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PubMed2004

Biomechanical comparison of median sternotomy closures.

BACKGROUND: Poor healing of median sternotomy can significantly increase morbidity, mortality, and hospital costs. Effective union requires reliable sternal fixation. Although wire has proven the most reliable and widely used sternotomy closure material, no experimental studies have compared a large variety of wiring techniques in a human model. We developed an easily reproducible experimental model using cadaveric human sterna and compared several wiring methods to assess closure strength and stability. METHODS: Fifty-three fresh adult human cadaveric sternal plates with adjacent ribs were fixed with specially designed spiked stainless steel clamps and attached to a texture analyzer. Single peristernal and transsternal, alternating single peristernal and transsternal, figure-eight peristernal, figure-eight pericostal, and Robicsek closures using no. 5 stainless steel wires were tested. We evaluated bone density, stiffness, and displacement using perpendicular, repetitive variable force loads of 800 Newtons cycling at a rate of 0.5 mm/s. RESULTS: There were no significant differences in age, sex, or bone density in outcome measures of the sternal groups. No clamp failures or clamp damage to the specimens occurred. The single peristernal and alternating peristernal and transsternal closures proved superior in strength and stability (p < 0.001). The figure-eight peristernal, then the single transsternal, then the Robicsek were next stablest groups in decreasing order. The figure-eight pericostal closure had the highest failure rate (p < 0.001). CONCLUSIONS: This novel model of sternotomy closure testing was reliable, inexpensive, and easily reproducible. The mechanical stability of peristernal and alternating peristernal and transsternal wires was significantly greater than that of the other tested methods. Pericostal figure-eight closures were not sufficiently stable to be considered a reliable method of primary sternotomy repair.

Aged↗

PubMed1983

Use of computed tomography to assess mediastinal complications after median sternotomy.

Thirty computed tomographic (CT) scans from 27 patients who had undergone median sternotomy were reviewed. A control group of 15 asymptomatic patients was studied either early (within 21 days) or late (46 days to 22 years) after sternotomy. Twelve patients with symptoms ranging from sternal click to obvious mediastinitis also were studied within 30 days of sternotomy. The CT findings were correlated with the patient's clinical course. Imperfect sternal closure (sternal step-offs and gaps) was found in 10 of the 15 asymptomatic patients. Focal retrosternal fluid collections, air, and hematomas were seen in more than 75% of the asymptomatic patients. Retrosternal abscess, presternal abscess, and sternal disruption were noted in 3 symptomatic patients. Computed tomography correctly diagnosed the extent of mediastinal abscess in all patients. In the 3 patients in whom there was a discrepancy between the CT scan and the clinical findings, the scan ultimately was shown to be correct. These results indicate that computed tomography is a valuable tool in diagnosing wound problems after sternotomy because it accurately depicts the extent and depth of the wound infection.

Adult↗

PubMed1978

Extended indications for median sternotomy in patients requiring pulmonary resection.

We have employed median sternotomy in 9 patients for resection of both benign and malignant lung lesions. The most frequent use of this approach was for bilateral wedge resection, though unilateral resection was done in 2 patients. Our experience supports the previously documented usefulness of median sternotomy for minor bilateral resections and suggests that more complex pulmonary resections are possible when an appropriate indication exists. We compared the effects of median sternotomy with those of lateral thoracotomy on postoperative vital capacity and peak airway flow. Both incisions results in a marked loss of measured lung function, but recovery occurs notably sooner after median sternotomy than ater lateral thoracotomy.

Adult↗

PubMed1998

Bilateral lung volume reduction surgery via median sternotomy for severe pulmonary emphysema.

