port access cardiac surgery technique CPB femoral cannulation outcomes

ls /home/daytona/workspace/ 2>/dev/null || mkdir -p /home/daytona/workspace

~/port_access_surgery.py

from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, HRFlowable
from reportlab.lib.enums import TA_LEFT, TA_CENTER

OUTPUT = "/home/daytona/workspace/Port_Access_Surgery.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=2.5*cm,
    rightMargin=2.5*cm,
    topMargin=2.5*cm,
    bottomMargin=2.5*cm,
    title="Port-Access Surgery",
    author="Orris Medical",
)

styles = getSampleStyleSheet()

# Custom styles
title_style = ParagraphStyle(
    "CustomTitle",
    parent=styles["Title"],
    fontSize=22,
    textColor=colors.HexColor("#1a3a5c"),
    spaceAfter=6,
    fontName="Helvetica-Bold",
)
subtitle_style = ParagraphStyle(
    "Subtitle",
    parent=styles["Normal"],
    fontSize=10,
    textColor=colors.HexColor("#555555"),
    spaceAfter=16,
    fontName="Helvetica-Oblique",
)
h1_style = ParagraphStyle(
    "H1",
    parent=styles["Heading1"],
    fontSize=14,
    textColor=colors.HexColor("#1a3a5c"),
    spaceBefore=18,
    spaceAfter=6,
    fontName="Helvetica-Bold",
    borderPad=4,
)
h2_style = ParagraphStyle(
    "H2",
    parent=styles["Heading2"],
    fontSize=11,
    textColor=colors.HexColor("#2e6da4"),
    spaceBefore=12,
    spaceAfter=4,
    fontName="Helvetica-Bold",
)
body_style = ParagraphStyle(
    "Body",
    parent=styles["Normal"],
    fontSize=10,
    leading=15,
    spaceAfter=6,
    fontName="Helvetica",
)
bullet_style = ParagraphStyle(
    "Bullet",
    parent=styles["Normal"],
    fontSize=10,
    leading=14,
    spaceAfter=3,
    leftIndent=16,
    bulletIndent=4,
    fontName="Helvetica",
)
bold_body = ParagraphStyle(
    "BoldBody",
    parent=body_style,
    fontName="Helvetica-Bold",
)
caption_style = ParagraphStyle(
    "Caption",
    parent=styles["Normal"],
    fontSize=8,
    textColor=colors.HexColor("#666666"),
    fontName="Helvetica-Oblique",
    spaceAfter=8,
)

def h1(text):
    return Paragraph(text, h1_style)

def h2(text):
    return Paragraph(text, h2_style)

def body(text):
    return Paragraph(text, body_style)

def bullet(text):
    return Paragraph(f"• {text}", bullet_style)

def sp(n=1):
    return Spacer(1, n * 0.3 * cm)

def hr():
    return HRFlowable(width="100%", thickness=0.5, color=colors.HexColor("#cccccc"), spaceAfter=4, spaceBefore=4)

story = []

# Title
story.append(Paragraph("Port-Access Surgery", title_style))
story.append(Paragraph("Principles, Technique, Anaesthetic Considerations and Outcomes", subtitle_style))
story.append(hr())
story.append(sp())

# Intro
story.append(body(
    "Port-access surgery is a technique for performing intracardiac operations through small chest incisions "
    "and thoracoscopic ports rather than a full median sternotomy, while still using cardiopulmonary bypass (CPB). "
    "It is most commonly applied to <b>mitral valve repair/replacement</b>, <b>ASD closure</b>, <b>tricuspid valve surgery</b>, "
    "and <b>surgical ablation of atrial fibrillation</b>."
))
story.append(sp())

# Principles
story.append(h1("Principles"))
story.append(hr())

principles = [
    ("1. Avoid Full Sternotomy",
     "All access is through limited incisions (mini-thoracotomy, parasternal, or hemisternotomy), preserving "
     "chest wall integrity and reducing trauma."),
    ("2. Peripheral CPB",
     "Because central cannulation of the aorta and cavae is not feasible through a small incision, bypass is "
     "established via femoral artery and femoral vein cannulation."),
    ("3. Remote Aortic Occlusion and Cardioplegia Delivery",
     "The aorta must be cross-clamped and cardioplegia delivered without direct surgical access to the ascending "
     "aorta. This is achieved either by an endoaortic balloon catheter (positioned intraluminally under TEE/fluoroscopic "
     "guidance) or by a transthoracic clamp inserted through a separate small chest incision."),
    ("4. Video / Endoscopic Visualization",
     "The operative field is visualized indirectly via thoracoscope, video camera, or robotic optics (da Vinci system) "
     "rather than direct open-field inspection."),
    ("5. One-Lung Ventilation",
     "Collapse of the ipsilateral lung (right lung for right-sided approaches) is required to create working space in "
     "the hemithorax and provide adequate surgical exposure."),
    ("6. Team Integration",
     "The technique demands tight synchronization between surgeon, anaesthesiologist, and perfusionist. The anaesthesiologist "
     "carries active intraoperative duties (TEE guidance, PA venting, lung isolation management) that are as technically "
     "critical as the surgical steps."),
    ("7. Convertibility",
     "The chest and groins are always prepared simultaneously so that rapid conversion to full sternotomy and central "
     "CPB is possible if complications arise."),
]

