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Ann Thorac Surg 1998;66:1429-1430
© 1998 The Society of Thoracic Surgeons

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How to Do It

Full sternotomy through a minimally invasive incision: a cardiac surgeon’s true comfort zone

^a Cardiac Surgical Unit, Massachusetts General Hospital, Boston, Massachusetts, USA

Accepted for publication May 28, 1998.

Address reprint requests to Dr Akins, Department of Surgery, Massachusetts General Hospital, White 503, Boston, MA 02114

	Abstract

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Increasing attention is being paid by cardiac surgeons to performing cardiac surgical procedures through less invasive approaches, including the use of limited incisions. A limited incisional approach is described that achieves full sternotomy, allows the use of standard operative instruments and techniques, permits rapid, easy conversion to normal sternotomy exposure, and is easy to learn.

	Introduction

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Although minimally invasive approaches to cardiac surgical operations have become very prevalent in recent years, there is little consensus on what constitutes a minimally invasive approach. Features that have been mentioned include avoidance of cardiopulmonary bypass, avoidance of sternotomy, or limited incisions with standard operative techniques.

For valvular operations, standard cardiopulmonary bypass through a midline approach is still preferred by most surgeons. Parasternal and various techniques of partial sternotomy have been tried [1–5], but all have potential disadvantages, including the damage or removal of costal cartilages or the potential stretching or division of internal mammary arteries. In addition, the safety of the operation can be compromised.

To provide a less invasive midline approach that allows a standard operation to be performed but with some of the advantages of limited incisions, I have developed a technique that allows for a full sternotomy and the performance of standard cardiac procedures through a limited skin incision.

	Technique

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A limited midline skin incision is made beginning at the sternal-manubrial junction. For aortic valve operations, the incision is 8 to 10 cm in length. For mitral valve operations, the incision usually extends lower to a length of about 10 to 12 cm. This approach can also be used for coronary artery bypass operations, or combined valve-coronary operations, for which the incision ends just above the sternal-xiphoid junction and is usually 12 to 15 cm in length (Fig 1). The subcutaneous tissues are mobilized from the anterior portion of the sternum. The linea alba is not opened. The sternum is then completely divided longitudinally from the jugular notch to the xiphoid. (There are no transverse sternotomies required.) Depending on the actual length of the sternum, the sternum can be divided with a standard sternal saw beginning in the jugular notch or a full sternotomy can be achieved with a small oscillating saw.

View larger version (34K): [in this window] [in a new window]   Fig 1. Limited midline skin incisions that allow full sternotomy: for aortic valve operations (AVR), 8 to 10 cm; for mitral valve operations (MVR), 10 to 12 cm; and for coronary artery bypass operations (CABG), 12 to 15 cm. (© 1998 by Edith Tagrin; used by permission.)

Harvesting of the left internal mammary artery is accomplished with use of the same Finichetto spreader with canting upward of the left-sided portion against the under left side of the sternum while the right side is pushed down.

Routine cannulation of the ascending aorta for arterial return, the right atrium for venous drainage, and the right superior pulmonary vein for left ventricular venting are easily achieved through this incision.

Standard cardiac operations are performed in their usual fashion. The complete sternotomy allows relatively easy postbypass placement of pacing wires and chest drainage tubes. Routine closure of the sternum with five or six wires is accomplished with little difficulty.

	Results

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Over the past several years I have gradually shortened the standard midline sternotomy incision, until I have reached a reasonable balance between incision size and exposure. Since February 1997 I have used the described limited incision approach on virtually all first-time operations, including 25 aortic valve replacements/reconstructions or left ventricular myectomies, 28 mitral valve reconstructions or replacements, 200 coronary artery bypass operations, and 33 combined valve and coronary operations. There have been no intraoperative complications attributable to the incisional approach, no increased bleeding, and no sternal wound complications. Occasionally in patients with large hearts, exposure of distal circumflex coronary arteries for bypass grafting requires some enlargement of the skin incision.

Subjectively patients no longer complain of intrascapular back pain, which was a common complication with previous full sternal distraction. In addition, patients seem to equate the magnitude of the operation with the size of the incision and thus with the smaller incisions seem to rehabilitate faster. Length of stay continues to shorten for all of our patients, and it is therefore difficult to measure the exact impact of the limited incisional approach on length of postoperative recovery. The vast majority of patients are discharged in 4 to 5 days. At follow-up the lower incision is especially satisfying to some patients because they are able to wear low-cut or open-collar shirts that do not show the incision.

	Comment

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The primary goal of every cardiac surgeon is to do the right operation well. The standard median sternotomy, the best tolerated major incision in the body, has become the favored incision of cardiac surgeons for several very good reasons: exposure to all contents of the entire anterior mediastinum is possible, the incision heals well in virtually all cases, and patients experience very limited discomfort from the sternotomy itself. Thus techniques that can preserve the benefits of this approach, such as the one described here, have some advantages.

Some of the potential advantages of limited incisions are also met by this approach. The smaller skin incision does not allow excessive spreading of the sternum, thus avoiding potential disruption of the costovertebral junctions or paravertebral hemorrhage that can at times accompany too aggressive sternal spreading. The upper abdominal discomfort associated with opening the linea alba is avoided. The patient is pleased to see only an 8- to 15-cm incision, which will actually shorten with healing. (Wounds also heal from end to end.)

This approach avoids some of the problems associated with other minimal access approaches, namely costal cartilage damage or removal, internal mammary artery damage or ligation, and transverse sternotomy incisions that are more difficult to close securely. Extension of the incision into normal full sternotomy exposure is easily done.

Standard cardiac operations can be performed with normal cannulas and instruments. The safety of this approach is obvious—should something untoward occur during the operation, the surgeon need only open the remaining skin to have normal full exposure to the entire mediastinum.

Additionally, the technique is easy for every surgeon to learn. Initial use of this approach can begin with progressive shortening of the standard incision, such as starting near the sternal-manubrial junction and ending above the sternal-xiphoid junction, until the surgeon becomes comfortable making the incisions as short as described. At the same time, standard operative techniques are maintained.

	References

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1. Cosgrove D.M., III, Sabik J.F. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62:96-97.
2. Konertz W., Waldenberger F., Schmautzler M., Ritter J., Liau J. Minimal access valve surgery through superior partial sternotomy: a preliminary study. J Heart Valve Dis 1996;5:638-640.[Medline]
3. Doty D.B., DiRusso G.B., Doty J.R. Full-spectrum cardiac surgery through a minimal incision: mini-sternotomy (lower half) technique. Ann Thorac Surg 1998;65:573-577.[Abstract/Free Full Text]
4. Kasegawa H., Shimodawa T., Matsushita Y., Kamata S., Ida T., Kawase M. Right-sided partial sternotomy for minimally invasive valve operation: "open-door method". Ann Thorac Surg 1998;65:569-570.[Abstract/Free Full Text]
5. Tam R.K.W., Almeida A.A. Minimally invasive aortic valve replacement via partial sternotomy. Ann Thorac Surg 1998;65:275-276.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Cary W. Akins Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Akins, C. W. Search for Related Content PubMed PubMed Citation Articles by Akins, C. W.