BACKGROUND: Lung volume reduction surgery either via sternotomy or by thoracoscopy has been demonstrated to be effective for selected emphysema patients in North America and Europe. The present study summarizes short-term results of bilateral lung volume reduction performed via median sternotomy for the first consecutive 39 patients with severe diffuse emphysema in Okayama, Japan, from July 1995 to February 1997. METHODS: There were 35 men and 4 women, and the age range was 54 to 74 years with a mean age of 65 years. All were former heavy smokers and none of them had alpha1-antitrypsin deficiency. Only 9 patients (23%) showed a bilateral upper lobe pattern of emphysema. The operation was done through a median sternotomy, and the most emphysematous portions were excised bilaterally with a linear stapling device fitted with strips of bovine pericardium to prevent air leakage. RESULTS: No operative death was encountered. The first 33 patients completed 3-month follow-up assessment, and their mean forced expiratory volume in 1 second had improved by 41% from 735 mL to 1,037 mL. Other parameters of pulmonary function tests, arterial blood gas analysis, 6-minute walking distance, and dyspnea scale also had improved significantly. These improvements lasted for at least a year. CONCLUSIONS: Bilateral lung volume reduction surgery via median sternotomy is a safe and effective procedure for selected severe emphysema patients. Although the pattern of emphysema might be different between countries, the results in Japanese patients were similar to those previously reported in North American and European patients.

Aged↗

PubMed1998

Less invasive cardiac operations through a median sternotomy: 100 consecutive cases.

BACKGROUND: In the beginning of 1997, we developed a routine approach to intracardiac operations through a less invasive median sternotomy. A limited (6 to 9 cm) median skin incision followed by a subcomplete (manubrium and body) median sternotomy makes opening and closing of the chest easier; conventional central cardiopulmonary bypass is instituted, and no modifications to the surgical techniques are necessary. METHODS: In 100 consecutive patients (mean age, 62.04 years; range, 9 to 92 years), 70 aortic, 13 mitral, and 17 other cardiac procedures were performed. Surgical technique required many self-made instruments; anesthetic "fast-tracking" management was performed. RESULTS: Four patients died. One conversion to a standard sternotomy and five reoperations for bleeding were necessary. Cross-clamp time ranged from 33 to 140 minutes (mean +/- standard deviation, 69.23 +/- 20.99 minutes) and total drainage loss ranged from 120 to 1,800 mL x m(-2) x 24 h(-1) (mean, 288 mL x m(-2) x 24 h(-1)). The postoperative course was shorter than usual, and one complication in the healing wound was observed. The scar was shorter than 9 cm in all patients. CONCLUSIONS: Our work shows that a less invasive approach to many cardiac operations is possible through a modified median sternotomy. This technique provides many potential and practical advantages: there is less trauma and pain reported by patients, and the small wound reduces the risk of infection and blood loss. Patients are extubated and discharged from the hospital earlier.

Adolescent↗

PubMed2002

Full sternotomy with minimal skin incision for congenital heart surgery.

PURPOSE: The purpose of this paper is to analyze the feasibility of the full sternotomy with minimal skin incision and its related complications and risks. METHODS: A total of 405 patients with simple congenital heart disease underwent open heart surgery exclusively under full sternotomy with minimal skin incision. We reviewed the available medical records of the patients retrospectively. Bypass time, aorta cross clamp time, and period of hospital stay were compared with the control group (223 patients with standard long skin incision). RESULTS: Full sternotomy with minimal skin incision provided adequate surgical views and successful repair was done in all patients. There was no mortality. One patient had chylopericardium after the operation and another patient had a postoperative bleeding at the sternum. Minimal skin incision took the similar aorta cross-clamp time and total cardiopulmonary bypass time compared with full skin incision in atrial septal defect patients. Among the ventricular septal defect patients, minimal skin incision took a little longer aorta cross-clamp time (10%), but similar total cardiopulmonary bypass time compared with full skin incision. CONCLUSION: Minimal skin incision with full sternotomy provides improved cosmetic results. There was no increased mortality and morbidity using minimal access. It can be applied to more complex congenital heart disease contrast to other minimal invasive techniques for atrial septal defect.

Adolescent↗

PubMed1999

A biomechanical study of median sternotomy closure techniques.

