Totally endoscopic ASD repair using direct aortic cannulatio
Although totally endoscopic surgery (TES) has been widely applied for the treatment of atrial septal defect (ASD), small children receive few benefits from this technique due to risks of the femoral cannulation.

A 23-month-old boy, weighing 10.5 kg, with the diagnosis of sinus venosus ASD underwent successful repair by TES. The surgeons performed this surgery through 4 small trocars (one 12 mm trocar and three 5 mm trocars), without robotic assistance. In this case, the arterial cannula was inserted directly into the ascending aorta instead of the femoral artery (FA). The defects were repaired on the beating heart with CO2 insufflation.

Learning Points:-
- Femoral cannulation in small children pose some risks, such as increased arterial line pressure, critical lower limb ischaemia, and post-operative iliac or femoral arterial stenosis.

- Putting the arterial cannula directly into the ascending aorta is a good solution but is difficult to be performed through TES, especially in small children.

- The major concern of operating on the beating heart is the air embolism, which requires special preventative methods.

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