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PubMed1982

Brachial plexus injury following median sternotomy. Part II.

Brachial plexus injury may be a consequence of median sternotomy. In a previous study, we documented that median sternotomy can cause first rib fractures and that the first rib fractures may be associated with brachial plexus injury. In the current study, two groups of patients were compared for the incidence of brachial plexus injury and first rib fracture. In Group A, an Ankeney retractor was used with the crossbar placed caudal to the incision: in Group C, a Cooley sternal retractor was used with the crossbar placed cephalad to the incision. The major effective difference between these two retractors was the more caudal placement of the retractor blades with the Cooley retractor than with the Ankeney retractor. Our previous study showed that first rib fractures were caused by high placement of the sternal retractor and that they could be avoided by placing the retractor at a lower position. In the present study, 33% in Group A and 14% in Group C sustained first rib fractures (p = 0.024). Signs of brachial plexus injury occurred in 18% of Group A and 12% of Group C (p = 0.52). We found no correlation between the presence of rib fracture and the presence of neurologic symptoms, but all patients who had both neurologic symptoms and a rib fracture had the symptoms only on the same side as the rib fracture. We also found that standard chest x-ray films identified only 15% of the rib fractures seen on special first rib views. The study demonstrates that the incidence of first rib fractures following median sternotomy is reduced when the sternal retractor is placed at a lower position and that the incidence of brachial plexus injury may also thereby be reduced.

Age Factors↗

PubMed1980

A cosmetically acceptable incision for the median sternotomy.

The median sternotomy incision has become the routine approach for most cardiac surgical procedures. This generally gives a poor cosmetic result. In certain patients, particularly those who are asymptomatic and undergoing short, low-risk procedures, cosmetic considerations are of relatively greater importance. We describe a transverse skin incision which gives adequate exposure for the median sternotomy. It has been used successfully in 40 female patients. This technique provides a cosmetically acceptable incision for the median sternotomy approach.

Adult↗

PubMed1994

Protection of the patent internal mammary artery by-pass graft from subsequent sternotomy.

OBJECTIVE: We describe a technique to protect the patent internal mammary artery graft from injury by repeat sternotomy. INTERVENTIONS: The internal mammary artery is dissected as far proximally as possible. The left pleural space is opened widely thus allowing the left lung to protrude through the pleural defect once mechanical ventilation is resumed. The left lung is then interposed between the internal mammary graft and the sternum. The internal mammary artery is thereby protected from adherence to the sternum and injury upon resternotomy. RESULTS: In two patients in whom this technique was employed repeat sternotomy was easily performed without injury to the internal mammary artery. CONCLUSIONS: This simple technique effectively protects the patent internal mammary artery bypass graft from injury at subsequent sternotomy.

Humans↗

PubMed1996

Effects of intramuscular or interpleural administration of morphine and interpleural administration of bupivacaine on pulmonary function in dogs that have undergone median sternotomy.

OBJECTIVE: To evaluate effects of interpleural or IM administration of morphine and interpleural administration of bupivacaine on pulmonary function in dogs that have undergone median sternotomy. DESIGN: Experimental trial. ANIMALS: 18 healthy dogs. PROCEDURE: Dogs underwent median sternotomy and were randomly assigned to groups of 6 dogs each. Group-A dogs were given morphine (1.0 mg/kg of body weight) i.m.; group-B dogs were given 0.5% bupivacaine (1.5 mg/kg) interpleurally; and group-C dogs were given morphine (1.0 mg/kg) interpleurally. Heart rate; systolic, diastolic, and mean arterial pressures; rectal temperature; pain score; and arterial blood gas partial pressures were measured and pulmonary function testing was performed immediately after extubation (time 0) and up to 48 hours later. Serum cortisol and morphine concentrations were measured at time 0 and up to 12 hours after surgery. RESULTS: There was a significant decrease in pH, PaO2, mean oxygen saturation of hemoglobin, and dynamic compliance; and a significant increase in PaCO2, alveolar-arterial difference in partial pressure of oxygen, pulmonary resistance, and work of breathing for dogs in all groups after surgery. Serum cortisol concentrations were significantly increased, compared with preoperative values, in all dogs. Serum cortisol concentrations were significantly higher in group-B dogs between 3 and 5 hours after surgery, compared with group-A dogs. CONCLUSIONS: Median sternotomy was associated with significant alterations in pulmonary function. Effects of interpleural administration of bupivacaine and morphine were similar to effects of i.m. administration of morphine.

