Ann Thorac Surg 1999;68:274-277
© 1999 The Society of Thoracic Surgeons
How to Do It
A special adapted retractor for the mini-sternotomy approach
Massimo Massetti, MDa,
Gerard Babatasi, MD, PhDa,
Satar Bhoyroo, MDa,
Olivier Le Page, MDa,
Andre Khayat, MDa
a Thoracic and Cardiovascular Surgery Department, University Hospital Caen, Caen, France
Address reprint requests to Dr Massetti, Department of Thoracic and Cardiovascular Surgery, CHU "Cote de Nacre," 14000 Caen, France
e-mail: massetti-m{at}chu-caen.fr
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Abstract
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Minimally invasive cardiac operations are now possible through different approaches. To provide the best exposure and sufficient space to manipulate the heart, a special adapted thoracic retractor has been developed for the ministernotomy approach. It is universally adjustable and provides excellent and consistent exposure especially below the incision edges. The retractor has the further advantage of a very low profile on the surgeon’s side and at the cephalic and caudal extremes of the operative field, which permits the greatest possible access through a limited access. We have successfully used this retractor in more than 180 patients. A less invasive median sternotomy through a 6–9-cm incision has been our original approach.
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Introduction
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As minimally invasive cardiac surgery became a reality, a variety of "less invasive" techniques have been proposed worldwide [1–13]. Although the minimally invasive direct coronary artery bypass (MIDCAB) approach, avoiding cardiopulmonary bypass and cardioplegic arrest, became minimally invasive [1], valve surgery debates have begun over the appropriate significance of "less invasive" and over which incision provides the better exposure and sufficient space to manipulate the heart. Among the different approaches, the partial sternotomy seems to have become the preferred choice for most intracardiac operations [5, 7, 8, 10, 12, 13]. Sometimes, minimizing access implies maximizing technical difficulties, and "less invasive" has been synonymous with "poor" and complex exposure in performing the operations. Classical thoracic retractors are too cumbersome and pediatric instruments sometimes bring about technical difficulties. For these reasons, a permanent, reusable, and specially designed sternal retractor has been developed in order to facilitate exposure through a less invasive median sternotomy. This technique, experienced in our center since the end of 1996, has become the routine approach for all nonredo intracardiac operations, and to date, more than 180 patients have been successfully operated. The surgical technique, named "short cut median sternotomy" (SCMS), and the results of the first 100 cases have been already reported [3].
The SCMS retractor is a unique instrument conceived for the concept of "keyhole" cardiac surgery through a midsternotomy approach. It enhances visualization of both valvular and the entire spectrum of intracardiac procedures; it facilitates the central cannulations, enhancing visibility behind the incision edges. This retractor features: a) a strong spreader retractor with a graduated arm. b) Multiple detachable asymmetrical sternal blades in three sizes (3-, 4-, and 6 cm) to accommodate various patient sizes; the right side’s blade is 1 cm deeper. c) Readily detachable self-retaining retractor of both cranial and caudal edges of incision requiring placement only during part of the procedure and providing excellent exposure during cannulation and intracardiac manipulation (Fig 1). This two-size kit "loop" presents multi-size detachable self-retaining blades for the soft tissues and potential application for other adaptable components such as left atrial and malleable retractors and a tube holder for carbon dioxide administration.
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Fig 1. (A) The SCMS retractor with its self-retaining blade for soft tissue. (B) Better exposure of the aorta and mitral annulus is accomplished, when the appropriate asymmetrical sternal blades are positioned.
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After the surgical field is prepared and draped as for a classical sternotomy, a midline skin incision 6–9 cm long is performed from the second to the fourth interspace in the aortic procedures (Fig 2) and from the third to the fifth interspace in the mitral operations. The soft tissue overling the sternum is mobilized and a median sternotomy (manubrium and body) is carried out. Unlike a child’s sternum, the adult sternal bone is inflexible, and as such, the sternum must be divided until the xyphoid appendage, which is preserved, and an enlightening disposable retractor (Mini Harvest; USSC, Norwalk, CT) helps the manipulations both cephalad and caudal under the skin flap. A small retractor is first introduced in the cleft between the two vertical halves of the sternum. Once the initial separation has been achieved, the mediastinal fat is divided and the pericardium longitudinally opened just over the region in which surgery is to take place. The pericardial edges are sewn to the skin (the right side sewn stronger than the left one), delivering the cardiac structures further into the incision. According to the incision length, the SCMS retractor is inserted with the appropriate blades; the asymmetrical blades are positioned in order to elevate and rotate clockwise the heart and the base of the great vessels. The spreading of the two sternal edges is limited to 5–6 cm (Fig 3A).
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Fig 2. Postoperative view of a patient who underwent aortic valve replacement, showing a small midline incision (6 cm in length).
