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Ann Thorac Surg 1998;65:573
© 1998 The Society of Thoracic Surgeons

How to Do It

Full-Spectrum Cardiac Surgery Through a Minimal Incision: Mini-Sternotomy (Lower Half) Technique

Donald B. Doty, MD, Gregory B. DiRusso, MD, John R. Doty, MD

Division of Cardiovascular and Thoracic Surgery, Department of Surgery, LDS Hospital, Salt Lake City, Utah, USA

Accepted for publication October 27, 1997.

Dr Donald Doty, 324 Tenth Ave, #160, Salt Lake City, UT 84301.


   Abstract
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 Footnotes
 Abstract
Introduction
 Technique
 Techniques for Specific Cardiac...
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 References
 
A technique is described in which most, if not all, cardiac operations may be performed through a standard small incision. A midline, lower half sternotomy is used. This provides traditional exposure of the heart and allows the surgeon to directly visualize the operating field and use familiar instruments. The complete spectrum of coronary revascularization and cardiac valve operations has been performed through this less-invasive incision.


   Introduction
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 Abstract
 Introduction
Technique
 Techniques for Specific Cardiac...
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Traditional surgical dictums, such as "wounds heal from side to side and not end to end" and "always make an incision big enough to assure complete exposure," are gradually yielding to less invasive operations. Smaller incisions are becoming an expectation of patients and seem to provide benefits of accelerated physical recovery. Cardiac operations are in particular being performed more frequently through smaller or alternative incisions than traditional median sternotomy. Certain operations can now be accomplished using thorascopic instruments through very small "port" incisions. The ideal minimally invasive incision will permit access to all areas of the heart, require a minimum of specialized equipment, and provide an advantage to the patient of more rapid return to normal activities.

This article presents techniques that have evolved at LDS Hospital, Salt Lake City, Utah, since December 1996 in an attempt to perform cardiac operations through a small incision while at the same time provide the versatility and opportunity of performing most, if not all, operations through a standard incision (Table 1). A midline, lower half sternotomy is employed. This approach provides traditional exposure with which the cardiac surgeon is familiar and allows the surgeon to directly visualize the field of operation. Special or custom instruments and cannulas are seldom required because nearly all equipment and supplies are typically in the standard cardiac surgery inventory.


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  		Operations Performed Through Mini-Sternotomy

 

   Technique
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A vertical skin incision 10 cm in length is made in the midline over the sternum extending from the third intercostal space inferiorly (Fig 1). The pectoralis major and intercostal muscle are separated from the sternum in the third interspace to free the internal mammary vascular pedicle. The sternum is divided transversely at the third interspace and then vertically in the midline from that point inferiorly through the xiphoid process using an oscillating saw (Fig 2). The upper half of the sternum remains intact. A small Kuyper-Murphy retractor (Canadian type) with concave blades 3 inches (7.6 cm) wide (Pilling-Weck Co, Ft. Washington, PA) is used to separate the sternal edges. As with all sternal retractors, this device not only separates but also elevates the sternal edges. This leaves the intact upper sternum 2.5 cm or so below the sternal edges obscuring the exposure of the underlying anatomic structures, especially the ascending aorta. A Cheanvechai-Favaloro Internal Mammary Retractor with the Cheanvechai Swivel Rake Assembly (sharpened) is used to elevate the intact upper sternum anteriorly and superiorly (Fig 3).



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  		A vertical skin incision 10 cm in length is made in the midline from the third intercostal space inferiorly.

 


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  		Pectoralis and intercostal muscle is separated from the sternum in the third intercostal space using electrocautery. The sternum is divided transversely at the third interspace and vertically in the midline from that point inferiorly.

 


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  		The sternal edges are separated and the intact upper sternum is elevated using a modified Favaloro retractor. The aortic occlusion clamp is brought into the thorax through a separate stab incision.

