Marsteller).

Correspondence: Laura E. Winner, DrPH, MBA, BSN, LSSBB, Lean Sigma Deployment, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, 750 East Pratt St, 15th Floor, Baltimore, MD 21205 ( [email protected] ).

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site ( www.qmhcjournal.com ).

Background and Objectives: 

Many health care organizations now employ Lean tools to improve value in health care, yet reports of their effectiveness vary. This variation may be explained by the context in which Lean is implemented, whether as a tool or as a management system. This article reports on a structured literature review conducted to understand the evidence base for the impact of Lean Management System implementation in health care.

Methods: 

A search of PubMed, Scopus, Emerald, EMBASE, CINAHL, and Business Source Complete databases was conducted in November 2017 and repeated in July 2020 to assess the evidence for the impact of Lean Management Systems in health care from 2000 to July 2020. Articles were included if they (1) reported on a Lean Management System or (2) reported on Lean Management System components as described by Mann1 (ie, leader standard work, visual controls, daily accountability process, and discipline).

Results: 

A total of 52 articles met the inclusion criteria. Although all articles described some combination of leader standard work, visual management, and daily accountability as part of their Lean Management System, only a handful described use of all 3 components together. Only one explicitly mentioned the fourth component, discipline, required to consistently apply the first 3. The majority reported on single-unit or department implementations and most described daily huddles at the unit level that included review of key performance indicators, identification of improvement opportunities, and problem solving. The role of the leader in a Lean Management System was described a coach and a mentor. Barriers to adoption such as insufficient training and increased workload for nurses were noted along with the importance of relevance to the local context for unit teams to find value in huddle boards and huddles. As yet, evidence of Lean Management System effectiveness in driving health care improvement is absent due to weak study designs and lack of statistical rigor.

Conclusion: 

Well-designed research on Lean Management Systems in health care is lacking. Despite increasing adoption of Lean Management Systems over the past 10 years and anecdotal reports of its effectiveness, very few articles provide quantitative data. Those that do report unit-level implementation only, little use of a comprehensive package of Lean Management Systems elements, and weaker study designs and statistical methods. More rigorous study designs and robust statistical analysis are needed to evaluate effectiveness of Lean Management Systems in health care. This represents a rich area for future health care management research.

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Current State of Practice in Developing Lean Six Sigma Training and Certification Programs -an Irish Perspective

• Conference paper
• First Online: 02 August 2024
• Cite this conference paper

• Olivia McDermott 18 ,
• Michelle Regan 19 ,
• Manjeet Kharub 20 ,
• Anna Trubetskaya 19 ,
• Michael Sony 21 &
• Jiju Antony 22  

Part of the book series: IFIP Advances in Information and Communication Technology ((IFIPAICT,volume 681))

Included in the following conference series:

• European Lean Educator Conference

The study aims to review how Lean Six Sigma training and certification programs are conducted in organisations to develop employee competence and advance the programs. The types of training and certification programmes, the approach to development, the critical factors for success and failure, and barriers to development were all investigated. A quantitative survey was conducted with Operational Excellence professionals from various Irish manufacturing industry sectors who had Lean Six Sigma programs. It was found external accreditations of LSS expertise were more prevalent than internal certifications in Irish organisations, and many organisations encouraged completing of continuous improvement projects with valid financial savings before individuals were certified. As well as this, a lack of management support, not setting aside time for the individuals to complete the training, and a lack of recognition and reward for completing training and projects were deemed critical failure factors. The findings from this study can be used to develop a best-practice Lean Six Sigma training and certification program that is open to all employees and is externally accredited. This paper is one of few studies that expose the current practice for designing a Lean Six Sigma training and certification programme in industry.

