Ann Thorac Surg 2005;79:363-364
© 2005 The Society of Thoracic Surgeons
How to do it
Hydrodissection in Redo Sternotomies
Rosauro Mejia, MBBSa,*,
Pankaj Saxena, MCha,
Robert K. Tam, MD, FRACSa
a Department of Cardiac Surgery, The Prince Charles Hospital, Chermside, Australia
Accepted for publication October 16, 2003.
* Address reprint requests to Dr Mejia, Department of Cardiac Surgery, The Prince Charles Hospital, 627 Rode Rd, Chermside QLD 4032, Australia
rossmejia{at}hotmail.com
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Abstract
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Injection of pressurized normal saline into the retrosternal tissue has been used in redo sternotomies. This technique has been labeled as hydrodissection. It is a simple but effective technique to help minimize the trauma and risk of complications in redo sternotomies. My colleagues and I present a series of 6 consecutive patients in whom hydrodissection was performed. There was no injury to the heart or any vessel on reentry.
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Introduction
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Today, as more patients are returning for repeat cardiac procedures, the number of redo sternotomies has increased to approximately 16% [1] of the workload in cardiac surgery. Reoperations are technically more demanding and are associated with increased morbidity and mortality. The reported incidence of damage to the heart, great vessels, or extracardiac grafts during reoperations is 1% to 6%, and the mortality rate is 38% in patients who sustain major cardiac or vessel injury [2, 3].
Various methods are used to reduce the risk of injury to the heart and major vessels. The key to safe re-sternotomies is direct dissection of all adhesions in the retrosternal space [4, 5]. Gazzaniga and Palafox [6] used a direct visual technique with a 5.0-mm thoracoscope to dissect the heart and mediastinal tissues free from the posterior table of the sternum.
My colleagues and I describe a simple but effective approach to help minimize the trauma and risk of complications in redo sternotomies. Through the aid of hydrodissection, which has been previously used in ophthalmic [7] and urologic [8] surgery, the mediastinum can be entered and the heart mobilized in a bloodless plane to decrease the risk of injury to the heart and vessels.
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Technique
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The patient is placed in the routine supine position, prepared, and draped in the standard manner. The skin incision is extended 3 cm below the previous scar to enhance the exposure of the retrosternal space. The sternal wires are divided and removed. The periosteum is exposed in the midline. The retro-subxiphoid space is opened with sharp dissection and coagulative diathermy. A self-retainer is then applied to the inferior aspect of the wound, and bone hooks are used to lift the sternum upward, thus enabling direct vision of the inferior aspect of the posterior table of the sternum.
A bag of normal saline is placed in an Infu-Surg pressure bag (Ethox Corp, Buffalo, NY), and the pressure bag is inflated. A Baxter intravenous infusion set (Baxter Healthcare, Singapore) is attached to a 0.90 x 90-mm Terumo spinal needle (Terumo Medical Corp, Elkton, MD). Pressurized normal saline 100 to 200 mL is injected between the posterior table of the sternum and the heart and mediastinal tissue. While the pressurized normal saline is injected, the needle is advanced cephalad, taking care to remain in the midline and immediately underneath the posterior table of the sternum (Fig 1). The patient is monitored closely for signs of cardiac tamponade. This technique expands the bloodless tissue plane between the sternum and the heart so that dissection of the adhesions can be performed quickly and safely. Once the heart has been separated from the posterior table of the sternum, a Hall's reciprocating saw can be used confidently to divide the sternum. The surgical plane created by hydrodissection can also be used to separate adhesions for the rest of the heart and the pericardium.
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Fig 1. View of the xiphisternum with self-retainer and bone hooks in position. The pressurized normal saline is injected into the retrosternal space.
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This technique was performed in 6 consecutive patients who required redo sternotomies (performed by a single surgeon). This group of patients contained 3 men and 3 women. The average age was 81.8 years (range, 75 to 85 years). Five of the patients were undergoing their second operation, and 1 patient presented for his third cardiac operation. Four of the 6 patients had previous coronary artery bypass grafts, and all had patent left internal mammary artery to left anterior descending artery grafts. The other 2 patients had had previous aortic valve replacement. None of the patients experienced any complications, including sternal infection, from the previous operation. The average time from incision to commencement of cardiopulmonary bypass was 25.8 minutes (range, 15 to 45 minutes). None of the patients had their pericardium closed in the original operation. The average intraoperative blood loss was 266 mL (range, 150 to 400 mL). There was no injury to the heart or any vessel on reentry.
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Comment
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Cardiac reoperations constitute an increasing proportion of the workload in most cardiac units. They are technically more difficult and time consuming. Redo sternotomies are associated with an increased morbidity and mortality. Hydrodissection offers a simple, effective, and inexpensive technique to increase the safety of reentry into the mediastinum. The materials required are inexpensive and are found in all units. This technique for redo sternotomies is also sufficiently simple to adopt, even for the inexperienced surgeon.
We believe that 100 to 200 mL of normal saline is sufficient to enter the mediastinum quickly and safely. However, a greater volume may be used if necessary. On-table cardiac tamponade is a possibility; therefore, if a larger volume of normal saline is needed, we suggest that an on-table echocardiograph be used to assist in the diagnosis.
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References
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- Data analysis of The Society of Thoracic Surgeons National Cardiac Surgery Database, January, 1998. Cited J Card Surg 2002;17:4–13
- Loop FD. Catastrophic hemorrhage during sternal reentry. Ann Thorac Surg. 1984;37:271–272[Medline]
- Dobell ARC, Jain AK. Catastrophic hemorrhage during redo sternotomy. Ann Thorac Surg. 1984;37:273–278[Abstract]
- Culliford AT, Spencer FC. Guidelines for safely opening a previous sternotomy incision. J Thorac Cardiovasc Surg. 1979;78:633–638[Abstract]
- Grunwald RP. A technique for direct-vision sternal reentry. Ann Thorac Surg. 1985;40:521–522[Abstract]
- Gazzaniga AB, Palafox BA. Substernal thorascopic guidance during sternal reentry. Ann Thorac Surg. 2001;72:289–290[Abstract/Free Full Text]
- Vasavada AR, Singh R, Apple DJ, Trivedi RH, Pandey SK, Werner L. Effect of hydrodissection on intraoperative performance: randomized study. J Cataract Refract Surg. 2002;28:1623–1628[Medline]
- Nezhat CH, Nezhat F, Seidman DS, Nasserbakht F, Nezhat C, Roemisch M. A new method for laparoscopic access to the space of Retzius during retropubic cystourethropexy. J Urol. 1996;155:1916–1918[Medline]
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Abstract
Introduction
