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Ann Thorac Surg 1998;66:1050-1054
© 1998 The Society of Thoracic Surgeons

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Supplement

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

^a Department of Thoracic and Cardiovascular Surgery, University Hospital, Caen, France

Address reprint requests to Dr Massetti, Department of Thoracic and Cardiovascular Surgery, CHU "Cote de Nacre," 14033 Caen, France
e-mail: (massetti-m{at}chu-caen.fr)

Presented at "Facts and Myths of Minimally Invasive Cardiac Surgery: Current Trends in Thoracic Surgery IV," New Orleans, LA, Jan 24, 1998.

Abstract

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 · m^-2 · 24 h^-1 (mean, 288 mL · m^-2 · 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.

The longitudinal median sternotomy with a 20-cm skin incision has been, since the beginning of the cardiac surgery era, the best approach for most cardiac operations. It allows a wide exposure of the heart and the origin of the great vessels, but this quality of exposure is sometimes paid for by the patients in terms of "surgical aggressiveness" (postoperative bleeding, wound infection, pain, thoracic wall instability, and unaesthetic scar) [1–3]. The need to avoid these hazards can explain the interest in the so-called minimally invasive approaches, which have increased in number over the last 2 years [4–17].

Coronary surgery was the first to be concerned with a minimally invasive philosophy, but at present, single-vessel coronary artery disease involving the left anterior descending artery through an anterior minithoracotomy remains the primary indication for miniinvasive coronary artery bypass [3]. More recently, many minimal approaches to valve surgery have been developed. Cosgrove and associates popularized longitudinal parasternal thoracotomy either for aortic or mitral procedures. In their experience, a transverse sternotomy replaced the parasternal incision for the aortic operations [5, 6]. Konertz and colleagues [7] first proposed a superior partial sternotomy for aortic and mitral valve operations, and a "J" sternotomy has been used by Svensson [12] for valvular aortic and coronary operations or reoperations. A right anterior minithoracotomy and other hybrid ministernotomies have been tested clinically for mitral and aortic procedures [8–17]. The reduced surgical approach, sometimes with video assistance, is the main technical aspect of these techniques; nevertheless, peripheral cannulation for cardiopulmonary bypass, the opening of pleural spaces with or without costal resection, the ligation of internal mammary vessels, and the complexity of the conversion to the standard sternotomy sometimes decrease the minimally invasive character of the operations.

The aim of this work is to show how a less invasive median sternotomy, now named "short-cut median sternotomy," can be performed for all cardiac operations except for the coronary procedures. One hundred consecutive patients operated on successfully form the basis of this report, and our early results confirm that the short-cut median sternotomy simplifies the technique for the surgeon and provides beneficial results to patients.

Material and methods

One-hundred consecutive patients underwent cardiac operations that used short-cut median sternotomy as the surgical approach at the University Hospital "Cote de Nacre" of Caen-France during a 1-year period. Informed consent was obtained from all patients. Table 1 shows demographic and clinical data, whereas Table 2 lists the diagnostic details of the patients. Only coronary operations were excluded from this protocol; 1 patient had been previously operated on for an aortic valve replacement.

Surgical technique
A midline skin incision (6 to 9 cm long) is made from the second to the fourth interspace for aortic procedures and from the third to the fifth interspace for mitral and tricuspid operations (Fig 1). The length of the skin incision is usually less than the half the length of the sternal bone. The skin and subcutaneous tissue are dissected and a median sternotomy (manubrium and body) is carried out with a sagittal saw (Zimmer Micro 100, Linvatee Largo, FL); the portion of sternum under the skin flap (cephalad and caudal) is easily divided with the aid of an illuminating disposable retractor (USSC Mini Harvest; United States Surgical Corp, Norwalk, CT). Once the thoracic retractor has been inserted, the spreading of the two sternal edges is limited to 5 to 6 cm. The section of the sternal bone ends at the xiphoid appendage, which is preserved. The pericardial incision (longitudinal) exposes, in the aortic procedures, the entire ascending aorta and the tip of the right atrial appendage. In the atrioventricular valve operations, all of the right atrium and the proximal ascending aorta are exposed. The pericardial edges are hung up from the chest wall to elevate the heart toward the surface for better exposure.