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Olivia McDermott

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Department of Mechanical Engineering, CVR College of Engineering, Hyderabad, India

Manjeet Kharub

Oxford Brookes Business School, Oxford Brookes University, Oxford, England

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McDermott, O., Regan, M., Kharub, M., Trubetskaya, A., Sony, M., Antony, J. (2024). Current State of Practice in Developing Lean Six Sigma Training and Certification Programs -an Irish Perspective. In: van Kollenburg, T., Kokkinou, A., McDermott, O. (eds) Challenging the Future with Lean. ELEC 2023. IFIP Advances in Information and Communication Technology, vol 681. Springer, Cham. https://doi.org/10.1007/978-3-031-63265-5_17

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Exploring the roles of lean design and operations in improving construction logistics collaboration and supply chain performance

• P. Le , Thuy Quynh Loan Nguyen , Thuy Trang Nguyen
• Published in Architectural Engineering and… 24 July 2024
• Engineering, Business

40 References

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Lean Management Tools and Techniques: A Literature Review for Manufacturing Firms and Employees

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The current state of Lean implementation in health care: literature review

Affiliation.

• 1 Division of Quality Technology and Management, Linköping University, Linköping, Sweden. [email protected]
• PMID: 20924253
• DOI: 10.1097/QMH.0b013e3181fa07bb

Purpose: The purpose of this article is to discuss the current state of implementation of Lean production in health care. The study focuses on the definition of Lean in health care and implementation process, barriers, challenges, enablers, and outcomes of implementing Lean production methods in health care.

Design/methodology/approach: A comprehensive search of the literature concerning the implementation of Lean production in health care was used to generate a synthesis of the literature around the chosen research questions.

Findings: Lean production in health care is mostly used as a process improvement approach and focuses on 3 main areas: (1) defining value from the patient point of view, (2) mapping value streams, and (3) eliminating waste in an attempt to create continuous flow. Value stream mapping is the most frequently applied Lean tool in health care. The usual implementation steps include conducting Lean training, initiating pilot projects, and implementing improvements using interdisciplinary teams. One of the barriers is lack of educators and consultants who have their roots in the health care sector and can provide support by sharing experience and giving examples from real-life applications of Lean in health care. The enablers of Lean in health care seem not to be different from the enablers of any other change initiative. The outcomes can be divided into 2 broad areas: the performance of the health care system and the development of employees and work environment.

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International Journal of Operations & Production Management

ISSN : 0144-3577

Article publication date: 1 July 2014

The advent of recession at the beginning of twenty-first century forced many organizations worldwide to reduce cost and to be more responsive to customer demands. Lean Manufacturing (LM) has been widely perceived by industry as an answer to these requirements because LM reduces waste without additional requirements of resources. This led to a spurt in LM research across the globe mostly through empirical and exploratory studies which resulted in a plethora of LM definitions with divergent scopes, objectives, performance indicators, tools/techniques/methodologies, and concepts/elements. The purpose of this paper is to review LM literature and report these divergent definitions, scopes, objectives, and tools/techniques/methodologies.

Design/methodology/approach

This paper highlights various definitions by various researchers and practitioners. A total of 209 research papers have been reviewed for the research contribution, research methodology adopted, tools/techniques/methodologies used, type of industry, author profile, country of research, and year of publication.

There are plethora of LM definitions with divergent objectives and scope. Theory verification through empirical and exploratory studies has been the focus of research in LM. Automotive industry has been the focus of LM research but LM has also been adopted by other types of industries also. One of the critical implementation factors of LM is simultaneous adoption of leanness in supply chain. LM has become an integrated system composed of highly integrated elements and a wide variety of management practices. There is lack of standard LM implementation process/framework.

Originality/value

The paper reviews 209 research papers for their research contribution, research methodology, author profile, type of industry, and tools/techniques/methodology used. Various characteristics of LM definitions are also reviewed.

• Lean manufacturing
• Lean production
• Lean literature review

Bhamu, J. and Singh Sangwan, K. (2014), "Lean manufacturing: literature review and research issues", International Journal of Operations & Production Management , Vol. 34 No. 7, pp. 876-940. https://doi.org/10.1108/IJOPM-08-2012-0315

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Laser and Light-Based Therapies for Hirsutism Management in Women With Polycystic Ovarian Syndrome : A Systematic Review

• 1 Monash Health, Department of Dermatology, Melbourne, Australia
• 2 Monash Centre for Health Research and Implementation (MCHRI), Faculty of Medicine Nursing and Health Sciences, Monash University, Australia
• 3 Department of Obstetrics and Gynecology, Research Unit of Clinical Medicine, University of Oulu and Oulu University Hospital, Oulu, Finland
• 4 Eastern Health Clinical School, Monash University, Melbourne, 3128, Australia
• 5 Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy

Question   Are laser and light-based hair reduction therapies, either as stand-alone treatments or in combination with other systemic therapies, effective in addressing hirsutism in adults and adolescents with polycystic ovary syndrome (PCOS)?

