Asian Cardiovasc Thorac Ann 2008;16:414-415
© 2008 Asia Publishing EXchange Ltd
Two Easy Ways to Ensure Safe Sternotomy and Sternal Closure
Giuseppe De Cicco, MD,
Carlo Fucci, MD,
Roberto Lorusso, MD
Cardiac Surgery Unit, Civic Hospital, Brescia, Italy
For reprint information contact: Giuseppe De Cicco, MD, Tel: 39 030 399 5636, Fax: 39 030 399 5004, Email: giudeci{at}libero.it, U.O. di Cardiochirurgia, Spedali Civili di Brescia, Piazzale Spedali Civili, 1-25125 Brescia, Italy.
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ABSTRACT
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Appropriate sternotomy and sternal closure are the most important factors in mechanical stability of the sternum and prevention of several postoperative complications. Easy techniques for identifying the sternal midline to facilitate opening and for obtaining reinforced closure are described. These techniques require minimal additional time. They are particularly indicated in patients at risk of sternotomy-related complications, and helpful to young surgeons in training.
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INTRODUCTION
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Midline sternotomy, introduced by Julian and colleagues1 in 1957, is the most frequent incision in cardiac surgery. Although it is a well-established approach, the incidence of postoperative dehiscence and other sternotomy-related adverse events ranges from 0.5% to 2.5%.2 Mechanical stability of the sternum is the most important factor in preventing such complications.3 We describe easy techniques for proper identification of the midline of the sternum, allowing symmetrical bone cutting, and for appropriate closure to prevent subsequent dehiscence.
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TECHNIQUES
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After the standard skin incision, the midpoint of the superior margin of the manubrium (point 1) and the midline of the xiphoid process (point 2) are identified, as shown in Figure 1
. Subsequently, the 2nd intercostal space is located. After suspending mechanical ventilation to avoid lung injury, modified applied at the 2nd intercostal space (point 3, Figure 1). It is important to place the rings of the forceps equidistant from the ideal line starting at the midline of the xiphoid. This precaution avoids asymmetric positioning of the forceps with erroneous identification of the midpoint of the sternum at the 2nd intercostal space. The autostatic closure of the dedicated forceps allows its automatic positioning parallel to the longitudinal axis of the sternum, making identification of the midpoint easier. After restarting mechanical ventilation, electrocautery is applied to indicate the appropriate line for sternotomy by connecting points 1 and 3 of the sternum, and then points 3 and 2.
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Figure 1. Application of modified Backhaus forceps for midline sternotomy; (A) White arrow indicates the midpoint obtained by handmade forceps applied at the 2nd intercostal space; (B) The modified Backhaus forceps; (C) Diagram of the forceps at the 2nd intercostal space (ICS). M = manubrium, X = xiphoid.
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Six simple wires perpendicular to the line of the sternotomy is the standard method of sternal closure in our institution. Two wires are passed through the manubrium, and 4 wires are passed distally in the sternal body (Figure 2). However, 2 additional wires are also passed parallel to the sternotomy line and beyond the 3rd and 5th wires to position the 3 central wires perpendicular to the parallel ones (Figure 2).
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Figure 2. Wire application for sternal closure; (A) The 6 perpendicular wires in association with the 2 longitudinal wires (*) are passed medially to the perpendicular wires, M = manubrium, X = xiphoid; (B) Diagram showing the 6 perpendicular wires and the 2 longitudinal wires (*) between the 2nd and 4th intercostal spaces (ICS); (C) Postoperative radiograph.
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DISCUSSION
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Between November 2004 and March 2006, more than 400 patients underwent surgery via a midline sternotomy using these techniques. There was no incidence of sternal dehiscence or sternotomy-related complications in these patients.
Identification of the exact midline of the sternum is the most important factor in ensuring an appropriate sternotomy, which is directly related to the prevention of certain postoperative complications: pain, sternal dehiscence, pericardial fluid due to undue sternal stump movement, and mediastinitis. Therefore, an effective technique for midline sternotomy and subsequent re-approximation is mandatory. In our opinion, the described techniques are effective and particularly of the midpoint easier. indicated in patients with a small sternum where an asymmetric sternotomy is likely, or in several clinical conditions (bilateral mammary artery harvesting, chronic obstructive pulmonary disease, diabetes, obesity) in which sternal dehiscence has been shown to be more frequent.4 Several procedures have been proposed to achieve effective sternal management, but our techniques were found to be easily and quickly applied in all surgical cases, especially helpful to young surgeons in training, and improved our postoperative results. Our technique of sternal closure adds negligible cost and operative time as well as being reproducible and beneficial in terms of postoperative sternal stability.
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REFERENCES
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- Julian OC, Lopez-Belio M, Dye WS, Javid H, Grove WJ. The median sternal incision in intracardiac surgery with extracorporeal circulation: a general evaluation of its use in heart surgery. Surgery 1957;42:753–61.[Medline]
- Casha AR, Yang L, Kay PH, Saleh M, Cooper GJ. A biomechanical study of median sternotomy closure techniques. Eur J Cardiothorac Surg 1999;15:365–9.[Abstract/Free Full Text]
- Song DH, Lohman RF, Renucci JD, Jeevanandam V, Raman J. Primary sternal plating in high-risk patients prevents mediastinitis. Eur J Cardiothorac Surg 2004;26:367–72.[Abstract/Free Full Text]
- Gosolow LM, Wagner JD, Feeley M, Sharp T, Havlik R, Sood R, Coleman JJ. Risk factors for predicting surgical salvage of sternal wound-healing complications. Ann Plast Surg 1999;43:30–5.[Medline]
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ABSTRACT
INTRODUCTION