OBJECTIVE: Sternal dehiscence is a complication of median sternotomy incisions with high mortality and morbidity. Different techniques of sternal closure have been described. Rigid fixation of the sternum results in earlier union. We measured the rigidity of sternotomy fixation using a mechanical model in order to differentiate different techniques of sternal closure using their biomechanical characteristics. METHODS: We measured the force-displacement curves of six different fixation techniques using a metal sternal model using a computerized materials-testing machine. We tested straight wires (the most commonly used surgical technique), figure-of-8 wires, 'repair' technique (used when a wire breaks), Ethibond, Sterna-band and a 'multitwist' closure described for the first time. RESULTS: At 20 kg force, twisted wires used for sternotomy closures start to untwist. The most rigid closure was a multitwist closure that displaced only 0.37 mm at a force of 20 kg. Straight wires displaced 0.78 mm, figure-of-8 wires 1.20 mm, Sterna-band 1.37 mm, repair wires 5.08 mm, Ethibond 9.37 mm. The single factor Anova test for the rigidity of the different closures had P-values <0.0001. CONCLUSIONS: We applied a mathematical model to calculate chest wall forces during coughing, in order to determine the force placed upon a sternotomy closure. We conclude that severe coughing may cause wires to untwist. We discuss potential applications of different wire closures based on their characteristics.

Biomechanical Phenomena↗

PubMed1988

Median sternotomy as an approach for pulmonary surgery.

A median sternotomy incision was employed in 73 cases of pulmonary surgery instead of posterolateral thoracotomy. An anterior mediastinal approach was used in three groups of patients: group 1 patients (47 cases) underwent simultaneous bilateral surgery for pulmonary disorders on both sides, in group 2 patients (15 cases), this approach was selected to facilitate surgery on the involved mediastinal structures, and group 3 patients (11 cases) had left lung cancer with extensive dissection of lymph nodes done via median sternotomy, as well as routine dissection of nodes by posterolateral thoracotomy. A median sternotomy approach for pulmonary surgery provided an excellent operative field, and most patients experienced less postoperative pain and a quicker recovery. The surgical indications for this approach, the surgical procedure, the results, and the advantages and disadvantages of using a median sternotomy incision are discussed.

Angiography↗

PubMed2000

Early percutaneous tracheostomy after median sternotomy.

OBJECTIVE: Tracheostomy offers significant advantages over endotracheal intubation in patients requiring long-term assisted ventilation. However, in patients who have undergone median sternotomy, it is believed that the danger of microbial contamination and consecutive infection of the sternal wound with microbes from the tracheostomy is high when conventional tracheostomy is performed. In contrast, percutaneous techniques are less likely to result in tracheostomy infection and thus bacterial contamination of neighboring structures. Nonetheless, to date there has been no prospective study confirming or disproving this assumption. Our study evaluated outcome after percutaneous tracheostomy in patients with a median sternotomy. METHODS: A total of 144 cardiac surgical patients had elective percutaneous tracheostomy at the bedside until postoperative day 14, with 4 different techniques. Systematic microbiologic monitoring of the sternal and tracheal wounds was used. RESULTS: In 13 patients sternal wound infection was suspected, but was confirmed in only 4 (2.8%) patients who actually showed microbial contamination of the sternum. In 2 of these patients, the identified microbes were not identical to those cultured from the trachea. The other 2 patients had sternal and tracheal cultures positive for methicillin-resistant Staphylococcus aureus. Cross-contamination of the sternotomy with microbes from the patient's airways was therefore ruled out. No patient had clinical signs of tracheostomy infection. Likewise, there were no cases of mediastinitis. CONCLUSIONS: On the basis of our data, we conclude that cross-contamination of the sternal wound with microbes from the trachea is not a problem. Elective percutaneous tracheostomy is safe, even if performed during the first 14 days after median sternotomy.

Analysis of Variance↗

PubMed1995

Transposition of the greater omentum for recalcitrant median sternotomy wound infections.