Findings   In this systematic review of 6 studies reporting data on 423 patients, laser and light-based therapies were found to be effective in reducing hirsutism severity, improving psychological well-being, and enhancing quality of life in women with PCOS, with generally tolerable adverse effects. Simultaneous use of metformin or the combined oral contraceptive pill may offer additional benefits.

Meaning   These findings alongside broader efficacy data and patient preference informed the 2023 International Evidence-based PCOS Guideline, which has now introduced new recommendations on the use of laser and light-based hair reduction therapies for women with PCOS and hirsutism.

Importance   Hirsutism represents a significant concern for women with polycystic ovary syndrome (PCOS), with deleterious psychological effects warranting acknowledgment and a clear imperative to provide effective management. To our knowledge, this is the first review to exclusively examine the effectiveness of laser and light-based therapies in addressing hirsutism in women with PCOS.

Objective   To synthesize the existing literature regarding the effectiveness of laser and light hair reduction therapies, either as stand-alone treatments or in combination with systemic agents, in treating hirsutism for women with PCOS.

Evidence Review   A systematic literature review was performed using MEDLINE, Embase, EMCARE, and CINAHL according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses ( PRISMA ) reporting guidelines. Articles written in English, reporting on patients who met pre-established inclusion criteria were selected. Objective and subjectively measured outcomes relating to the effect of laser or light-based hair reduction therapies on hirsutism were abstracted. Heterogeneity among included studies precluded a meta-analysis, necessitating a narrative synthesis.

Findings   Six studies reporting data on 423 individual patients with PCOS who underwent laser or light-based hair reduction therapies were included: 4 randomized clinical trials and 2 cohort studies. Alexandrite laser demonstrated significant improvements in hirsutism severity and psychological outcomes, particularly at high-fluence application. Alexandrite laser was also found to be more effective than intense pulsed light (IPL). The combination of diode laser with either metformin or combined oral contraceptive pill was superior to the application of diode laser alone, just as the addition of metformin to IPL demonstrated superior results to IPL treatment alone. Overall, most interventions were well tolerated. The overall certainty of evidence across all outcomes and comparisons was limited in part due to the observational nature of some studies.

Conclusions and Relevance   This systematic review highlights the potential of laser and light hair reduction therapies, both as stand-alone treatments and in combination with other pharmacological agents in PCOS. However, this review was limited by low certainty of the evidence, few studies evaluating effectiveness and safety in those with skin of color, and heterogeneity in outcome assessment. Future studies are needed to provide more robust evidence among diverse individuals with PCOS and hirsutism.

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Tan K , Coster T , Mousa A, et al. Laser and Light-Based Therapies for Hirsutism Management in Women With Polycystic Ovarian Syndrome : A Systematic Review . JAMA Dermatol. 2024;160(7):746–757. doi:10.1001/jamadermatol.2024.0623

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• Published: 01 August 2024

Periareolar minimally invasive approach for cardiac surgery: a case series and description of technique with a review of literature

• Hatan Mortada 1 , 2   na1 ,
• Abdulaziz Alsuhaim 3   na1 ,
• Nasser Alkhamees 4 &
• Omar Fouda Neel 5 , 6  

Journal of Cardiothoracic Surgery volume  19 , Article number:  477 ( 2024 ) Cite this article

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Minimally invasive cardiac surgery (MICS) has garnered significant attention for its potential benefits, including decreased surgical trauma, accelerated recovery, and improved aesthetic outcomes. This case series aims to elucidate the technical aspects and assess the aesthetic, functional, and quality of life outcomes associated with the utilization of a periareolar incision approach in female patients undergoing cardiac surgery.

The periareolar MICS technique, performed with or without high-definition (HD) 3D endoscopic visualization, limited rib-spreading, and a periareolar incision spanning the 3 to 9 o’clock positions, was employed. We present a case series encompassing five female patients who underwent various cardiac procedures for different pathologies using this approach.

