Ann Thorac Surg 2004;78:358-359
© 2004 The Society of Thoracic Surgeons
How to do it
Sternal closure with reabsorbable pin and cord in pediatric less invasive cardiac surgery
Hiroshi Oiwa, MD, PhDa*,
Ryoichi Ishida, MDa,
Kenichi Sudo, MD, PhDa
a Department of Cardiovascular Surgery, Kyorin University School of Medicine, Tokyo, Japan
Accepted for publication June 6, 2003.
* Address reprint requests to Dr Oiwa, Department of Cardiovascular Surgery, Kyorin University School of Medicine, 6-20-2, Shinkawa, Mitaka, Tokyo 181-8611, Japan
e-mail: hiroshioiwa{at}hotmail.com
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Abstract
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In pediatric less invasive cardiac surgery, we recently closed a patient's sternum using reabsorbable radiolucent poly-(L-lactide) acid sternal pins together with multifilament polydioxanone cord after a lower partial median sternotomy. This combination completely prevents postoperative sternal deformity, and leaves no radiopaque material identifiable radiographically, which is a significant cosmetic benefit.
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Introduction
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In pediatric less invasive cardiac surgery, a lower partial median sternotomy is the most common approach, because it makes cannulation easier and safer than in the transxiphoid approach and cause less postoperative wound pain than full sternotomy. In the initial series of pediatric less invasive cardiac surgery performed in our hospital, reclosure of the sternum was done only with radiolucent multifilament dioxanone cord because it was considered that the absence of radiopaque material immediately evident on radiography is a cosmetic benefit, especially in Japan. However, deformities in the lower part of the sternum, such as moderate bulging and depression were observed in around one-fifth of all cases because of the inadequate fixative strength of dioxanone cord alone for sternal closure. We, therefore, closed the sternum with a combination of reabsorbable radiolucent poly-(L-lactide) acid sternal pins (Gunze Ltd., Kyoto, Japan) and multifilament polydioxanone cord. These surgical materials were designed primarily for fixing fractured bone [1, 2], and then for stabilizing the divided costa after thoracotomy to reduce postoperative pain [3]. Recently, they were remodeled for use in the sternum. The sternal pin is reabsorbed within a few years postoperatively, thus minimizing disruption of the growth of sternal nuclei. Our technique, described in detail in this paper, completely prevented postoperative sternal deformities and, furthermore, revealed no radiopaque material on radiographs.
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Technique
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The subjects were twenty-two consecutive children requiring heart surgery using sternal pins, with an average age of 5 years and 6 months (range, 15 months to 12 years) and an average weight of 18.6 kg (range, 8.3 to 39.2 kg) who underwent the following procedure: less invasive cardiac surgery in which the sternum was closed with a combination of reabsorbable radiolucent poly-(L-lactide) acid sternal pins and multifilament dioxanone cord. The diagnoses were: atrial septal defect in thirteen patients; partial anomalous pulmonary venous drainage in one; and ventricular septal defect in eight.
The details of the surgical technique follow. A median skin incision (5% of the patient's height) from below the nipple level, and a lower partial sternotomy splitting the sternum in the midline below the third intercostal level (at the sternal border) to form an inverted Y shape, were performed. At sternal splitting, careful and gradual opening of the sternum is important in order to minimize both damage to the tissue connecting the chondral and bony parts of the sternum and subluxation of the ribs at the costchondral junction. The aortic cannulation was done through a conventional stab incision or by the Seldinger method. Bicaval cannulation and establishment of a cardiopulmonary bypass were performed by the usual procedure. Intracardiac repair was also performed in the conventional manner. To reclose the sternum, one or two poly-(L-lactide) acid sternal pins (length, 10, 15, or 25 mm) (Fig 1-A)
were inserted vertically into small holes dug from the median cut surface in the lowest or second lowest segment of the sternal bone marrow, and then 4 to 6 sutures of multifilament polydioxanone cord (diameter, 0.8 or 1.0 mm) were passed through prongs of the sternum (Fig 1-B), which were then drawn together before the ends of the cord were tied together. Neither dehiscence nor deformity of the sternum was detected after surgery. No sternal infection occurred in any case. The cosmetic results (eg, in the case shown in Fig 2)
and the surgical results were both satisfactory.
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Fig 1. (A) Photograph of poly-(L-lactide) acid sternal pins: the upper one is 10 mm long, and the lower one, 15 mm. (B) A lower partial sternotomy splitting the sternum in the mid-line below the third intercostal level and giving it an inverted Y shape was performed (top). To restore the sternum, one or two poly-(L-lactide) acid sternal pins were inserted in the lowest or the second lowest segment of the sternal bone marrow (middle). Finally, the sternum was closed and the two prongs of bone were secured together with 4 to 6 strands of multifilament dioxanone cord (bottom).
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Comment
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Even in pediatric cardiac surgery, it is believed that shortening the length of a median sternotomy reduces postoperative pain. From the standpoint of pain, full sternotomy is less desirable. The transxiphoid approach to the heart is an excellent procedure because it leaves no sternal deformity and makes possible avoidance of radiopaque stainless steel wire [4]. This approach is also the best in regard to postoperative pain. However, this method is still a challenging and technically difficult procedure even for a skilled surgeon, especially at the cannulation of the ascending aorta. On the other hand, a lower limited sternotomy facilitates exposure of the surgical field for safer less invasive cardiac surgery in pediatric cases [5, 6]; but if radiopaque stainless steel wire is not used, and radiolucent multifilament dioxanone cord alone is employed for reclosure of the sternum, sternal deformities can occur in some cases. The combined use of reabsorbable radiolucent poly-(L-lactide) acid sternal pins and multifilament polydioxanone cord offers sufficient fixative strength for sternal closure, thus resolving this problem and providing exactly the same cosmetic and surgical results as in the transxiphoid approach. The method offers the additional cosmetic benefit of an absence of radiopaque material, a benefit that may be of importance, at least in Japan, where some patients feel inferior or embarrassed about having had cardiac surgery (perhaps because, to them, it signifies weakness). We believe that, apart from the other benefits of our method, this aspect may afford confidence and encouragement of patients.
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References
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- Bergsma J.E., de Bruijn W.C., Rozema F.R., Bos R.R.M., Boering G. Late degradation tissue response to poly (L-lactide) bone plates and screws. Biomaterials 1995;16:25-31.[Medline]
- Matsusue Y., Yamamura T., Oka M., Shikinami Y., Hyon S.H., Ikeda Y. In vitro and in vivo studies on bioabsorbable ultra-high-strength poly (L-lactide) rods. J Biomedical Materials Research 1992;26:1553-1567.
- Tatsumi A., Kanematsu N., Nakamura T., Shimizu Y. Bioabsorbable poly-l-lactide costal coaptation pins and their clinical application in thoracotomy. Ann Thorac Surg 1999;67:765-768.[Abstract/Free Full Text]
- Barbero-Marcial M., Tanamati C., Jatene M.B., Atik E., Jatene A.D. Transxiphoid approach without median sternotomy for the repair of atrial septal defects. Ann Thorac Surg 1998;65:771-774.[Abstract/Free Full Text]
- Black M.D., Freedom R.M. Minimally invasive repair of atrial septal defects. Ann Thorac Surg 1998;65:765-767.[Abstract/Free Full Text]
- Murashita T., Hatta E., Miyatake T., et al. Partial median sternotomy as a minimal access for the closure of subarterial ventricular septal defect. Feasibility of transpulmonary approach. Jpn J Thorac Cardiovasc Surg 1999;47:440-444.[Medline]
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