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Ann Thorac Surg 2000;69:1340-1341
© 2000 The Society of Thoracic Surgeons
Discussion
DR ALAA Y. AFIFI (Gulfport, MS): I enjoyed this presentation very much. It is always a pleasure to be able to see a well-known center such as East Carolina examine a topic that has not been addressed in detail previously. We have been so focused on patency of MIDCAB approaches and now are looking at patency of OPCAB approaches compared with the standard sternotomy and cardiopulmonary bypass. Based on these findings and very nice illustrations, what changes, if any, are being made at your institution to minimize dehiscence, infection, and other wound complications in terms of your MIDCAB population?
DR NG: Well, certainly we have considered what we can do to change this to reduce our complication rate, and that is part of the reason we looked at these specific factors, to see if we could weed out those patients who perhaps we should consider some other approach. Unfortunately we did not specifically identify anything. There were some changes with technique that were used by our surgeons that I think showed some benefit. One was going from using initially Dexon to reapproximate the costal cartilages to using PDS; the other being using a support bra in the perioperative period for women with pendulous breasts to help support the tissue and prevent superficial dehiscence. Those are the two particular areas I think we were able to do something about.
DR ALVAN W. ATKINSON (Raleigh, NC): This morning, we had some discussion about EVH techniques for vein harvesting, and we noticed when we first started doing this that we tried to make very small incisions, and there was a lot of trauma to the wound edges struggling through, so we have started to make just slightly larger incisions and we have had a lot fewer superficial skin problems. Do you think maybe there is an effort here to make a super mini small incision where if you made a slightly bigger incision and did not struggle quite so much or maybe divided the rib or something that you might have fewer wound problems?
DR NG: I think that is absolutely correct. I think the tendency may have initially been to make a smaller incision and therefore have to create more tension in order to create exposure. However, with the advancements in the devices to help retract and visualize, that incidence has been reduced. And I think that is certainly something that needs to be considered, local trauma to that area, because it is certainly an area that is already compromised by having to take down the mammary on that side.
DR GLENN J.R. WHITMAN (Baltimore, MD): We too had trouble with the anterior thoracic mini-thoracotomy approach. Although we may have had problems with postoperative wound complications, our main problem was that we found it extremely difficult to learn how to effectively take down a long segment of internal mammary artery through that approach.
We have now turned to what I think may be a growing trend in the country, which is a lower midline sternal incision. If you incise the lower half of the sternum and T off to the patient’s left side, then the same retractors that we use to take down the mammary through a full sternotomy can be used. The surgeon then does not have to learn a new approach to take down the mammary as this aspect of the procedure is so very similar to the typical midline sternotomy. Furthermore, if trouble arises, you simply have to extend that incision rather than close a thoracotomy and then go to the midline.
This lower midline sternotomy seems to have the same postoperative wound complications, actually less, than the full-fledged median sternotomy, and obviously, therefore, much less than the anterior thoracotomy complications you have seen. I wondered whether your group had tried this midline lower sternotomy and what you thought about this approach to small incision operations.
DR NG: I do not know if we have actually taken the lower sternotomy approach to this in particular, but I know that we are using mini sternotomies from the more superior portion of the sternum. Perhaps Dr Elbeery can comment in more detail.
DR JOSEPH R. ELBEERY (Greenville, NC): Yes, I could probably answer that better than Peter can. I am not real fond of the lower midline sternotomy, because the times we have tried it, I found it quite difficult to get the mammary down underneath the manubrium through that approach. Using any of the commercially available MIDCAB mammary retractors, I think you can get the whole mammary down just as you would through a full sternotomy. So at least on the left side I do not get enough mammary through the lower sternotomy, although I know people are doing it that way.
On the right side, I think it works quite well because the right mammary seems to drop off the sternum a little sooner. But on the left, I have not found that to be a good technique in my own hands. Furthermore I do not know what the complication rate of the hemisternotomy is, and whether you are going to have some nonunions where it is T’d off. The validity of this technique remains to be seen as well.
DR DANIEL L. MILLER (Rochester, MN): Over the last 3 years, we have been referred 10 patients from our region for herniation much like you showed today. Of those 10, 8 had complete avulsion of at least two or three costal cartilages from the sternum. This was more than likely caused from excessive opening of the retractor medially causing avulsion of the cartilages. In working with our cardiac surgeons, they now cut the fifth rib laterally before opening the retractor so this avulsion does not occur. You can get into a lot of trouble with late complications secondary to avulsion of the costal cartilages such as costal chondritis and draining fistulas as you had in your patient.
I have one question. In the 6 patients that had their incisions T’d off, was there any increased incidence of complications in that group, especially in your diabetic patients?
DR NG: No, not that I am aware of.
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