Ann Thorac Surg 2004;77:1109
© 2004 The Society of Thoracic Surgeons
How to do it
T-modification of sternotomy to accommodate a low-lying tracheostomy
Kenneth J. Woodside, MDa,
Joseph B. Zwischenberger, MDa,
D. Adrian Olveraa,
Vincent R. Conti, MDa*
a Division of Cardiothoracic Surgery, Department of Surgery, The University of Texas Medical Branch, Galveston, Texas, USA
Accepted for publication May 5, 2003.
* Address reprint requests to Dr Conti, Division of Cardiothoracic Surgery, Department of Surgery, The University of Texas Medical Branch, Galveston, TX 77555-0528, USA
e-mail: vconti{at}utmb.edu
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Abstract
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A low-lying tracheostomy can complicate a sternotomy for coronary artery bypass grafting. A modified "T" exposure, transecting the manubrium at the first intercostal space, can be utilized to maintain sternoclavicular architecture and avoid injury to the tracheostomy at the sternal notch.
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Introduction
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Median sternotomy for cardiac surgery exposure can be challenging in the presence of a preexisting tracheostomy. The risk of mediastinitis and sternal wound infections from a tracheostomy performed poststernotomy is well recognized [1]. However, a preexisting tracheostomy may also increase risk of infection and stomal damage during the sternotomy. A modified "T" exposure, transecting the manubrium at the first intercostal space, can be utilized to spare the upper manubrium and avoid injury to the tracheostomy, even when in close proximity to the sternal notch.
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Technique
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The "T" median sternotomy skin incision is only carried to the midportion of the manubrium. The sternotomy is performed with a sternal saw from the xiphoid to the mid-manubrium and then extended in a "T" fashion into the first intercostal space (Fig 1). Coronary artery bypass grafting or other cardiac operations can be performed as usual with standard takedown and use of the left internal mammary artery as appropriate. For closure, the sternum is approximated with a figure-8 wire between the top portion of the manubrium and the lower manubrium and gladiolus. The remainder of the sternum can be secured transversely with interrupted wire in the usual manner, and the remainder of the wound is closed in layers. This approach yields a secure closure and opposes the upper and lower portions of the sternum. A significant margin (4 to 6 cm) of skin is intact between the edge of the incision and the tracheostomy (Fig 2).
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Fig 1. "T" modification of the sternotomy at the first intercostal space (dotted "T" lines). The low-lying location of the tracheostomy is indicated (hatched circle).
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Comment
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Patients with a history of laryngectomy with tracheostomy placement can be somewhat problematic, as the tracheostoma can soil the surgical wound with sputum, and a full sternotomy can disrupt the structural support of the tracheostoma or cause direct airway injury. This case presented a unique challenge, as location of the tracheostomy was particularly low, immediately above and adherent to the sternal notch. We used a modified "T" sternotomy at the first intercostal space, similar to the reported manubrium-sparing modifications at the second intercostal space [2–3]. Our approach allows adequate exposure for standard cannulation and access to all the coronary artery targets, as well as utilization of the internal mammary arteries. Our approach also maintains a margin of intact and healthy tissue around the surgical wound and assures the structural integrity of the tracheostoma.
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References
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- Curtis J.J., Clark N.C., McKenney C.A., et al. Tracheostomy: a risk factor for mediastinitis after cardiac operation. Ann Thorac Surg 2001;72:731-734.[Abstract/Free Full Text]
- Ricci M., Salerno T.A., Houck J.P. Manubrium-sparing sternotomy and off-pump coronary artery bypass grafting in patients with tracheal stoma. Ann Thorac Surg 2000;70:679-680.[Abstract/Free Full Text]
- Legarra J.J., Sarralde J.A., López Coronado J.L., Trenor A.M. Surgical approach for cardiac surgery in a patient with tracheostoma. Eur J Cardiothorac Surg 1998;14:338-339.[Medline]
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Abstract
Introduction