View larger version (16K): [in this window] [in a new window]   Fig 1. Placement of the skin incision for the aortic (A) and mitral (B) procedures; a subcomplete median sternotomy is accomplished.

View larger version (162K): [in this window] [in a new window]   Fig 2. Aortic valve replacement: The prosthesis is sutured with a suspended continuous technique using a 2/0 monofilament.

Once the operation has been completed, the air is removed from the heart with the assistance of a transesophageal echocardiographic probe. The deairing technique is the same as for the standard approach, but gentle suction on the ascending aorta through a 14-gauge needle is maintained for a longer time. After the insertion of temporary pacing wires, the cross-clamp is removed and, when necessary, the heart is defibrillated by external patches. After cardiac function returns to normal, the cannulas are removed and the chest is closed in layers, leaving one drain in the pericardium and one in the retrosternal space. As for the opening, the closure of the portion of sternum under the skin flaps is facilitated by the light-assisted retractor, and the wire stitches are placed as U stitches. A small subcutaneous drain tube is positioned anterior to the sternum. A subcuticular absorbable suture (5/0 monofilament) is then employed for the skin layer (Fig 3).

View larger version (144K): [in this window] [in a new window]   Fig 3. Patient operated on for subaortic stenosis, seen on the fourth postoperative day.

All datas are expressed as mean ± standard deviation. The operations performed were as follows:

Aortic valve replacement/repair 72/2 Aortic root operation 14 Mitral valve replacement/repair 15/4 Left atrium reduction 11 Tricuspid annuloplasty 2 Congenital (atrial septal defect and others) 7 Resection of cardiac tumor 3 Infected pacemaker lead 1 Associated carotid operation 2

The mean aortic cross-clamping time was 69.23 ± 20.99 minutes, whereas total bypass time was, on average, 102.09 ± 50.31 minutes. A profuse hemorrhage related to a subannular cardiac rupture occurred in an 88-year-old patient immediately after decannulation; a rapid conversion to the standard sternotomy was necessary to repair this complication with success.

There were four in-hospital deaths. One patient died of uncontrolled sepsis related to infection of his endocardial pacemaker leads. One patient died of mesenteric infarction related to an unknown mesenteric artery stenosis. One patient suffered Legionella pneumonia and succumbed to adult respiratory distress syndrome on postoperative day 24. The last death occurred in a patient affected by severe chronic obstructive lung disease, who died of respiratory failure due to pneumonia with endotoxin shock.

Perioperative myocardial infarction, defined as either the development of new Q waves or an elevation of the MB fraction of creatine kinase accompanied with either elevation of ST segments or the onset of new conduction disturbances, developed in 1 patient. A recent history of significant coronary disease treated by percutaneous transluminal coronary angioplasty justified this complication. Sternal wound infection that required debridement and drainage occurred in 1 patient, and another 1 suffered a transient ischemic attack on the fifth postoperative day, from which, however, he recovered completely. The chest drainage lost during the first 24 hours averaged 288 mL/m² (range, 170 to 2,080 mL/m²). Five patients underwent reexploration for bleeding. The perioperative complications (those occurring within the initial hospitalization and the first 30 postoperative days) were as follows:

In-hospital death 4 Conversion to standard sternotomy 1 Perioperative myocardial infarction 1 Sternal wound infection 1 Transient ischemic attack 1 Transient atrioventricular block 1 Reexploration for bleeding 5 Pneumonia 3 Low cardiac output 3 Renal insufficiency 1

All patients were extubated early according to our policy, but the duration of postoperative intubation has been significantly reduced, with approximately 50% of patients extubated within 6 hours in comparison with 12 hours in the pre–fast-track anesthetic protocol.

