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Ann Thorac Surg 2004;77:1107-1108
© 2004 The Society of Thoracic Surgeons

How to do it

A new retraction-suspension device for limited upper sternotomy

Maurizio A. Boaron, MDa*

a Unità Operativa di Chirurgia Toracica, Ospedale Maggiore-Bellaria, Bologna, Italy

Accepted for publication May 2, 2003.

* Address reprint requests to Dr Boaron, Chirurgia Toracica, Ospedale Maggiore, Largo B. Nigrisoli 2, 40100 Bologna, Italy
e-mail: maurizio.boaron{at}ausl.bologna.it


   Abstract
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 Abstract
Introduction
 Technique
 Comment
 References
 
A limited sternal splitting incision is useful for the surgical approach to different diseases of the upper mediastinum. To provide optimal exposure, a specifically designed sternal retractor has been developed. Through a V-shaped opening and elevation of the sternum, surgery of the thymus gland, mediastinal goiters, and, more generally, biopsy or resection of most anterior mediastinal masses are possible. The device has been used in 30 patients who had different diseases, with totally satisfactory results.


   Introduction
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 Abstract
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Technique
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The author discloses that he owns the patent to the retractor.

 

Retraction of the sternal edges after a limited sternal split is generally achieved using a pediatric rib retractor. The correct placement of this instrument may be difficult; furthermore, even a limited retraction often causes sternal fractures. Surgical techniques including both a longitudinal and a partial [1] or complete [2] transverse split (J-shaped or inversed T) have been proposed. These techniques prevent sternal fractures thanks to the transverse split, but result in increased complexity. Furthermore, the operative field behind the middle and lower sternum remains narrow.

With the aim of reducing the inconvenience of an upper sternal split while improving the operative field, a new retractor has been developed.


   Technique
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The operation is carried out under general anesthesia with tracheal intubation and standard patient monitoring. The patient is positioned in the supine position with a roll under the shoulders to provide neck extension. The level of the skin incision depends on the underlying disease. In the case of cervicomediastinal goiters a collar incision 1 cm above the sternal notch is used, whereas for thymus or upper mediastinum surgery it is carried out 2 cm caudally. After preparation of the subcutaneous flap, cervical structures are exposed and possibly dissected according to the particular type of surgery. When access to mediastinum is indicated, the external surface of the sternum is exposed and the periosteum is opened longitudinally by electrocautery. A partial longitudinal sternotomy (whose extension is variable according to the presentation) is carried out with an oscillating saw. The specifically designed retractor is then put into place.

The device (Fig 1) is a self-retaining retractor with the ability to spread with great force. In contrast to other thoracic retractors, its blades are part of the two arms connected through a pinion. Thus it opens in a V-shaped manner, while the blades of the other thoracic retractors open in a parallel manner. Because the flexibility of the adult sternal bone is limited, the V-shaped opening provides a better distribution of forces, usually resulting in only microfractures that are clinically irrelevant and do not require reconstruction.



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  		Fig 1. The self-retaining retractor for limited sternotomy. The sternal retractor allowing lifting of the sternum is also shown.

 
The retractor is gradually opened and dissection of anterior mediastinal structures is begun. A retraction of the upper edges of 5 to 7 cm may be achieved. The particular shape and ergonomics of the instrument provide a progressive resistance-related retraction.

Dissection behind the uncut portion of the sternum is obviously more tedious; however, it may often be completed without difficulty. If a wider surgical field is required, the retractor may be integrated with an original lifting device, which is connected to the self-retaining retractor to form a joint system (Fig 2). This is tailored to provide good exposition of the middle and even inferior mediastinum thanks to the upward lifting of the sternum. When the lifting device is applied there is a slight restriction of the visual field; we are currently working to reduce the tool's dimensions and consequently its visual hindrance, by utilizing a high resistance steel. These instruments are not yet commercially available.



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  		Fig 2. The integrated system.

 
After the biopsy or excision of the mediastinal lesion is completed, the retractor is removed and the sternal edges closed by one or two wire sutures. The fascia and subcuticular tissue are then closed in layers.

The retractor has been used in 30 procedures so far. Indications for a partial sternal split were thymus surgery (n = 13), mediastinal goiters (n = 7), tracheal surgery (n = 1), and biopsy or exeresis of upper mediastinum masses (n = 9). The lifting device was used in 9 of 30 cases (thymus surgery, n = 5; mediastinal masses, n = 4).

No operative complication was recorded, and blood loss was never significant. The postoperative course was uneventful in all cases. No sternal infection occurred, and wound healing was fully satisfactory in all cases. We cannot do any comparison with procedures carried out through a full sternotomy as in our institution the indications for limited or complete sternotomy are different.


   Comment
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Upper sternotomy has a recognized role in the access to the superior mediastinum. It is often employed during thymus surgery; other indications include tracheal surgery and biopsy or removal of most benign or malignant tumors of the upper mediastinum and those mediastinal goiters whose treatment could be unsafe through cervicotomy.

The commercially available rib retractors usually used after a partial sternal split often cause uncontrolled sternal fractures, especially if a transverse section is not performed. Furthermore, vision and possibility of dissection behind the uncut portion of the sternum are restricted.

The new device described in this report was designed with the aim of overcoming such limitations. Thanks to its shape, a satisfactory retraction of sternal edges may be achieved without transverse split. Furthermore it is equipped with a third sternal blade (in a different axis) that allows lifting of the middle and lower sternum, thus providing a satisfactory operative field including not only the superior mediastinum, but also the middle and inferior compartments.

Although the device proved fully satisfactory in different kinds of mediastinal procedures, myasthenia surgery represents its main indication. Cervicotomy with partial sternotomy appears to be a satisfactory compromise between the two opposite approaches most frequently used, namely simple cervicotomy and full median sternotomy. When using this device a good exposition of the base of the neck and of the anterior mediastinum is possible, permitting an easy dissection and removal of all the thymic tissue and almost all mediastinal fat, possibly with a no-touch technique [3]. The identification of phrenic nerves is easy. Lifting of the sternum, a technique also advocated in the case of cervicotomy [4] or video-assisted approaches [5], provides a further increase of the operative field that may be useful in selected cases. Small encapsulated thymomas may also be removed: their complete exposition permits the resection without traction or uncontrolled maneuvers that could cause the rupture of the specimen.


   References
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  1. Bellows C.F., Hartz R.S., Cullinane C., Pigott J.D. Cosmetic approach to anterior mediastinal masses. Ann Thorac Surg 2002;74:1724-1726.[Abstract/Free Full Text]
  2. Grandjean J.G., Lucchi M., Mariani M.A. Reversed-T upper mini-sternotomy for extended thymectomy in myasthenic patients. Ann Thorac Surg 2000;70:1423-1425.[Abstract/Free Full Text]
  3. Trastek V.F. Thymectomy. In: Kaiser L.R., Kron I.L., Spray T.L., eds. Mastery of cardiothoracic surgery. Philadelphia: Lippincott-Raven, 1998:105-111.
  4. Cooper J.D., Al-Jilaihawa A.N., Pearson F.G., Humphrey J.G., Humphrey H.E. An improved technique to facilitate transcervical thymectomy for myasthenia gravis. Ann Thorac Surg 1988;45:242-247.[Abstract]
  5. Takeo S., Sakada T., Yano T. Video-assisted extended thymectomy in patients with thymoma by lifting the sternum. Ann Thorac Surg 2001;71:1721-1723.[Abstract/Free Full Text]



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This Article
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Maurizio A. Boaron
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Related Collections
Right arrow Mediastinum

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