Analgesics, Opioid↗

PubMed1995

[Longitudinal sternotomy--a method for the surgical option in pulmonary and hepatic echinococcosis].

Emphasis is laid on the utilization of longitudinal sternotomy as an operative method of choice, practicable in echinococcosis with bilateral pulmonary location, eventually associated with liver involvement. Experience had with performing longitudinal sternotomy in some of the patients operated in the clinic of thoracic surgery of the Higher Medical Institute--Sofia and in other surgical units throughout the country, covering the period 1985 through 1990, is shared. A clinical case of interest concerning bilateral lung echinococcosis, partially complicated, and associated with hydatid disease of the liver, is described. A new and rational treatment tactics yielding a very good outcome is introduced, namely--single-stage longitudinal sternotomy with right-side frenotomy and echinococcotomy of the lung and liver cysts according to well-established surgical tenets, with ensuing plastic reconstruction of the disrupted right hemidiaphragm integrity and osteosynthesis of the sternum.

Adult↗

PubMed1998

Bilateral thoracotomy for coronary artery bypass grafting in a patient with unfavorable median sternotomy.

In this report, we describe a patient who underwent coronary artery bypass grafting (CABG) through bilateral thoracotomy and distal median sternotomy, because he had received terminal tracheotomy as a treatment to prevent aspiration pneumonia due to Wallenberg's syndrome. On the first day after the terminal tracheotomy, he suddenly complained of severe anterior chest pain. Emergency coronary angiogram revealed complete occlusion of the proximal right coronary artery (RCA), severe stenosis of the left anterior descending artery (LAD) and the large first diagonal branch. Catheter intervention for RCA was attempted but it was unsuccessful, and therefore he was required to have urgent operation. The patient had received total laryngectomy and terminal tracheotomy two weeks before urgent CABG, and the large hole of the tracheotomy was just placed above the incisura juglaris of the sternum. So high risks of sternal infection and severe mediastinitis after ordinary median sternotomy were considered and we applied the bilateral thoracotomy approach. To our knowledge, this is very rare but effective approach to vascularize both right and left coronary artery and to use both left internal thoracic artery (LITA) and gastroepiploic artery (GEA) graft. It seemed that this approach is safe and effective for cardiac surgery in such situations that median sternotomy is not favorable as in the described patient or in patients having reoperation.

Coronary Angiography↗

PubMed1998

[Contribution of planar scintigraphy and SPECT with Ga-67 in the diagnosis of infectious complications after median sternotomy].

The prognosis of infections complications after median sternotomy depends of precocious diagnoses and depth extension of infection. We wanted to analyze the use of 67Ga scintigraphy in this pathology, comparing planar studies an SPECT. We studied 22 patients with suspect of infection complication after median sternotomy, the final diagnoses were 5 mediastinitis, 10 osteomyelitis and 7 patients with other pathology. 67Ga scintigraphy diagnosed correctly the 5 mediastinitis, 9 of 10 osteomyelitis and descarted both pathology in the other 7 patients. Planar studies only were able to diagnose correctly 3 of 5 mediastinitis and the another 2 were correctly diagnosed by SPECT. 67Ga scintigraphy is useful in the diagnosis of infection complication after median sternotomy and SPECT is better than planar studies in the diagnosis of mediastinitis.

Diagnosis, Differential↗

PubMed2004

[Urgent partial sternotomy for the treatment of iatrogenic vascular injury to the thoracic outlet: a report of two cases].

Two patients underwent surgery for iatrogenic vascular injuries at the thoracic outlet. Injuries occurred during mediastinoscopy in one patient (male, aged 60 years) and removal of a Portovac catheter in the other (female, aged 49 years). We performed partial sternotomy in both cases to expose the proximal of a. carotis communis and vena cava superior, respectively. After distal and proximal control of the vessels, the injured vessel was primarily sutured in the first patient, and the tip of the catheter was removed through a venotomy incision in the latter. No postoperative complications occurred in both patients. Partial sternotomy incision provides an appropriate and quick access to the injured vessels and surrounding structures at the thoracic outlet.

Female↗

PubMed1991

Hepatic vein and retrohepatic vena caval injuries in children. Sternotomy first?