Comment

The current increase in interest in "minimally invasive" techniques has been in part stimulated by recognition of their efficacy in other surgical specialties [18]. As modern cardiac surgery improved the prognosis of most types of operations, less invasive approaches and aesthetic results became important issues [1, 2]. Technical aspects of these modified approaches like resection of the rib cartilages, sacrifice of the internal mammary vessels, the opening of pleural spaces, and the complexity of conversion to a standard sternotomy affect postoperative morbidity [19–21]. Furthermore, femoral vein and artery cannulation were often required to perform cardiopulmonary bypass. Cosgrove and associates [5, 6] from Cleveland first described innovative minimal-access approaches for aortic and mitral valve operations. Konertz and colleagues [7] from Berlin proposed an interesting approach to valve operations: the superior partial paramedian sternotomy permits the surgeon to expose either the aortic or the mitral valve. Several other reports concerning video-assisted mitral procedures through a minithoracotomy have been published [15, 17], but the elective indication seems to be directed still to selected patients. However, the definition of what is "minimally invasive" remains clouded and often is focused on the size and location of incisions. Each option should be considered as a trade-off between the exposure provided, the ease and speed of the operation, and postoperative patient recovery.

Our short-cut median sternotomy remains faithful to the principle of the median approach to the heart. A small incision (6 to 9 cm), associated with a subcomplete median sternotomy (manubrium and body) with a limited opening over the mediastinum, gives excellent exposure of the base of heart. A few specifically adapted instruments facilitate the approach (Fig 4). Nevertheless, many aspects must be emphasized to perform the operation safely.

View larger version (82K): [in this window] [in a new window]   Fig 4. The specific adapted instruments for the SCMS approach: (A) the illuminating disposable retractor, (B) the sagittal saw, and (C) the modified blades for the thoracic retractor.

We have used 2/0 polypropylene suture with a suspended continuous technique for all valve replacements. This technique, used routinely since 1991 in our department, has many technical advantages: raising the annulus, it facilitates the suture especially, in the small aortic root; fewer knots are necessary; and the execution is faster. The temporary pacemaker wires are preferentially positioned before the release of the aortic clamp. The deairing techniques must be meticulous and echo-guided; gentle aortic suction is continued up to the decannulation.

Respect of the median approach shows, in our opinion, many potential and practical advantages: The small skin incision associated with a limited opening of the mediastinum reduces the pain from overstretching of the ribs and thoracic ligaments; the postoperative chest wall function and therefore total lung compliance are greatly preserved, particularly in elderly patients. In our experience of minimally invasive coronary artery bypass grafting, removal of rib cartilages and minithoracotomy increased postoperative pain. In addition, the opening of the pleural space has also been found to be a source of postoperative pulmonary complications [19–21]. This bone-limited median sternotomy appears fast in healing, stable, and less painful. There is also less potential for wound infection and blood loss. Patient recovery is accelerated, allowing a short intensive care unit stay and hospital discharge, with an overall reduction in cost. Reoperation should be less difficult. An important advantage of this technique, experienced in 1 case, is the easy and rapid conversion to the standard sternotomy when necessary. Last, but not least important, is the aesthetic result. Many works have reported the potential for psychological disturbance, especially in female patients, when an unsightly scar is present in the middle of the thorax. Essentially this approach shows a better aesthetic result because of the limited extension of the scar.

In conclusion, this short-cut median sternotomy provides beneficial results for the patients. In our institution it became a "fact" and not a myth for many cardiac operations.

Acknowledgments

We appreciate the enthusiastic support and cooperation of our anesthesiologists: Ronan Deredec, Frederic Flais, Jean Louis Gerard, Annie Gringore, Pierre Lebreton, Michel Nivaud, Pierre Renouf, Marine Tasle, and Claude Zerr. We also acknowledge the support of our perfusionists and of the operating room team.

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