During a 3-year period, 25 patients underwent transposition of the greater omentum, either alone or in combination with muscle flaps, for treatment of recalcitrant median sternotomy wound infections. Most patients underwent radical sternectomy for deep and extensive sternal wounds; the others had significant defects involving the lower third of the sternum. The most common combination of flaps was omentum and bilateral pectoralis major musculocutaneous flaps (14 patients). Delay to reconstruction after the recognition of median sternotomy infection ranged from 2 to 36 days (average, 13.9 days) except for one patient treated outside by the "open method" for 18 months. Definitive closure was performed after an average of 1.8 debridements (range, 1-4). Hospitalization averaged 28.5 days (range, 13-42 days) in 16 of the 19 surviving patients. The majority of these patients had far more extensive sternal defects than those usually treated by muscle flaps alone. Healing was ultimately achieved in 95% of infected sternotomy wounds. Seventy-four percent of patients healed their sternal wounds uneventfully without subsequent problems. Flap site complications in the remaining patients included recurrent chondritis (16%) and partial (4%) or complete (4%) flap loss. Donor-site complications included abdominal wall herniation (21%), hematoma (8%), and seroma (4%). There were no problems with chest wall instability or intra-abdominal morbidity. Six patients (24%) succumbed to multisystem failure unrelated to sternal infection. We present our experience--including indications, technique, and outcome--with transposition of the greater omentum for recalcitrant median sternotomy wound infections.(ABSTRACT TRUNCATED AT 250 WORDS)

Heart Valve Prosthesis↗

PubMed2000

Abdominal recovery after laparotomy and omental transposition into a grossly contaminated median sternotomy wound.

Grossly contaminated median sternotomy wounds are frequently treated with transposed omental flaps. A laparotomy adjacent to such an infected wound carries the risk of peritonitis. It has been suggested that this risk may increase when the omentum, which has anti-infective properties, is removed from the abdominal cavity and is transposed to the chest. The authors evaluated abdominal recovery after laparotomy and omental transposition into an adjacent, grossly contaminated median sternotomy wound. The study group included 15 patients who had sternal wound reconstruction with an omental flap between 1990 and 1998. All patients underwent median sternotomy reconstruction according to a "two-compartment" operative sequence protocol, which included division of the surgical field into an upper (thoracic) contaminated zone and a lower (abdominal) clean zone. The control group was comprised of 15 patients who underwent elective laparotomy for splenectomy during the same time period. The effect of the surgical procedure on the abdomen was compared between the two groups. The timing of the reappearance of peristalsis and regular bowel function, and the incidence of bowel obstruction and postoperative peritonitis were similar in the two groups. The findings indicate that laparotomy and omental transposition in the presence of a grossly contaminated median sternotomy wound is a safe procedure, and is associated with a low rate of abdominal complications.

Aged↗

PubMed2002

Assessment of the diagnostic capacity of planar scintigraphy and SPECT with 99mTc-HMPAO-labelled leukocytes in superficial and deep sternal infections after median sternotomy.

Sternal infection is a rare complication of median sternotomy but is associated with considerable morbidity and mortality, particularly in the case of deep sternal infection (mediastinitis). Successful treatment depends on early diagnosis and on the location (deep or superficial) of the infection. Radiological techniques have many limitations, and although 67Ga scintigraphy is effective, it delays diagnosis by 48 h. We assessed the diagnostic capacity of planar scintigraphy and single photon emission computed tomography (SPECT) with 99mTc-hexamethylpropylene amine oxime (HMPAO)-labelled leukocytes in deep sternal infections after median sternotomy. We prospectively studied 41 patients with clinical suspicion of deep sternal infection 4 and 20 h after administration of the tracer. The final diagnosis was deep sternal infection in nine patients and superficial sternal infection in 10, with infection being ruled out in 22 patients. Planar scintigraphy did not detect any of the deep sternal infections at either 4 h or 20 h. SPECT correctly identified eight of the nine deep sternal infections at 4 h and all seven at 20 h, with no false positive results. Planar scintigraphy identified 16 of the 18 superficial sternal infections at 4 h and all of them at 20 h. SPECT identified 17 of these 18 infections at 4 h and all of them at 20 h. Other infections unrelated to the sternotomy were identified in seven patients. Leukocytes labelled with 99mTc-HMPAO are a highly reliable method for the early diagnosis of sternal infections after median sternotomy. Use of SPECT allows determination of the depth of the infection and differentiation of superficial from deep sternal infections. It is also possible to detect other sites of infection, thus providing alternative diagnoses.