 
The standard T bar of this device may be used or a modified assembly using an L bar for cardiac valve operations or a right-angled bar for coronary bypass operations (Product Development Department, Pilling-Weck Co). As the intact upper sternum is elevated from the underlying mediastinal structures, the exposure "grows" to the familiar median sternotomy approach, in spite of the small skin and sternal incisions. The pericardial sac is opened from the diaphragm to the aortic reflection superiorly. The thymic fat is divided in the midline beneath the sternum, and the right lobe of the thymus is excised. The right pleural space is opened. Retraction stitches are placed on the edges of the pericardial sac and attached tightly to the sternal retractor or to the skin to elevate the heart anteriorly. A stab incision is made on the anterior chest wall on the right side below the clavicle, and a 10-inch (26.4 cm) or 12-inch (31.8 cm)-long DeBakey aortic aneurysm clamp (Pilling-Weck) is passed through the stab incision into the open right pleural space. The length of the clamp is chosen to place the hinge of the device in the chest wall with the jaws of the clamp across the ascending aorta (see Fig 3). This maneuver was suggested by John B. Flege, Jr, MD. Aortic cannulation is as high on the ascending aorta as possible, and the usual pursestring stitches are placed to accommodate the perfusion cannulas. It is usually possible to insert the cannula near the pericardial reflection even though this site is beneath the intact upper sternum. A 24F thin-walled, wire-reinforced femoral perfusion cannula is employed (TF-A-024-25; Baxter Research Medical, Salt Lake City, UT). This cannula is small and flexible enough to be introduced directly through the primary incision and find unobtrusive placement on the chest wall at the upper end of the incision. The assistant surgeon penetrates the aorta with a no. 11 scalpel and the surgeon immediately inserts the obturator-dilator advancing the overlying cannula into the aortic arch. This technique has provided safe and consistent introduction of the cannula into the relatively inaccessible portion of the aorta. Venous cannulation is by either a single two-stage cannula (29 to 37F or 36 to 46F thin wall) or a double-cannula bicaval technique (30F thin wall; Baxter Research Medical). A two-stage cannula is brought out through the primary incision, whereas double bicaval cannulas are brought out through separate stab incisions, which later become the exit site for the thoracostomy drains. In the latter technique, the superior vena caval cannula enters the right hemithorax through a stab incision on the chest wall above the right costal margin. This cannula is brought across the open right pleural space to enter the wall of the right atrium and then advanced into the superior vena cava. The inferior vena caval right-angled cannula enters through a stab incision slightly to the right of the midline below the costal margin, into the right atrium, and is advanced into the inferior vena cava. Caval tourniquets may be employed. Venous drainage may also be accomplished via the right internal jugular vein by introducing a 24F thin-walled, wire-reinforced cannula (SPC 2538, TF-024 with long tip and multiple holes; Baxter Research Medical) by percutaneous needle guidewire technique. This is the preferred method of venous cannulation for coronary artery bypass procedures. Active venous uptake using a centrifugal pump is required when this method of venous uptake is employed.

Cardiopulmonary bypass is established, the lungs are collapsed, and the aortic aneurysm clamp is guided across the open right pleural space into the pericardial sac. The aorta is occluded in an anterior-posterior manner with the posterior blade of the clamp in the transverse sinus. The occlusion clamp is placed as close to the aortic perfusion cannula as possible, providing a significant length of ascending aorta below the clamp. A standard vent catheter may be introduced through the right superior pulmonary vein and may exit through the primary incision or be brought out through the right pleural space and a separate stab incision. Perfusion catheters for retrograde or antegrade cardioplegia are small enough to be placed through the primary incision. It is commonly necessary to use instruments 2.5 cm longer than are usually employed, but extra-long or specially made instruments are seldom required. Sutures are usually tied manually; a knot pusher should be available and will be used for especially deep knot tying. The heart may be defibrillated with standard internal paddle electrodes. Child-size paddles are required if the incision is very small. Air is removed from the heart in the usual fashion after closure of cardiac incisions. Sternal closure is accomplished by a wire suture placed between the divided portion of the sternum and the intact sternum above on the left side. Another similar suture is placed on the right side. These wires are crossed anterior to the sternum and tied to the opposing suture. The effect is to tightly secure the sternal edges at the T as the two wire knots are twisted down. Three or four wires are placed parasternally to secure the divided lower sternum. Thoracostomy drains are brought out through previously placed stab incisions used for venous uptake or vent cannulas.


