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Ann Thorac Surg 2001;72:289-290
© 2001 The Society of Thoracic Surgeons

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How to do it

Substernal thoracoscopic guidance during sternal reentry

Accepted for publication February 13, 2001.

Address reprint requests to Dr Gazzaniga, 1310 W Stewart Dr, Ste 502, Orange, CA 92868
e-mail: algazz{at}aol.com

	Abstract

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Reentry sternotomy is commonplace, as more patients are returning for second, third, or more repeat cardiac procedures. Catastrophic hemorrhage remains the most dreaded complication during reentry and carries a significant morbidity and mortality. Although various methods are used to reduce the risk of hemorrhage, we have found that substernal thoracoscopy is preferable. Our experience with this technique in both adults and children is presented.

	Introduction

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An increasing number of patients undergo reoperation after previous cardiac surgical procedures. Reentry into the mediastinum can produce severe hemorrhage, either by lacerating the heart or a blood vessel, or both. In a recent review, Follis and associates [1] described their experience with resternotomy in 610 patients at the University of New Mexico. Catastrophic hemorrhage occurred in 4 patients with one death directly related to reentry. Over the past several years, in selected cases, we have used thoracoscopic guidance during reentry sternotomy for patients with either congenital (n = 12) or acquired (n = 39) heart disease. Indications in adult patients were more than one previous sternotomy, coronary artery bypass grafting with previous internal mammary artery use (right or left), coronary artery bypass grafting with vein grafts immediately behind the sternum, previous aortic, mitral, or tricuspid valve operation, aortic aneurysm, and cardiac enlargement. Indications in pediatric patients were enlarged heart, previous right ventricular outflow patch or conduit (n = 4), two or more sternotomies (n = 3), central shunt (n = 1), and any previous aortic arch operation (n = 1).

	Technique

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After standard prepping and draping, the usual skin incision was made and sternal wires or tapes were removed. If the xiphoid was not removed during previous procedures, it was removed, and using rakes, the lower end of the sternum was elevated. Under direct visualization, the heart and mediastinal tissues were dissected free of the sternum. When direct vision was no longer possible, a 5.0-mm thoracoscope (Karl Storz, Charlton, MA) was placed at the lower end of the incision and dissection continued. Bipolar cautery scissors (Ethicon, Somerville, NJ) were always used for this portion of the procedure. This maneuver kept annoying bleeding from divided adhesions to a minimum, allowing for better visualization.

In most instances, the heart could be completely dissected away from the sternum and the sternum divided with the reciprocating saw. In some cases, however, the dissection could be done only in stages and the sternum was serially divided with the oscillating saw. Beginning at the lower end of the sternum the saw divided only that portion of the sternum that had been dissected (Fig 1). Further dissection was done and the sternum divided only where it had been dissected (Fig 2). This process was repeated until the area under the sternum had been completely dissected to the suprasternal notch (Fig 3). The intraoperative photographs shown here are in a 12-year-old boy with a previous right ventricular outflow patch.

View larger version (140K): [in this window] [in a new window]   Fig 1. Thoracoscopic view of the substernal space in a 12-year-old boy with previous right ventricular outflow patch. In the foreground are divided adhesions lysed under direct vision. The sternum has been partially divided and further adhesions on the right are visible.

View larger version (153K): [in this window] [in a new window]   Fig 2. Adhesions on the right seen in Figure 1 have been divided with the cautery scissors and the sternum opened beyond the outflow patch.

View larger version (144K): [in this window] [in a new window]   Fig 3. View to the suprasternal notch. The manubrium is free of adhesions and the sternotomy was completed with the reciprocating saw.

	Comment

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Eddy and associates [3] described modifying the Rultract retractor (Rultract, Inc, Cleveland, OH) so that an extended bar is placed at right angles to the patient and only one of the rake retractors is used to elevate the xiphoid area. The patient is placed in the Trendelenburg position and the suprasternal notch is dissected under direct vision. The Mayfield retractor (Genzyme Surgical Products, Cambridge, MA) combines techniques by placing an endoscope, suction, and cautery in one unit. Presumably, this apparatus would accomplish with one instrument the same thing we have described. There are advantages, however, to having the endoscope separate so it can be repositioned independently without also moving the cautery.

Although we have been selective in the use of substernal thoracoscopy, as experience is gained it adds little time to the operation and actually makes dissection quicker because the anterior portion of the heart is nearly freed up before sternotomy. It is not difficult to adapt this method to all reentry sternotomies. Thoracoscopic substernal dissection is safe, effective and probably eliminates the potential for catastrophic hemorrhage.

	References

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1. Follis F.M., Pett S.B., Jr, Miller K.B., Wong R.S., Temes R.T., Wernly J.A. Catastrophic hemorrhage on sternal reentry: Still a dreaded complication?. Ann Thorac Surg 1999;68:2215-2219.[Abstract/Free Full Text]
2. Garrett H.E., Jr, Matthews J. Reoperative median sternotomy. Ann Thorac Surg 1989;48:305.[Abstract]
3. Eddy A.C., Miller D., Johnson D., et al. Anterior sternal retraction for reoperative median sternotomy. Am J Surg 1991;161:556-559.[Medline]
4. Grunwald R.P. A technique for direct-vision sternal reentry. Ann Thorac Surg 1985;40:521-522.[Abstract]
5. Temeck B.K., Katz N.M., Wallace R.B. An approach to reoperative median sternotomy. J Cardiac Surg 1990;5:14-25.[Medline]

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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): Alan B. Gazzaniga Brian A. Palafox Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gazzaniga, A. B. Articles by Palafox, B. A. Search for Related Content PubMed PubMed Citation Articles by Gazzaniga, A. B. Articles by Palafox, B. A. Related Collections Cardiac - other