No intraoperative complications occurred, and all patients experienced uneventful postoperative recoveries. The periareolar approach resulted in well-healed incisions with minimal scaring, preserving breast contour and yielding satisfactory cosmetic outcomes. Patients reported negligible pain levels and expressed contentment with the scar appearance.

The periareolar incision technique in MICS represents an efficacious approach characterized by favorable aesthetic outcomes and enhanced patient experience. Further investigations are warranted to compare different MICS approaches with respect to pain management and their impact on quality-of-life domains.

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Introduction

Minimally invasive procedures offer a range of potential benefits, including reduced surgical trauma, decreased pain, minimized blood loss, shorter hospital stays, faster recovery, improved cosmetic outcomes, and enhanced patient satisfaction [ 1 , 2 , 3 ]. Within specialized centers, minimally invasive mitral valve repair (MIMVr) or replacement (MIMVR) has become a standard procedure [ 4 ]. In the context of cardiac surgery, optimizing both aesthetic and functional aspects is of utmost importance. Patients undergoing MIMVr, for instance, experience earlier resumption of activities, reduced wound infections, decreased trauma, and expedited recovery [ 5 ]. Therefore, a comprehensive understanding of different minimally invasive surgical approaches can significantly enhance the overall patient experience. In the field of plastic and reconstructive surgery, zigzag transareolar approaches have been employed to achieve a close approximation of the nipple and improve exposure. However, concerns persist regarding scar appearance and the potential risks of ductal injury and capsular contracture [ 6 ]. From a cosmetic standpoint, it is crucial to investigate whether the periareolar approach technique offers superior aesthetic outcomes in terms of breast shape, postoperative scarring, and satisfaction when compared to other minimally invasive cardiac surgery (MICS) approaches [ 7 ]. Although Durdu et al. have conducted a comparison between minimally invasive and conventional surgeries, limited research exists on the comparison of different types of MICS approaches in relation to postoperative pain and quality of life [ 8 ]. Therefore, the objective of this study is to evaluate the aesthetic and functional outcomes, as well as the impact on quality of life, in patients who have undergone cardiac surgery utilizing the periareolar incision technique at our institution. Moreover, we have conducted a thorough review of the literature, summarizing, and presenting the findings in a concise and informative manner, including a review of relevant studies in a dedicated literature review table.

• Surgical technique

All patients underwent periareolar MICS +/- HD 3D endoscopic visualization with minimal rib-spreading. A soft tissue retractor with a maximum diameter of 4 cm is utilized, along with a rib spreader when necessary for further exposure. During the procedure, patients are positioned in a 30-degree left lateral decubitus position. In all cases, transesophageal echocardiography (TEE) was performed to confirm preoperative diagnosis and evaluate postoperative end results. Following appropriate sterile preparation and draping, 5000 units of heparin are given to target an ACT more the 200 msec. Our Cardio-Pulmonary bypass (CPB) perfusion technique consists of femoro-femoral cannulation combined with internal jugular cannulation. The right common femoral vessels are exposed through a 2 cm oblique groin incision. Under ultrasound and TEE guidance, Seldinger technique is used to cannulate the right internal jugular vein with a 17 F cannula, while the exposed right common femoral vein is cannulated with a 25 F multistage cannula. Arterial cannulation is obtained through sewing an 8 mm Hemashield graft to the right common femoral artery. At this point, the plastic surgery team conducts a preoperative marking for a classic periareolar breast augmentation technique, with an incision ranging from 3 o’clock to 9 o’clock. Size of the incision differs from one patient to another depending on the areolar size. Dissection is performed in an inferior fashion, leaving a 2 cm thick S flap extending down to the prepectoral pocket. Dissection above the pectoralis muscle is carried out at the level of the 4th intercostal space, similar to prepectoral breast augmentation techniques. If a breast implant is present, the implant will be removed to expose the thoracic wall.