   Techniques for Specific Cardiac Operations
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 Technique
 Techniques for Specific Cardiac...
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 References
 
Coronary Artery Bypass
After the sternum is divided, the right-angled bar on the internal mammary artery retractor is applied. The left edge of the sternum is elevated and the mammary pedicle dissection started in the third intercostal space adjacent to the transverse sternal incision. The internal mammary pedicle is developed at the lower half of the sternum. The intact portion of the sternum is elevated anteriorly using the rake retractor. This allows the mammary artery pedicle to be developed superiorly to the usual extent of dissection. If the radial artery is used, it may be anastomosed to the internal mammary artery at the pericardial reflection. Vein grafts may be anastomosed directly to openings in the ascending aorta. All coronary arteries are accessible through this operative exposure. Bypass of the right coronary artery and left anterior descending coronary artery with its diagonal branches is performed as usual. A wet, soft gauze roll placed behind the heart improves exposure of the heart for operations on the left anterior descending coronary artery. The circumflex coronary artery marginal branches are exposed by displacing the apex of the heart into the open right hemithorax. This maneuver is made possible by placing the venous uptake cannula via the right internal jugular vein so that there is no cannula between the heart and the sternum anteriorly. A dry gauze sponge placed between the posterior table of the sternum and the apex of the heart will usually hold the heart behind the sternal edge and provide good exposure of the posterior aspects of the left ventricle. Marginal branches of the circumflex artery may be exposed to the atrioventricular groove. Distal anastomoses are performed in the usual fashion under direct vision using optical magnification.

Aortic Valve Replacement
Exposure of the aortic root and subvalvular left ventricular outflow tract is enhanced by completely dividing the ascending aorta above the sinotubular junction. This allows the aortic root to be displaced inferiorly into the center of the exposure. Closing the aortic occlusion clamp from front to back on the aorta flattens the posterior wall of the aorta, allowing very accurate closure of the aorta after valve replacement. A superior incision in the left atrium for combined aortic and mitral operations is a simple matter with the aorta divided.

Mitral Valve Replacement
The mitral valve is exposed through the usual incision into the left atrium on the right side behind the intraatrial groove. The transseptal approach is used for greater exposure and for combined mitral and tricuspid valve procedures.


   Comment
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 Techniques for Specific Cardiac...
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References
 
New techniques for coronary artery bypass and cardiac valve surgery have been described and are being evaluated for potential reduction of perioperative morbidity and accelerated postoperative recovery. On the one hand, coronary artery bypass can be performed directly through one or more minimal incisions without cardiopulmonary bypass [1] [2] [3], and on the other hand, operations on coronary arteries and the mitral valve are performed by Port-Access (Heartport, Inc, Menlo Park, CA) techniques on cardiopulmonary bypass with the heart arrested [4]. A small thoracotomy incision is usually employed in both techniques, which has the added advantage of avoiding midline sternotomy. Unfortunately, either approach is limited to simple bypass grafting to a few accessible coronary arteries or to simple mitral valve operations. Minimally invasive direct coronary artery bypass grafting on the beating heart is probably a compromise in the precision of coronary anastomosis in favor of elimination of cardiopulmonary bypass. Useful techniques for immobilization of portions of the heart have been described [5] and are appealing, but application of these methods is limited to only a few accessible coronary arteries. Port-Access techniques allow for cardiac arrest and myocardial protection using cardiopulmonary bypass, but requirements for thoracoscopy and fluoroscopy, femoral artery and vein cannulation, and unfamiliar exposure may lengthen operating time, and costs may be increased. Somewhere between the extremes of minimally invasive direct coronary artery bypass grafting and Port-Access are techniques to perform cardiac valve operations through minimal incisions using more standard approaches on cardiopulmonary bypass [6] [7] [8]. This approach makes sense because of the potential of adapting a small incision to the broad spectrum of cardiac operations. We decided to follow a course of providing a small incision that provided a familiar operative exposure using standard instruments and cardiopulmonary bypass techniques. We chose a lower half sternotomy because the whole heart is accessible through a small skin incision. Our experience began in December 1996. We were encouraged by Moreno-Cabrol’s letter [9] published in April 1997, which described a partial sternotomy dividing the sternum transversely in the second intercostal space and vertically through the lower two thirds of the sternum. A larger skin incision is required, of course. He also employed retractor elevation of the upper intact sternum, which is essential to obtaining adequate exposure.

