Ann Thorac Surg 2000;70:679-680
© 2000 The Society of Thoracic Surgeons
How to do it
Manubrium-sparing sternotomy and off-pump coronary artery bypass grafting in patients with tracheal stoma
Marco Ricci, MD, PhDa,
Tomas A. Salerno, MDa,
James P. Houck, MDa
a Division of Cardiothoracic Surgery, Erie County Medical Center and State University of New York at Buffalo, Buffalo, New York, USA
Address reprint requests to Dr Houck, 462 Grider St, Buffalo, NY 14215
e-mail: giacomoph{at}email.msn.com
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Abstract
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The presence of a tracheal stoma in patients with previous total laryngectomy who require cardiac operations is associated with an increased risk of wound complications and tracheal injuries when a full sternotomy is used. The aim of this report is to describe a technique of manubrium-sparing sternotomy, which can be used in patients undergoing coronary artery bypass grafting without cardiopulmonary bypass
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Introduction
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Access to the mediastinum may be difficult in patients who have undergone laryngectomy and have a tracheal stoma. Performing a median sternotomy in such patients substantially increases the risk of developing sternal wound complications [1]. Furthermore, dissection of the sternal manubrium and sternal notch from surrounding soft tissues may be hazardous, as it may result in unwanted and potentially troublesome complications such as bleeding and inadvertent tracheal injury. Injuries to the trachea may occur especially in those patients in whom the trachea is displaced anteriorly, laying close to the sternal notch, as a result of a "low" tracheal stoma. On the basis of these considerations, Kaiser and Salerno [1] in 1985 described the use of an alternative technique of median sternotomy, which consisted of limiting the division of the sternum to its lower and middle portion (xiphoid and body), preserving the integrity of the sternal manubrium. This approach was used successfully in 2 patients who previously had a total laryngectomy, in whom conventional coronary artery bypass grafting with cardiopulmonary bypass was undertaken using saphenous vein conduits for coronary revascularization.
Coronary artery grafting without cardiopulmonary bypass through a limited sternotomy was subsequently described by Arom and coworkers [2], who reported on 16 patients in whom a ministernotomy was used to gain access to the mediastinum. Although somewhat similar to the approach described herein, their technique consisted of dividing only the middle portion of the sternum (10 to 12 cm) to the left of the midline, and terminating the upper aspect of the sternal incision into the left second intercostal space. As reported by them, this approach also allowed for harvesting of the left internal mammary artery, along with revascularization of one or two coronary arteries (left anterior descending coronary artery and right coronary artery) on the beating heart. In contrast to our approach, their technique was used as part of a minimally invasive strategy of coronary revascularization and not by necessity, as is the case when dealing with patients with a tracheal stoma.
The aim of this brief report is to describe the use of manubrium-sparing median sternotomy and complete, off-pump coronary artery revascularization in the presence of a tracheal stoma.
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Technique
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After the tracheal stoma is adequately secured and totally isolated from the surgical field with a plastic sterile drape, the operation is initiated by performing a midline skin incision from 6 to 7 cm below the sternal notch to 2 cm below the xiphoid process (Fig 1). The sternum is then divided in the midline, from the bottom to the top, sparing the manubrium (Fig 2). Disarticulation of the intact sternal manubrium at the manubriosternal junction is carried out, and a sternal retractor is inserted to gain access to the mediastinum. Alternatively, an internal mammary artery retractor (Rultract, or Favaloro retractor) can be used in the standard fashion to expose and harvest the left internal mammary artery (Fig 3). In this case, great care should be taken in avoiding excessive elevation of the left half of the sternum, as this may potentially result in stretching and inadvertent injury to the left internal mammary artery. In fact, the proximal portion of the mammary pedicle remains attached to the inner surface of the second condrosternal joint (Fig 3), whose mobility is limited as the manubrium of the sternum is left undivided. Once the internal mammary artery retractor is carefully positioned, the left internal mammary artery can be harvested using conventional techniques, as a pedicle or skeletonized. Then the internal mammary artery retractor is removed, and a sternal retractor is placed into position. The one routinely used by our group (Cardio Thoracic Systems, Inc, Cupertino, CA) can be directly attached to an adjustable mechanical stabilizer, whose mobile footplate is used to obtain stabilization of target coronary arteries during grafting on the beating heart.
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Fig 1. A midline skin incision is made from 6 to 7 cm below the sternal notch to 1 to 2 cm below the xiphoid process.
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Fig 2. The sternum is divided in the midline from the bottom to the top, sparing the manubrium. Disarticulation at the manubriosternal junction is performed.
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Fig 3. An internal mammary artery retractor is placed into position with great caution, avoiding excessive traction on the sternum; in fact, this may potentially result in injury to the proximal portion of the left internal mammary artery (arrow).
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As previously described [3], we routinely use a "single suture" in the oblique sinus of the posterior pericardium attached to a vaginal tape to obtain cardiac elevation and exposure of coronary targets. Using this technique, coronary arteries located on the lateral and inferior wall of the heart can be effectively brought into view and grafted, preserving hemodynamic stability. After completion of distal anastomoses on the beating heart, proximal anastomoses of saphenous vein coronary grafts are constructed on the ascending aorta in the usual fashion. In our experience, placement of a lateral occlusion clamp on this vessel is not impeded by incomplete division of the sternum. In addition, avoidance of cardiopulmonary bypass eliminates the need of placing the aortic cannula and the aortic cross-clamp, whose positioning at the upper aspect of the sternal wound may be problematic as the sternal manubrium is left intact [4]. Upon completion, the sternal body is reapproximated in the midline in the usual fashion. In addition, sternal wires are placed between the undivided manubrium and the body of the sternum.
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Comment
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Although we have used this technique only in a small number of patients undergoing coronary artery bypass grafting who previously underwent laryngectomy and tracheostomy, the same approach may be used in patients undergoing aortic or mitral valve procedures. In addition, elderly patients with severe obstructive pulmonary disease, or younger patients who perform heavy manual duties, may most benefit from this technique as preservation of the sternal manubrium may considerably enhance the stability of the thorax and upper girdle in the early postoperative period. In our patient, not only this approach provided the exposure necessary to harvest the left internal mammary artery, but it also allowed to adequately expose all coronary targets, including those located on the lateral and inferior wall of the heart (posterior descending coronary artery and marginal branches of the circumflex coronary artery). Importantly, preserving the integrity of the sternal manubrium virtually eliminated the hazards and potential complications of a full sternotomy in the presence of a tracheal stoma.
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References
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Kaiser L.R., Salerno T.A. Coronary artery bypass in patients with total laryngectomy. Ann Thorac Surg 1985;39:481-482.[Abstract/Free Full Text]
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Arom K.V., Emery R.W., Nicoloff D.M. Mini-sternotomy for coronary artery bypass grafting. Ann Thorac Surg 1996;61:1271-1272.[Abstract/Free Full Text]
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Bergsland J., Karamanoukian H.L., Soltoski P., Salerno T.A. "Single suture" for circumflex exposure in off-pump coronary artery bypass grafting. Ann Thorac Surg 1999;68:1428-1430.[Abstract/Free Full Text]
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Bowman G.A., Grishkin B.A., Head H.D. Sternotomy with tracheostoma. Ann Thorac Surg 1986;42:119.[Free Full Text]
Accepted for publication March 24, 2000.
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Abstract
Introduction