A right mini thoracotomy is performed in the fourth intercostal space, and a 2 − 0 ethibond pledgeted suture is used to retract the diaphragm caudally. The pericardium is opened 3 cm above the phrenic nerve then suspended laterally. Two pledgeted 3 − 0 prolene sutures are placed on the aorta below the planned cross clamp level for the cardioplegia cannula. Once the cardioplegia cannula is inserted, a transthoracic “Chitwood” aortic cross clamp is applied. Custodiol cardioplegia (1.5 L) is infused in an antegrade fashion to induce cardiac arrest during diastole. Patients body temperature is cooled down to 32 degrees celsius as a protective strategy for the brain and other organs during CPB. The left atrium is accessed through sondergaard’s groove while the right atrium is accessed through an oblique right atrial incision. In this study, the scar outcome at different stages in all patients was carefully assessed. All patients included in the study provided their consent to have their cases reported, and corresponding figures showcasing the scar progression were attached to support the findings. Patients were considered for inclusion in this study if they were female, had an indication for cardiac surgery, and expressed a preference for a minimally invasive approach with an emphasis on aesthetic outcomes. Exclusion criteria included male gender, inability to provide informed consent, and the presence of contraindications to minimally invasive surgery, such as severe pulmonary hypertension or previous right thoracic surgery. Patients with a history of breast surgery or implants were not excluded from this study.

Case study − 1

A 29-year-old female patient with a history of mitral valve prolapse with severe mitral valve regurgitation, as well as bilateral prepectoral breast augmentation, presented for minimally invasive mitral valve repair utilizing a periareolar incision approach with right-sided implant revision. The patient had an American Society of Anesthesiologists (ASA) classification of 3. Prior to the cardiac procedure, the plastic surgery team performed a periareolar incision on the right breast, extending from 3 to 9 o’clock, exposing the chest wall. Subsequently, the cardiac surgery team proceeded with the mitral valve repair using a bileaflet neochordae implantation technique and a slightly oversized annuloplasty ring. During the procedure, the plastic surgery team conducted an implant revision and closed the incision in a standard multilayer fashion. The estimated cross clamp time was 103 min, and no intraoperative complications occurred.

Following the surgery, the patient was admitted under the care of the cardiac surgery team for a five-day duration, including one day in the intensive care unit (ICU). The patient’s postoperative course was uneventful, apart from experiencing multiple episodes of delirium. Regarding the breast augmentation aspect, upon admission to the hospital, the patient reported no pain, redness, tenderness, hematoma, discharge, or signs of infection at the incision site. Subsequent follow-up visits at the clinic revealed a well-healed, flat scar with preserved breast shape. The scar size measured approximately 3 cm, without any noticeable hypo/hyperpigmentation changes. The patient expressed satisfaction with the augmentation results and scar outcome.

The patient reported temporary numbness around the areola and nipple for the initial two weeks following the surgery, which is a known and expected complaint associated with the periareolar incision technique, as documented in the literature. It is important to note that an areola diameter smaller than 3 cm can pose challenges in exposing cardiac structures during the surgery, sometimes requiring additional efforts, and potentially resulting in extensions beyond the areolar region, thereby increasing the risk of numbness in that area. However, in this particular case, the patient did not experience any complications related to the surgical approach. Additionally, the patient mentioned a small breast lump on the lower aspect of the breast, but subsequent radiological studies confirmed benign findings.

Case study − 2

A 17-year-old female patient was diagnosed with a superior sinus venosus atrial septal defect (SV-ASD) with partial anomalous pulmonary venous drainage (PAPVD) since birth. She had no other underlying medical conditions and was classified as ASA 3 by the anesthesia team. The anatomy of her ASD and associated anomalies necessitated surgical intervention. The plastic surgery team performed a periareolar incision encircling the areola, extending from 3 to 9 o’clock, to gain access to the chest wall and heart. The cardiac surgery team proceeded with the repair of the SV-ASD and the PAPVD using a two patch (bovine pericardium) technique, where a baffle was created to direct the drainage of the right superior and middle anomalous pulmonary veins to the left atrium and a second patch to enlarge the cavoatrial junction to prevent SVC narrowing. The total estimated cross clamp time was 164 min, and the operation proceeded smoothly without encountering any complications.