Adult↗

PubMed2006

Vacuum-assisted closure of the sternotomy wound: respiratory mechanics and ventilation.

BACKGROUND: Numerous authors have reported promising results with the use of vacuum-assisted closure therapy in poststernotomy mediastinitis. The negative pressure applied to the anterior mediastinum substantially exceeds the normal negative pressure in the pleural cavities, and interaction with respiratory physiology cannot be excluded. The aim of the present study was to evaluate whether the application of six clinically relevant negative pressures between -50 mmHg and -175 mmHg to the sternotomy wound affects respiratory parameters in a porcine model. METHODS: A midline sternotomy was performed in six mechanically ventilated pigs weighing 70 +/- 3 kg. Vacuum-assisted closure therapy was applied with continuous negative pressure in a randomized order to the sternotomy wound. The following respiratory parameters were monitored by a carbon dioxide-based noninvasive monitoring system connected to the ventilator: carbon dioxide elimination, peak inspiratory pressure, peak expiratory flow, alveolar minute volume, alveolar tidal volume, expired tidal volume, static compliance, and airway resistance. RESULTS: All pigs survived the treatment, and there was no significant change in the respiratory parameters investigated at any of the six negative pressures applied. A tendency toward increased airway resistance was noted when -175 mmHg was applied, although this change was not significant. CONCLUSIONS: The application of negative pressure therapy in the treatment of deep poststernotomy infections is a novel modality gaining increased attention. In this study, no impairment in respiratory mechanics, ventilation, or oxygenation was detected when comparing applied pressures ranging from -50 mmHg to -175 mmHg in the sternotomy wound.

Airway Resistance↗

PubMed2004

Pyogenic granuloma caused by exposed sternotomy wires.

BACKGROUND: This case describes a 75-year-old African American man who developed a pyogenic granuloma on the chest due to trauma induced by exposed sternotomy wires from his coronary bypass procedure. OBJECTIVE: To describe a previously unreported cause of pyogenic granuloma. MATERIALS AND METHODS: The pyogenic granuloma was excised and during the procedure, exposed sternotomy wires were uncoiled at the base of the lesion. The sternotomy wires were retightened and reappositioned along the sternum, and the wound was closed primarily. RESULTS: The pyogenic granuloma has not recurred after 15 months of follow-up. CONCLUSIONS: Pyogenic granulomas are vascular benign tumors that commonly appear secondary to trauma. The source of the trauma in this case was the exposed sternotomy wires.

Aged↗

PubMed1990

Rib cage mechanics after median sternotomy.

A substantial reduction in lung volumes occurs after sternotomy, but the mechanism or mechanisms are unclear. Measurements were made of lung volumes and of chest wall motion with four pairs of magnetometers (two pairs for anteroposterior rib cage, one for lateral rib cage, and one for anteroposterior abdominal dimensions) in 16 men before and one week and three months after coronary artery grafting. Reductions in all lung volumes occurred after sternotomy and were greater in the supine than in the sitting position. Supine vital capacity was reduced one week after surgery, with almost complete recovery at three months. One week after sternotomy there was a significant reduction in tidal volume from a mean (95% confidence limits) value of 0.88 (0.76-1.00) litre to 0.61 (0.52-0.70) l, and in supine rib cage displacement from 3.87 (1.96-5.78) mm to 0.44 (-0.61-1.49) mm in the lateral plane. Respiratory frequency increased from 16 (13-19) to 21 (19-24)/min. Coordination of the rib cage was assessed by measuring the difference in timing of onset of chest wall motion and airflow in four planes. At one week nine of 14 patients showed uncoordination between airflow and rib cage motion in one or more dimensions, and this was still present in three patients at three months. No loss of the temporal relation between airflow and abdominal wall motion was detected. The results suggest that reduced and uncoordinated rib cage expansion contributes to the restrictive ventilatory defect that follows median sternotomy.

