Ann Thorac Surg 2005;79:e19-e20
© 2005 The Society of Thoracic Surgeons
How to do it
Sternal Approximation for Bilateral Anterolateral Transsternal Thoracotomy for Lung Transplantation
David C. McGiffin, MDa,*,
Jorge E. Alonso, MDb,
George L. Zorn, Jr, MDa,
James K. Kirklin, MDa,
K. Randall Young, Jr, MDc,
Keith M. Wille, MDc,
Kevin Leon, MDc,
Katherine Hart, BSa
a Division of Cardiovascular and Thoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
b Department of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
c Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
Accepted for publication September 19, 2004.
* Address reprint requests to Dr McGiffin, University of Alabama at Birmingham, Division of Cardiothoracic Surgery, 701 19th St S, LHRB 780, Birmingham, AL 35294-0007 (E-mail: david.mcgiffin{at}ccc.uab.edu).
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Abstract
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The traditional incision for bilateral sequential lung transplantation is the bilateral anterolateral transsternal thoracotomy with approximation of the sternal fragments with interrupted stainless steel wire loops; this technique may be associated with an unacceptable incidence of postoperative sternal disruption causing chronic pain and deformity. Approximation of the sternal ends was achieved with peristernal cables that passed behind the sternum two intercostal spaces above and below the sternal division, which were then passed through metal sleeves in front of the sternum, the cables tensioned, and the sleeves then crimped. Forty-seven patients underwent sternal closure with this method, and satisfactory bone union occurred in all patients. Six patients underwent removal of the peristernal cables: 1 for infection (with satisfactory bone union after the removal of the cables), 3 for cosmetic reasons, 1 during the performance of a median sternotomy for an aortic valve replacement, and 1 in a patient who requested removal before commencing participation in football. This technique of peristernal cable approximation of sternal ends has successfully eliminated the problem of sternal disruption associated with this incision and is a useful alternative for preventing this complication after bilateral lung transplantation.
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Introduction
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Bilateral sequential lung transplantation has been traditionally performed through a bilateral anterolateral transsternal thoracotomy (clamshell incision), with sternal division occurring at the level of the fourth intercostal space. Closure of the sternum has usually been performed with two or three interrupted stainless steel wires. To reduce the incidence of sternal override with this type of closure, Kirschner wires or Steinmann pins have been inserted into the cancellous bone of the sternum to stabilize the sternal ends; this technique has been used in lung transplant patients [1] as well as in patients undergoing non–lung transplant thoracic surgical procedures [2]. However, an important disadvantage of this incision is the substantial incidence of sternal disruption at the site of the transverse sternotomy, resulting in chronic pain and deformity. In a series of patients undergoing bilateral lung transplantation with this incision, Brown and colleagues [3] and Meyers and colleagues [1] reported the incidence of sternal complications of 36% and 34%, respectively. Migration of Kirschner wires inserted to assist in stabilization of the sternal fragments has been reported [1]. Strategies to avoid sternal disruption include the use of a sternal fixation device consisting of anterior and posterior plates that are secured to the sternal fragments by screws [3] and using the clamshell incision without sternal division [1].
This report details an alternative approach to stabilizing the sternal fragments using peristernal cables.
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Technique
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A standard bilateral anterolateral transsternal thoracotomy is performed through the fourth intercostal space with sternal division. At the time of closure, pericostal sutures are passed around the ribs and costal cartilages but left untied. The soft tissue overlying the sternum is detached from the sternum above and below the sternotomy for two interspaces. Using a cable passer (Biomet BMP Cable System; Biomet, Warsaw, IN), a 2-mm cable (length, 750 mm) is passed behind the sternum two interspaces above and two interspaces below the transverse sternotomy. Each limb of the cable is crossed in front of the sternum, and each limb together with the diagonally opposite limb of the other cable is passed through a metal sleeve. The two ends of the cables passing through each sleeve are then attached to a T-handle tensioner, and the two tensioners are then tightened until the two sternal fragments are securely approximated. The metal sleeves are then crimped to secure the cables, and the excess cable is then excised with a cable cutter (Fig 1). The radiologic appearance of the cable closure is of a figure-of-8 (Figs 2 and 3).
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Fig 1. The peristernal cables are passed behind the sternum through intercostal spaces above and below the sternal division, and then passed through the sleeves, tensioned, the sleeves crimped, and the excess cable excised.
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Fig 2. Anteroposterior chest radiograph illustrating the appearance of the peristernal cables in a figure-of-8 configuration. (L = left.)
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Forty-seven patients underwent lung transplantation (46 through a bilateral and 1 single lung transplant through unilateral anterolateral transsternal thoracotomy) with fixation of the transverse sternotomy using a peristernal cable system. This series included 24 male and 23 female patients with a mean age of 35.2 years (range, 12.2 to 59.3).
In all 47 patients, solid healing occurred. In 1 patient, override of one fragment over the other occurred owing to the cable cutting out of the inferior sternal segment, but solid bone union occurred.
Removal of the cables was performed in 6 patients—1 because of a wound infection (and after cable removal, the bone united), 3 patients for cosmetic reasons (all patients had cystic fibrosis and were very thin), 1 patient during the performance of a median sternotomy for an aortic valve replacement, and 1 patient who requested removal before playing football. Removal of the cable system was easily performed in all patients using a brief general anesthetic, making a short incision over the cables, dividing the cable, and extracting the cables and sleeves.
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Comment
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The only problem associated with this method that we have encountered has been the cosmetic appearance of the cables and in particular the sleeves, which, in very thin patients, can be rather obvious. Removal of the cables is an easy matter and is analogous to removal of orthopedic hardware after bone union in other situations.
The other solutions to sternal disruption, including sternal plates [3] and bilateral anterolateral thoracotomy without sternal division [1], have also been successful, and the method we described is an alternative to these methods. Bilateral anterolateral thoracotomy without sternal division may not have universal appeal as there may well be some discomfort on the part of some surgeons who wish to have ready access to the pericardial cavity in the event that cardiopulmonary bypass is urgently required.
This method of sternal approximation is another successful alternative that can be used to prevent sternal disruption after bilateral lung transplantation.
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Acknowledgments
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We thank Jane Owenby for manuscript preparation and David Fisher for illustrations.
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References
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- Meyers BF, Sundaresan RS, Guthrie T, Cooper JD, Patterson GA. Bilateral sequential lung transplantation without sternal division eliminates posttransplantation sternal complications J Thorac Cardiovasc Surg 1999;117:358-364.[Abstract/Free Full Text]
- Bains MS, Ginsberg RJ, Jones WG, et al. The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor Ann Thorac Surg 1994;58:30-33.[Abstract]
- Brown RP, Esmore DS, Lawson C. Improved sternal fixation in the transsternal bilateral thoracotomy incision J Thorac Cardiovasc Surg 1996;112:137-141.[Abstract/Free Full Text]
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Abstract
Introduction