Following the procedure, the patient was initially admitted to the Intensive Care Unit (ICU) and subsequently transferred to the ward under the care of the cardiac surgery team and discharged home on the 4th day postop. Throughout this period, there were no indications of pain, redness, swelling, discharge, or signs of infection at the incision site. The wound was diligently maintained, with regular assessments of its integrity, cleaning, and dressing performed by the plastic surgery team. During follow-up visits at the clinic, the patient did not report any concerns regarding the periareolar incision scar. No instances of numbness, pain, or discoloration were reported by the patient. In fact, the scar exhibited clarity and a flat appearance, characterized by well-defined borders. The patient expressed satisfaction with the overall outcome of the scar. The size of the scar measured approximately 2.8 cm, with minor hypopigmentation changes noted.

Case study − 3

A 35-year-old female patient was diagnosed with Left Atrial Myxoma after presenting with a headache and blurry vision. Aside from this condition, she had no other underlying medical issues and was classified as ASA 3 by the Anesthesia team. A transesophageal echocardiogram showed that tumor was located at the cranial aspect of the left atrium at the entrance of the right superior pulmonary vein. Surgical resection of the tumor was planned for the patient. The surgical approach involved a periareolar incision performed by the plastic surgery team, extending from 3 to 9 o’clock. This incision provided adequate exposure for the cardiac surgery team to perform an en Bloc resection of the myxoma. Following the successful resection, the plastic surgery team meticulously closed the incision. The total estimated cross clamp time was 92 min. The patient was admitted to the Intensive Care Unit (ICU) initially and subsequently transferred to the ward, she was discharged home on the 6th day postop. Throughout her hospitalization, the plastic surgery team consistently monitored the wound, which exhibited no signs of pain, redness, swelling, discharge, or infection. The wound was diligently cleaned and appropriately dressed.

During follow-up visits at the clinic, the scar was found to be clean with well-defined margins, flat, and mildly hyperpigmented. The patient expressed satisfaction with the outcome of the scar, reporting no history of color changes or raised areas at the incision site. However, she did experience numbness at the site of the incision for a duration of 1 month following the surgery.

Case study − 4

A 42-year-old female patient was diagnosed with a large size secundum atrial septal defect (ASD) with a deficient inferior rim. She had no other concurrent medical conditions and was assessed by the anesthesia team, who classified her as ASA 3. The surgical approach utilized in her operation was consistent with the previously mentioned cases, involving a periareolar incision performed by the plastic surgery team, extending from 3 to 9 o’clock. The ASD was successfully patched using bovine pericardium, with no complications encountered during the procedure. The total estimated cross clamp time was 100 min.

Following the surgery, the patient was admitted to the ICU and subsequently transferred to the ward and was discharged home on the 5th day postop. Throughout her hospital stay, the plastic surgery team consistently monitored and assessed the wound, which remained clean and exhibited no indications of pain, redness, swelling, discharge, or infection. During the patient’s follow-up visit at the clinic, she expressed satisfaction with the outcome of the scar. The scar appeared clean, flat, with well-defined margins. Overall, there was minimal pigmentation, except for a slight hypopigmentation noted at the 5 o’clock position. However, the patient conveyed contentment and satisfaction with the overall result (Fig.  1 ).

Scar Outcome at Different Stages in Different Patients. ( A ) Immediate postoperative scar after skin closure. ( B ) Scar appearance at 10 days after closure. ( C ) Scar appearance at 2 months after surgery. ( D ) Scar appearance at 4 months after surgery, where the scar is nearly invisible

Case study – 5

A 57-year old female patient was diagnosed with secundum ASD and cor triatriatum sinister. She had no other concurrent medical conditions and was assessed by the anesthesia team and classified as ASA 3. The surgical approach utilized in her operation was consistent with the previously mentioned cases, involving a periareolar incision performed by the plastic surgery team, extending from 3 to 9 o’clock. However, in this case a cor triatriatum sinister was present. Upon identification, resection of the fibromuscular membrane with complete visualization of the left atrium including the mitral valve and pulmonary veins was achieved. The ASD was patched utilizing bovine pericardium with no complications encountered during the procedure. The total estimated cross clamp time was 173 min. The patient was admitted to the ICU after the surgery and she was subsequently transferred to the ward. The wound was assessed and monitored daily by the plastic surgery team. On the 6th day postop, the patient was discharged home with no cardiac or wound complications. A comprehensive summary of patient demographics, clinical diagnoses, surgical approaches, and postoperative outcomes is presented in Table  1 .