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Fig 3. The SCMS retractor with the kit "loop" (A) and its application before aortic cannulation (B) for a central cardiopulmonary bypass.
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Cardiopulmonary bypass is centrally instituted; aortic cannulation is as high on the ascending aorta as possible, and the usual purse-string stitches are placed to accommodate the perfusion cannula. In the case of aortic valve work, a dual-stage venous cannula is used through an atrial appendage purse-string suture. For mitral valve access, an additional venous cannula is placed into the superior vena cava. The exposition of either cranial or caudal edges of incision is easily improved by the system kit "loop" of the SCMS retractor (Fig 3B); the pivotal blades of this mechanism provide for an upward and downward retraction, allowing for excellent exposure. Passing a tape around the aorta is best done after going on bypass. Retraction with this tape facilitates the exposure of the aortic root, and aortic cross-clamping is performed rapidly without difficulties with a 90° bent clamp. Once cardiopulmonary bypass is established, the lungs are collapsed and the heart emptied; venting of the left heart can be accomplished by a number of equally successful approaches. The superior pulmonary vein is cannulated in a traditional manner: a vent can be placed through the dome of the left atrium or through the aortic valve. Finally, direct venting of the pulmonary artery can be performed. Perfusion catheters for antegrade or retrograde cardioplegia are selected according to the type of surgery, and both aortic and mitral valve repair or replacement proceeds in a normal fashion. Dearing is achieved by suction on the aortic root vent, gentle shaking of the heart, and Trendelembourg maneuvers, which limit potential for air trapping in the left and right heart chambers. Defibrillation, when necessary, is accomplished with external pads while keeping the lungs inflated to increase tissue conductivity. Drainage is obtained by placing two chest tubes; a redon catheter is positioned anterior to the sternum after the two sternal edges are wired together with separate wires. All the maneuvers under the skin flaps, together with the control of hemostasis, are facilitated by the kit "loop" of the SCMS retractor and by the disposable light miniretractor.
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Comment
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Despite controversy, in only 2 years, many cardiac surgeons have learned to both replace and repair valves through small incisions with increasing safety and expertise [2–13]. The ideal minimally invasive incision will permit access to all areas of the heart, requires a minimum of specialized equipment, and provides an advantage to the patient of more rapid return to normal activities. There has been an unresolved controversy as to which incision provides the best exposure and how much exposure is optimal for heart surgery. The median approaches, such as the mini- or the partial sternotomies, seem to be the surgical compromise between the extremes of standard sternotomy incision and the port-access technologies. The restrictive exposure of the heart through this small incision can turn this simple operation into a technically demanding procedure that requires expertise on the part of the surgeon. Patient anatomy is variable, and depending on the body habitus, height, obesity, and the presence of enphesyma, the heart and the aortic root may occupy a different position in the mediastinum. Because of difficulty, on the basis of physical exam alone, to determine the extent of the incision and sternotomy that will provide adequate exposure in each individual patient, many surgeons proposed some preoperative exams such as chest radiograph, computed tomographic scan, or transesophageal echocardiography (TEE) in order to predict the level of the right atrium and aortic root [14]. To combine adequate access with a smaller scar, the SCMS approach has been proposed. This approach provides traditional exposure with which the cardiac surgeon is familiar and allows the surgeon to directly visualize the field of operation. Nevertheless, to perform safely and expeditiously, a special adapted sternal retractor has been designed. The SCMS retractor gives a powerful but easily controllable lift in a relatively atraumatic manner; it can easily be applied to the sternum providing excellent exposure, reducing the risk of sternal fracture and costo-chondral separation. Excellent for oversized patients, it also appears precise enough for the fragile sternum. The asymmetrical sternal blades allow for lift and the ability to rotate clockwise the pericardial sac under tension, providing for an ideal exposure to mitral, aortic, and tricuspid valves. The kit "loop" with the self-retaining soft tissue retractors centers the incision over the region in which surgery is to take place, enhancing visibility below the edges of incision, irrespective of a patient’s body size and habitus. These versatile components are easily positioned or removed from the sternal retractor during any portion of the procedure. Recent experiences suggest that small incisions are likely to be associated with less morbidity than classical median sternotomy [3].
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Acknowledgments
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We express our sincere thanks to Bertrand Bachet of Saint Jude Medical for collaboration in our work.
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Accepted for publication March 30, 1999.
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M. Boaron
Reply
Ann. Thorac. Surg.,
June 1, 2006;
81(6):
2337 - 2338.
[Full Text]
[PDF]
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M. Massetti, D. Buklas, S. Bichi, and E. Neri
Minimally Invasive Thoracic Retractors
Ann. Thorac. Surg.,
June 1, 2006;
81(6):
2336 - 2337.
[Full Text]
[PDF]
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Abstract
Introduction