There are several advantages to the lower half mini-sternotomy approach. The 10-cm skin incision is much smaller than the traditional midline sternotomy incision. Nevertheless, sternal elevation and retraction provides adequate and familiar exposure to the heart and great vessels. The entire heart is accessible through a small skin incision. The operative field is viewed directly without requirement for video-assisted visualization or specialized instrumentation. The aortic cross-clamp is placed through a separate stab incision to avoid obscuring the operative field. Perfusion cannulas may be either brought out through the primary incision or routed through separate stab incisions, which may also be used to exit thoracostomy drains, or kept entirely out of the operating field by using the internal jugular vein. Special defibrillation techniques are not required. The incision may be easily and rapidly extended to a full sternotomy should technical problems be encountered or if exposure is not adequate, in contrast to paramedian, transverse sternal, or intercostal incisions, which are more difficult to extend.

Complete coronary revascularization to all branches of the coronary arteries including those on the posterior wall of the left ventricle in the circumflex distribution can be performed through a mini-sternotomy incision on cardiopulmonary bypass using traditional graft conduits, including the internal mammary artery, radial artery, and saphenous vein. Saphenous vein grafts may be anastomosed proximally to the ascending aorta.

The exposure provided by mini-sternotomy, as with other minimally invasive incisions, is definitely limited compared with full sternotomy, and the operation is more tedious and challenging. The small size of the incision makes suture placement more dependent on needle angles, and the rhythm of operating is more difficult to obtain than in standard midline sternotomy incision. Coronary revascularization through a mini-sternotomy is easiest in patients with normal-sized hearts and good distal coronary artery targets for anastomosis. It is difficult when the heart is enlarged because of poor function or chronic arterial hypertension, in obese or deep-chested patients, and in patients with diffuse coronary disease.

The complete spectrum of cardiac valve operations may be performed employing the minimally invasive technique of lower half ministernotomy. Operations on the aortic valve are facilitated by completely dividing the ascending aorta, so that the aortic root may be moved inferiorly to the center of the exposure. Closure of the aortotomy is accurate and secure, because the aorta is occluded by the cross-clamp in an anterior-posterior dimension, allowing a flat exposure of the posterior wall of the aorta. The mitral valve is well positioned using the mini-sternotomy exposure. Standard incisions are employed for mitral valve replacement, annuloplasty, and valve repair. The transatrial septal approach is used when additional exposure is necessary and when the tricuspid valve is approached in conjunction with operation on the mitral valve. The mitral valve may also be exposed through the superior aspect of the left atrium, with the aorta divided during combined aortic and mitral valve operations. Triple-valve procedures are also possible in selected patients.

Cannulation for venous uptake is standard using a two-stage uptake cannula in the right atrial appendage brought out through the primary incision for operation on the aortic and mitral valves. Cannulas coming out through the incision obstruct positioning of the heart for exposure of the posterior wall of the left ventricle during coronary bypass operations. Venous drainage via the right internal jugular vein [10] is optimal for coronary artery bypass operations because the venous uptake cannula is completely out of the operating field. Active venous uptake using a centrifugal pump is required when jugular venous access is employed. Cannulas are brought out through separate stab incisions, which later become exit sites for thoracostomy drains, in operations requiring two venous cannulas.