This study provides valuable insights into the effectiveness of the periareolar incision technique in cardiac surgery for eligible patients. It emphasizes the importance of understanding the advantages, disadvantages, indications, and potential complications associated with different surgical approaches. By staying updated with new techniques and innovations, we can significantly improve healthcare outcomes and enhance the overall quality of life for patients undergoing cardiac surgery. Additionally, we have provided a narrative review of previous publications in Table  2 .

While the primary objective of cardiac surgery is to save lives, it is crucial to recognize the psychological, aesthetic, and mental well-being of patients as equally significant. Chest scarring has been shown to impact patients’ self-esteem and self-confidence, as well as various aspects of their lives such as career choices, success, relationships, and recreational activities [ 13 ]. This understanding has driven the development of new techniques in the surgical field that not only address the primary issue but also offer additional advantages. One such innovative technique is minimally invasive cardiac surgery, which reaps the benefits of the periareolar incision approach. Both patients and surgeons consistently report highly satisfactory results with this approach. The periareolar incision, a well-established technique in aesthetic and reconstructive surgery, has demonstrated minimal complications and excellent aesthetic outcomes [ 14 , 15 ]. This approach greatly facilitates wound care, reduces complications for surgeons, and promotes faster healing, improved cosmetic outcomes, and fewer complications for patients. Furthermore, this approach has shown that it can be utilized for various cardiac diseases. As this approach provides perpendicular visualization of the surgical field which aids in the repair of different structural heart disease pathologies. On the other hand, angled visualization might be necessary in mitral valve procedures which can be easily achieved using an endoscopic camera. However, it is important to acknowledge that the need for a standby plastic surgery team in the hospital is a limitation of this technique. While our study focuses on the periareolar minimally invasive approach, it is important to consider alternative techniques that have been described in the literature. One such technique is the tumescent local anesthesia approach for breast augmentation in transgender patients, as reported by Tettamanzi et al. [ 16 ]. This technique offers potential advantages, such as reduced postoperative pain and faster recovery. However, the periareolar approach provides direct access to the cardiac structures without the need for extensive dissection, which may be beneficial in certain cases. Future studies should directly compare these approaches to determine their relative benefits and limitations in the context of minimally invasive cardiac surgery.

Studying these emerging techniques requires dedicated efforts, and this study represents the first investigational description and evaluation of the periareolar incision approach in Saudi Arabia. Patient data were meticulously documented, evaluated, and recorded to minimize potential recall bias. Nonetheless, limitations are inherent in any study. While we believe our sample size is adequate for a case series study, a larger sample size would undoubtedly provide more robust results. Our study design primarily focuses on describing and documenting patients’ experiences from initial presentation to final follow-up, thereby capturing short-term patient experiences and lacking long-term pre- and post-intervention data. This study predominantly focuses on qualitative variables, with limited coverage of quantitative variables. We are optimistic that this study will serve as a foundation for future research projects on the periareolar incision technique in our region and beyond. We strongly encourage enthusiastic researchers to explore this topic from various perspectives, as it is crucial for improving healthcare and enhancing the quality of life for patients who undergo minimally invasive cardiac surgery with a periareolar incision. Key areas for further investigation include patient selection, comparative analysis of aesthetic outcomes with different approaches, periareolar scar revision, and the management of unwanted cosmetic results. Additionally, it is important to examine the periareolar incision approach from the surgeon’s perspective, assessing its efficacy in providing optimal visualization, facilitating surgical procedures, and enabling comfortable management of unexpected complications or mistakes. In addition to the periareolar approach, other minimally invasive techniques have been described in the literature. Baker et al. [ 11 ] and Durdu et al. [ 8 ] reported the successful use of the inframammary approach for minimally invasive cardiac surgery, with good outcomes and patient satisfaction. These studies further support the notion that minimally invasive approaches can provide both functional and aesthetic benefits for patients undergoing cardiac surgery. Moreover, many women have previously undergone breast augmentation or biopsies, and these existing scars could potentially be utilized to access the chest cavity and heart, thus minimizing the need for additional incisions [ 11 ]. As technology and endoscopic techniques continue to advance, it is essential for surgeons to consider not only the functional aspects of the procedure but also the aesthetic outcomes that can have long-lasting effects on patients’ psychological well-being. By prioritizing both functional and aesthetic goals, we can improve overall patient satisfaction and quality of life. One notable limitation of our study is the absence of patient-reported outcome measures, such as the BREAST-Q questionnaire, which would have provided valuable insights into patient satisfaction and aesthetic outcomes. The BREAST-Q is a validated tool that comprehensively assesses patients’ post-surgical well-being, including satisfaction with breasts, psychological well-being, physical well-being, and sexual well-being [ 17 ]. The inclusion of this questionnaire would have strengthened our evaluation of the periareolar minimally invasive approach and its impact on patient-reported outcomes. Future studies should prioritize the incorporation of the BREAST-Q to address this limitation and enable a more robust assessment of patient satisfaction and aesthetic outcomes associated with this technique.

