Ann Thorac Surg 2005;80:2393-2394
© 2005 The Society of Thoracic Surgeons
How to do it
Median Sternotomy Closure: A Simple Inexpensive Effective Technique
Harold Randecker, MD, FACS
*
Department of Cardiothoracic Surgery, Pasadena Bayshore Hospital, Pasadena, Texas
Accepted for publication July 19, 2004.
* Address correspondence to Dr Randecker, Stevens Hospital, 7504 196th Ave NE, Redmond, WA 98053; (Email: hrandecker{at}earthlink.net).
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Abstract
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A technique of median sternotomy closure that improves the usual rates of sternal infection, dehiscence, and re-exploration for hemorrhage is presented. This closure adds minimal time and expense to the case and diminishes the amount of blood loss and transfusion in the postoperative period.
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Introduction
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Sternal closure for cardiopulmonary bypass cases is critically dependent on obtaining a tight hemostatic rigid closure of the sternum. A tight hemostatic closure prevents hematoma formation in the peri-sternal tissue and in the mediastinal cavity or opened pleural cavities. By preventing hematoma formation and bleeding, the chances of secondary infection and mediastinal exploration are markedly diminished. A tight rigid sternal closure markedly diminishes the chances for sternal fracture, sternal movement causing patient discomfort, and sternal dehiscence. An inexpensive effective method of very tight hemostatic sternal closure is proposed in this article.
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Technique
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One hundred fifty-seven patients underwent sternal closure using one technique from July 1993 until March 1995 and from November 1997 until July 1998. One hundred forty-four patients (91.7%) had coronary artery bypass (76 patients [48.4%] used an internal mammary artery, 12 patients [7.6%] had cardiac valve replacements, and 1 patient [0.6%] had adult congenital heart surgery).
This technique initially compresses together the posterior plates on each side of the sternal incision with initial twisting of the wires over the top of the ribs. When these bundles are crossed and then twisted across the top of the sternum, the anterior plates on each side of the sternal incision are compressed together and at this point in the closure, the tension of the wire closure can be readjusted without breaking the wires. These maneuvers re-establish the mechanical stability of the sternum and provide a tight compaction of the cut edges of the sternum allowing blood to clot in the marrow space, which decreases blood loss. The technique adds approximately 4 to 5 minutes operating time to the case and an additional $1 to the cost of the surgery.
The technique is performed as follows and is shown in the accompanying diagrams. Place nine separate sternal wires as indicated in Figure 1. Wires 3 through 9 are placed to scrape the periosteum between the bone and mammary artery. All wires are pulled together to obtain a nearly tight closure of the sternum, and wires 3, 6, and 9 are tightened and loosely twisted. These two or three single wires are used to provide an initial near tight approximation of the cut edges of the sternal incision. Twist together on each side of the sternum over the top of rib 1, wires 1 and 2; over the top of rib 2, wires 4 and 5; and over the top of rib 4 or 5, wires 7 and 8 (Fig 2A, steps 1 and 2). Tighten these twists enough to bring the posterior plate of the sternum into apposition along the entire incision (Fig 2A, step 3). On completion of these maneuvers, the posterior plate should be in apposition with the anterior plate clearly seen (Fig 2A, step 4). Take each twist of wire and cross it with its opposite number from the other side of the sternal incision (Fig 2B, step 5). Twist each of these crossed wires tightly until the anterior plate of the sternum is in apposition along the length of the sternal incision (Fig 2B, step 6). Turn the ends of each of these three twists downward into the incision or periosteum to prevent the twist from causing incision disruption. Finish tightening wires 3, 6, and 9 as usual, or remove them as desired. The completed closure should appear similar to Figure 3.
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Fig 2. (A) Step 1 and 2: Wires 1 and 2 are twisted together on each side of the sternum over the top rib. Wires 4 and 5 over the top of rib 2, and wires 7 and 8 over the top of rib 4 or 5. Step 3: These twists are tightened enough to bring the posterior plate of the sternum into apposition along the entire incision. Step 4: Upon completion of these maneuvers, the posterior plate should be in apposition with the anterior plate clearly seen. (B) Step 5: Each twist of wire is crossed with its opposite number from the other side of the sternal incision. Step 6: Each of these crossed wires is twisted tightly until the anterior plate of the sternum is in apposition along the length of the sternal incision.
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Results
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At the end of 12 months follow-up, 1 patient had been explored for sternal bleeding, 1 patient had a sternal infection develop 3 months postoperatively, and 1 patient had a sternal wire removed because of discomfort. No sternal separations occurred. The postoperative infection rate of 0.6% for this technique versus the combined infection rate of 3.35% in four separate studies [1–4] with a similar operative technique, except for the sternal closure, is statistically significant to p < 0.0005 (–6.14) with the two-tailed test. The postoperative dehiscence rate of 0.0% for this technique versus the combined dehiscence rate of 2.37% in four separate studies [3–6], with similar operative technique, except for sternal closure, is statistically significant to p < 0.0005 (–5.15) with the two-tailed test. The postoperative exploration rate for sternal incision related hemorrhage of 0.6% is less than the usually stated rate of 5.2% [1–3] with similar operative technique, except for the sternal closure, and is statistically significant to p < 0.0005 (–7.57) with the two-tailed test. This technique when combined with Robicsek weave (passing the sternal wires used in this technique lateral to the weave wires) gives an excellent stabilized repair of a multiply fractured sternum.
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Comment
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The length of stay in the intensive care unit and in the hospital is unchanged compared with the 6 wire standard technique. The patients require no more pain medication than ordinary. The closure appears to be comfortable with a patient requiring one wire to be removed; it does not seem to bother patients who do not have much chest wall adipose tissue. The sternal dehiscence rate of 0% and infection and sternal bleeding rates of 0.6% show that this technique of sternal closure can help an average surgeon (such as myself) appear to be better than average.
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References
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- Wang F, Chang C. Risk factors of deep sternal wound infection in coronary artery bypass surgery J Cardiovasc Surg 2000;41(5):709-713.[Medline]
- Risnes I, Abdelnor M, Lundblad R, Baksaas ST, Svennevig JL. Sternal wound closure in patients undergoing open-heart surgerya prospective randomized study comparing intracutaneous and zipper techniques. Eur J Cardiovasc Surg 2002;22:271-277.
- Noyez L, Verkroost WA, van Astin NJC, Kaan JL, Lacquet LK. Sternal closurecomparison of two techniques. Cardiovasc Surg 1993;1:643-645.[Medline]
- Goodman G, Palatianos GM, Bolooki H. Technique of closure of median sternotomywith trans-sternal figure-of-eight wires J Cardiovasc Surg 1986;27:512-513.[Medline]
- Isik O, Ipek G, Mansuroglu D, Berki T, Tuzcu M, Yakut C. Monofilament absorbable sutures in median sternotomy J Cardiovasc Surg 1999;40:615-617.[Medline]
- Totaro P, Lorusso R, Zogno M. Reinforced sternal closures for prevention of sternal dehiscence in high risk patients J Cardiovasc Surg 2001;42:601-603.[Medline]
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Abstract
Introduction