Wound closure after mini-sternotomy requires modification of standard sternal fixation technique because of the T incision at the third intercostal space. Although there is potential for sternal nonunion at this point, and we have observed temporary early sternal instability in some patients, sternal motion appears to resolve in a few weeks. No patient has had sternal dehiscence requiring reoperation for sternal fixation. Apparently, the intact upper sternum imparts some reliable stability to the closure and provides a solid base for eventual sternal union. The wound is less painful than the standard full sternotomy, and the skin incision is cosmetically appealing. The intact upper sternum provides stability and support for the chest wall and should allow earlier upper body physical activity. Sternal injury or dislocation of the sternomanubrial joint has not occurred as a result of retraction on the upper sternum.

Complications that accompany the mini-sternotomy approach are similar to those in standard cardiac operations. No specific complications can be ascribed to the smaller incision or to diminished exposure of the operative field. Certainly, the operation is more tedious and probably takes more time due to the reduced space and crowding of the smaller incision. Early in our experience an aortic dissection occurred associated with femoral artery cannulation. This reinforced the desirability of direct cannulation of the ascending aorta by the technique described herein. The time of in-hospital convalescence is probably reduced by ministernotomy, and time to discharge home appears to be dependent on duration of chest tube drainage, cardiac performance, or cardiac arrhythmia.

In conclusion, the mini-sternotomy provides a smaller, less invasive incision for a wide range of cardiac operations. Standard instruments and cardiopulmonary bypass techniques are used and operative exposure is familiar. The sternal closure is secure and less painful than traditional sternotomy, accelerating postoperative recovery. Complete coronary revascularization and essentially all valve procedures can be performed with the mini-sternotomy, so this approach can provide a uniform method for most cardiac operations.


   Footnotes
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Abstract
 Introduction
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A video clip of this procedure can be viewed on the Internet at http://www.sts.org/bio/con/annals/atseq/ 65/573/1998.


   References
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 Footnotes
 Abstract
 Introduction
 Technique
 Techniques for Specific Cardiac...
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 References
 

  1. Grandjean JG, Mariani MA, Ebels T Coronary reoperation via small laporotomy using right gastroepiploic artery without CPB. Ann Thorac Surg 1996;61:1853-1855.[Abstract/Free Full Text]
  2. Calafiore AM, Angelini GD, Bergsland J, Salerno TA Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;62:1545-1548.[Abstract/Free Full Text]
  3. Acuff TE, Landreneau RJ, Griffith BP, Mack MJ Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;61:135-137.[Abstract/Free Full Text]
  4. Schwartz DS, Ribakove GH, Grossi EA, et al. Minimally invasive cardiopulmonary bypass with cardioplegic arrest: a closed-chest technique with equivalent myocardial protection. J Thorac Cardiovasc Surg 1996;111:556-566.[Abstract/Free Full Text]
  5. Jansen EW, Grundeman PF, Mansvelt Beck HJ, Heinmen RH, Borst C Experimental off-pump grafting of a circumflex branch via sternotomy using a suction device. Ann Thorac Surg 1997;63:S93-S96.
  6. Navia JL, Cosgrove DM Minimally invasive mitral valve operations. Ann Thorac Surg 1996;62:1542-1544.[Abstract/Free Full Text]
  7. Chitwood WR, Jr, Elbeery JR, Chapman WHH, et al. Video-assisted minimally invasive mitral valve surgery: the "micro-mitral" operation. J Thorac Cardiovasc Surg 1997;11:413-414.
  8. Cosgrove DM, III, Sabik JF Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62:596-597.[Abstract/Free Full Text]
  9. Moreno-Cabrol RJ Mini-T sternotomy for cardiac operations [Letter]. Thorac Cardiovasc Surg 1997;113:810-811.
  10. Flege JB, Jr, Wolf RK Venous drainage to the heart-lung machine via the internal jugular vein. Ann Thorac Surg 1997;63:861.[Abstract/Free Full Text]



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