for title_text, desc in principles:
    story.append(Paragraph(f"<b>{title_text}</b>", bullet_style))
    story.append(Paragraph(desc, ParagraphStyle("IndentBody", parent=body_style, leftIndent=20)))
    story.append(sp(0.5))

story.append(sp())

# Surgical Approach
story.append(h1("Surgical Approach"))
story.append(hr())
story.append(body("The mitral valve (or other intracardiac structures) can be reached through:"))
story.append(bullet("<b>Lower hemisternotomy</b>"))
story.append(bullet("<b>Right parasternal incision</b> — excising the cartilaginous portions of the 3rd and 4th ribs"))
story.append(bullet("<b>Right thoracotomy</b> — through a ~4 cm incision"))
story.append(sp())

story.append(body("Visualization is then achieved by one of three methods:"))
story.append(bullet("<b>Direct inspection</b> through the small incision"))
story.append(bullet(
    '<b>"Port access"</b> — thoracoscopic guidance and video assistance, which may include voice-activated '
    "or robotic movement of instruments"
))
story.append(bullet(
    "<b>Full endoscopic technique</b> using the da Vinci Robotic System (the most advanced form)"
))
story.append(sp(0.5))
story.append(Paragraph("Source: Miller's Anesthesia, 10e, p. 7643", caption_style))

# CPB Setup
story.append(h1("Cardiopulmonary Bypass Setup"))
story.append(hr())
story.append(body(
    "Because the chest is not fully opened, CPB is established via <b>peripheral (femoral) cannulation</b>:"
))
story.append(bullet("<b>Femoral artery</b> — arterial return"))
story.append(bullet("<b>Femoral vein</b> — venous drainage"))
story.append(sp())

story.append(h2("Aortic Occlusion"))
story.append(body("Two strategies exist to achieve a bloodless operative field:"))
story.append(sp(0.5))

story.append(Paragraph("<b>1. Endoaortic Balloon Clamp (Endo Clamp)</b>", bullet_style))
aoc1_text = (
    "An inflatable catheter positioned in the ascending aorta that occludes the aorta and delivers cardioplegia. "
    "Requires intraoperative fluoroscopy or TEE to confirm placement.<br/>"
    "Known risks: migration into the heart across the aortic valve; distal migration with occlusion of the "
    "brachiocephalic trunk."
)
story.append(Paragraph(aoc1_text, ParagraphStyle("IndentBody2", parent=body_style, leftIndent=20)))
story.append(sp(0.5))

story.append(Paragraph("<b>2. Transthoracic Cross-Clamps</b>", bullet_style))
aoc2_text = (
    "Introduced through small chest wall incisions. Examples include the <b>Chitwood transthoracic aortic "
    "cross-clamp</b> (Scanlan International) and the <b>Cosgrove Flex Clamp</b> (Cardinal Health)."
)
story.append(Paragraph(aoc2_text, ParagraphStyle("IndentBody2", parent=body_style, leftIndent=20)))
story.append(sp(0.5))
story.append(Paragraph("Source: Miller's Anesthesia, 10e, p. 7645-7646", caption_style))

# Robotic Surgery
story.append(h1("Robotic Port-Access Surgery"))
story.append(hr())
story.append(body(
    "The <b>da Vinci Robotic System</b> is the most advanced form of port-access surgery. The surgeon sits at "
    "a remote console with computer-enhanced 3D imaging and controls robotic arms positioned over the patient. "
    "The da Vinci SP (single port) platform received FDA approval for single-port access in 2014, with expanded "
    "urologic and ENT approvals from 2019."
))
story.append(sp())