The periareolar incision has emerged as a highly promising approach for MICS, offering numerous advantages while presenting minimal disadvantages. Our study findings support the effectiveness of the periareolar incision approach, with the majority of patients expressing high satisfaction and experiencing no complications related to the wound or cosmetic outcomes. The observed improvements in aesthetic, psychological, and physical outcomes highlight the potential of this approach in enhancing patient experiences and overall surgical outcomes. However, it is important to acknowledge that further extensive research is necessary to establish the periareolar incision approach as a standard of care for eligible surgical patients. Future studies should focus on larger patient cohorts and comparative analyses to validate the benefits of this approach against alternative techniques. Long-term follow-up assessments are needed to evaluate the durability of aesthetic outcomes and potential late complications. Additionally, multi-center studies and meta-analyses will contribute to a more comprehensive understanding of the periareolar incision technique’s efficacy and safety in diverse patient populations. By conducting rigorous research and accumulating substantial evidence, we can establish the periareolar incision approach as a preferred option in MICS procedures, ensuring improved surgical outcomes and patient satisfaction.

Data availability

The data are available upon request from the corresponding author.

Abbreviations

Minimally invasive mitral valve repair

Minimally invasive mitral valve replacement

Minimally invasive cardiac surgery

High definition

Transesophageal echocardiography

Cardiopulmonary bypass

Intensive care unit

American Society of Anesthesiologists

ASD-Superior sinus venosus atrial septal defect

Partial anomalous pulmonary venous drainage

Superior vena cava

Atrial septal defect

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Acknowledgements

This work was supported by the College of Medicine Research Center, Deanship of Scientific Research, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia.

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Author information

Hatan Mortada and Abdulaziz Alsuhaim are co-first authors, having contributed equally to this work.

Authors and Affiliations

Division of Plastic Surgery, Department of Surgery, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia

Hatan Mortada

Department of Plastic Surgery & Burn Unit, King Saud Medical City, Riyadh, Saudi Arabia

College of Medicine, King Saud University, Riyadh, Saudi Arabia

Abdulaziz Alsuhaim

Division of Cardiac Surgery, King Fahad Cardiac Center, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia

Nasser Alkhamees

Division of Plastic Surgery, Department of Surgery, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia, Saudi Arabia

Omar Fouda Neel

Division of Plastic Surgery, Department of Surgery, McGill University, Montreal, Canada

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H.M: Data curation, Formal analysis, Writing – original draft, Writing – review & editing. A.A.: Data curation, Formal analysis, Writing – review & editing. N.A.: Writing – review & editing. O.F.: Writing – review & editing. All authors read and approved the final manuscript.

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Correspondence to Hatan Mortada .

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This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted from the ethical committee.

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The study was approved by the Institutional Review Board and Research Ethics Committee of King Saud University Medical City in Riyadh, Saudi Arabia. This investigation adhered to the ethical principles mentioned in the Declaration of Helsinki. The patient’s medical records were obtained, and data was gathered. The patient’s informed consent was obtained for the images.

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Mortada, H., Alsuhaim, A., Alkhamees, N. et al. Periareolar minimally invasive approach for cardiac surgery: a case series and description of technique with a review of literature. J Cardiothorac Surg 19 , 477 (2024). https://doi.org/10.1186/s13019-024-02948-9

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Received : 17 November 2023

Accepted : 29 June 2024

Published : 01 August 2024

DOI : https://doi.org/10.1186/s13019-024-02948-9

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• Cardiac surgery
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