Coronary Artery Bypass↗

PubMed2005

Minimal access via lower partial sternotomy for congenital heart defects.

To evaluate the invasiveness of a minimal access approach for simple congenital heart defects, and determine whether it can be regarded as a standard operation, 83 patients with an atrial septal defect and 73 with a ventricular septal defect underwent repair through a minimal skin incision and lower partial median sternotomy. There were no operative deaths, severe intraoperative complications, or conversion to full sternotomy. The clinical course of 106 patients was compared with that of 21 treated using a full sternotomy by the same surgeon; there were no significant differences, except in the operative time for ASD patients. The clinical courses of 2 minimal access subgroups (50 patients operated on by residents and 106 treated by the staff surgeon were compared; operative time, bypass time, ventricular fibrillation time (ASD repair), and cardiac arrest time (VSD repair) were significantly shorter in those operated on by the staff surgeon, but there was no difference in clinical course. The minimal access approach produced good cosmetic results, its invasiveness was similar to that of a full sternotomy, and it may be considered a standard operation for pediatric patients with septal defects.

Adolescent↗

PubMed2004

Improved recovery after the endoscopic atraumatic coronary artery bypass procedure compared with sternotomy for off-pump bypass of the left internal thoracic artery to the left anterior descending coronary artery: a case-matched study.

OBJECTIVE: The endoscopic atraumatic coronary artery bypass (endo-ACAB) procedure allows single-vessel coronary artery bypass grafting (CABG), avoiding sternotomy or thoracotomy. We set out to define the effect of this surgical approach on postoperative recovery, blood loss, and return to work. METHODS: We performed a case-control comparison of our first 29 endo-ACAB procedures for left anterior descending coronary artery (LAD) disease against 29 control patients, who underwent off-pump beating heart CABG via sternotomy for isolated LAD disease in the same institution. Control pairs were matched for age, sex, and ventricular function. RESULTS: In a matched population, endo-ACAB is associated with shorter postoperative ventilation times (6.2 hours versus 9.0 hours, P = .034) and hospital stays (5.3 nights versus 6.4 nights, P = .04), less blood loss (363.9 mL versus 570.3 mL, P = .017), and lower transfusion requirements. Endo-ACAB patients were more likely to return to employment and did so at a mean of 6.6 weeks earlier than sternotomy patients (P = .019). CONCLUSIONS: Endo-ACAB for grafting of the left internal mammary artery to the LAD is associated with reduced blood loss and faster postoperative recovery. Avoiding sternotomy appears to be a significant factor in recovery after beating heart single-vessel CABG surgery.

Anastomosis, Surgical↗

PubMed1998

[Minimally invasive mitral surgery: mitral valve repair with a right-sided partial sternotomy].

We describe our concept and the results of mitral valve repair using a right-sided partial sternotomy. We performed mitral valve repair using this method in 50 patients with severe MR between April 1997 and October 1998. In 10 patients in whom good exposure was not attained, we changed to the ordinary full-sternotomy or T-shaped partial sternotomyprocedure. Forty patients with good exposure underwent successful mitral valve repair. The sites of repair were anterior in 15 cases, posterior in 16, and both in 9. There was no mortality, and intraoperative TEE performed in all 40 patients revealed that all had trivial or no regurgitation. The right-sided partial sternotomy (open door method) is a safe and useful method for minimally invasive valve Surgery. A better quality of life compared with traditional median sternotomy can be ensured for patients undergoing minimally invasive cardiac surgery only when receive the best-quality Surgery is performed.

Cardiac Surgical Procedures↗