# Anaesthetic Considerations table
story.append(h1("Anaesthetic Considerations"))
story.append(hr())

table_data = [
    [Paragraph("<b>Consideration</b>", bold_body), Paragraph("<b>Details</b>", bold_body)],
    [Paragraph("Lung Isolation", body_style),
     Paragraph("One-lung ventilation (OLV) required — double-lumen ETT or bronchial blocker", body_style)],
    [Paragraph("Patient Position", body_style),
     Paragraph("~30 degrees 'right side up' for most minimally invasive approaches", body_style)],
    [Paragraph("Monitoring", body_style),
     Paragraph("5-lead ECG, invasive arterial line, central venous access", body_style)],
    [Paragraph("PA Vent Catheter", body_style),
     Paragraph(
         "Flimsier than a standard PA catheter; noisy pressure tracings; no SvO2/CO monitoring. "
         "Some surgeons place it in the field, allowing the anaesthesiologist to use a full PA catheter.",
         body_style
     )],
    [Paragraph("TEE", body_style),
     Paragraph(
         "Essential for confirming endoaortic balloon clamp position and guiding retrograde coronary "
         "sinus catheter placement.",
         body_style
     )],
    [Paragraph("Retrograde Cardioplegia", body_style),
     Paragraph(
         "Via direct coronary sinus cannulation at the operative site, or by percutaneous coronary sinus "
         "catheter in the internal jugular vein positioned under echo guidance.",
         body_style
     )],
]

col_widths = [4.5*cm, 11.5*cm]
tbl = Table(table_data, colWidths=col_widths, repeatRows=1)
tbl.setStyle(TableStyle([
    ("BACKGROUND", (0, 0), (-1, 0), colors.HexColor("#1a3a5c")),
    ("TEXTCOLOR", (0, 0), (-1, 0), colors.white),
    ("ROWBACKGROUNDS", (0, 1), (-1, -1), [colors.HexColor("#f0f4f8"), colors.white]),
    ("GRID", (0, 0), (-1, -1), 0.4, colors.HexColor("#cccccc")),
    ("VALIGN", (0, 0), (-1, -1), "TOP"),
    ("TOPPADDING", (0, 0), (-1, -1), 6),
    ("BOTTOMPADDING", (0, 0), (-1, -1), 6),
    ("LEFTPADDING", (0, 0), (-1, -1), 8),
    ("RIGHTPADDING", (0, 0), (-1, -1), 8),
]))
story.append(tbl)
story.append(sp(0.5))
story.append(Paragraph("Source: Miller's Anesthesia, 10e, p. 7647-7648", caption_style))

# MICS
story.append(h1("MICS — Broader Category"))
story.append(hr())
story.append(body(
    "Port-access surgery falls under the umbrella of <b>Minimally Invasive Cardiac Surgery (MICS)</b>, "
    "which encompasses:"
))
story.append(bullet("<b>MIDCAB</b> — LIMA to LAD via limited left thoracotomy, on the beating heart"))
story.append(bullet("<b>OPCAB</b> — Off-pump coronary artery bypass"))
story.append(bullet("Mitral / aortic / tricuspid valve surgery"))
story.append(bullet("ASD closure"))
story.append(bullet("Surgical ablation of atrial fibrillation"))
story.append(bullet("Percutaneous valve procedures (TAVR, MitraClip) for high-risk patients"))
story.append(sp())
story.append(body(
    "Suggested benefits: less pain, decreased scarring, and shorter recovery times."
))
story.append(sp(0.5))
story.append(Paragraph("Source: Barash Clinical Anesthesia, 9e, p. 3361", caption_style))

# Outcomes
story.append(h1("Outcomes"))
story.append(hr())
story.append(body("Compared to full sternotomy, port-access surgery offers:"))
story.append(bullet("Mortality and morbidity rates <b>comparable</b> to open sternotomy"))
story.append(bullet("Reduced postoperative bleeding"))
story.append(bullet("Trends toward shorter hospital length of stay"))
story.append(bullet("Higher rate of direct discharge home"))
story.append(sp())
story.append(body(
    "Prospective randomized trials comparing minimally invasive to standard approaches remain limited, but "
    "the integrated team approach and technological advances support favorable postoperative outcomes."
))
story.append(sp(0.5))
story.append(Paragraph("Source: Miller's Anesthesia, 10e, p. 7648", caption_style))

# Footer rule
story.append(sp(2))
story.append(hr())
story.append(Paragraph(
    "Generated by Orris Medical AI | Sources: Miller's Anesthesia 10e; Barash Clinical Anesthesia 9e",
    caption_style
))

doc.build(story)
print("PDF created:", OUTPUT)

python /home/daytona/workspace/port_access_surgery.py