Major hepatic vein and retrohepatic vena caval injuries are often fatal because of massive uncontrollable hemorrhage. Children with these injuries can be identified by their unique and dramatic clinical presentation and the selective use of computed tomographic imaging. Volume resuscitation promotes abdominal wall tamponade and hemodynamic stability until the abdomen is opened, at which point there may be sudden exsanguination before vascular control can be obtained. An alternative approach is to open the sternum before opening the abdomen. Management in this sequence provides rapid vascular control and improves the efficiency of hepatic exclusion. To date, five children with major hepatic vascular injuries have been treated with the sternotomy-first approach and four have survived; an atriocaval shunt was used on two occasions. Although sternotomy before laparotomy improves the efficiency of hepatic exclusion and may offer improved survival, accurate preoperative case selection limits its routine use.

Adolescent↗

PubMed2003

A new proposal of skin-closure system for median sternotomy: usefulness and cosmetic results analysis of MEDIZIP Surgical Zipper in neoplastic immuno-compromised patients.

BACKGROUND AND OBJECTIVES: The authors evaluate the effectiveness and the cosmetic results obtained using the new skin closing system MEDIZIP Surgical Zipper in oncological immuno-compromised patients submitted to median sternotomy. METHODS: In our Institute, from 1999 to 2002, MEDIZIP was used to close the sternal wounds in 45 patients undergoing median sternotomy for bilateral metastasectomy, It took about half a minute (mean time: 32.00 +/- 11.48 sec) to perform the application. To evaluate the cosmetic results, a three-level scale was conceived: level 1: very good, level 2: satisfactory, level 3: inadequate. RESULTS: Overall forty-two 20 cm-long zippers were used, two 25 cm-long and one 30 cm-long. MEDIZIP remained in situ for an average of 9.98 +/- 2.23 days (median: 9 days; range: 8-13 days). The average time taken for inspection was 70.00 +/- 2.48 sec (median: 70, range: 45-130) and the zipper was removed in a few seconds. No wound infections were observed. We classified 39 patients at level 1 (very good, 87%), and 6 at level 2 (satisfactory, 13%). CONCLUSIONS: MEDIZIP can be considered an effective skin-closure system which is easily and quickly handled and assures good cosmetic results with non-invasive removal; it proves particularly useful in pediatric patients and in adults affected by neoplastic diseases and undergoing multiple combined anti-cancer treatments.

Adult↗

PubMed1996

Successful utilization of the median sternotomy approach in the management of descending necrotizing mediastinitis: report of a case.

We describe herein the case of a patient in whom a median sternotomy was successfully employed for mediastinal drainage in the treatment of descending necrotizing mediastinitis (DNM). Although most reports describe cervical or thoracotomy approaches, our experience strongly suggests that median sternotomy is a satisfactory alternative approach for treatment of this disease.

Adult↗

PubMed1990

Spectral analysis and acoustic transmission of mitral and aortic valve closure sounds in dogs. Part 2. Effects of neuromuscular blockade, sternotomy and pacemaker control, and a two-week recovery period.

The paper describes the effects of neuromuscular blockade, sternotomy and atrio-ventricular pacing, and a two-week recovery period on the spectra and acoustic transmission of mitral M1 and aortic A2 sound components in dogs. Results indicate that neuromuscular blockade does not affect the attenuation properties of the heart/thorax acoustic system even if it modifies the intensity of M1 and the phase of the transfer function. The immediate effect of sternotomy and cardiac pacing is an important increase in the attenuation of the heart/thorax acoustic system. This increased attenuation is different for both sounds (20 dB for M1 and 11 dB for A2) and disappears after a two-week recovery period. However, the resulting controlled dog model shows slightly different acoustic characteristics than those of the normal animal model.

Animals↗

PubMed1980

Angiographic evaluation of post-sternotomy arteriovenous fistula of the internal mammary artery and vein.

An arteriovenous fistula of the right internal mammary artery and vein following median sternotomy was demonstrated by angiography. This surgical complication has not been previously reported in the literature, despite the recent increase in cardiac surgery via median sternotomy. Clinical and radiologic awareness of this iatrogenic shunt and of its potential delayed appearance and cardiovascular effects are important. Arteriovenous fistulas are usually treated by surgical ligation and excision, or by transcatheter occlusion therapy.

Aged↗

PubMed2001

Surgical removal of left atrial myxoma through mini sternotomy and the superior transseptal approach.

A 32-year-old man admitted for treatment of a left atrial myxoma showed a 76 x 25 mm tumor in the left atrium originating in the interatrial septum upon echocardiography. The myxoma was surgically removed using a mini sternotomy and the superior transseptal approach. The hospital course was unremarkable. In the 2 years since operation, the patient has remained asymptomatic and tumor-free. The superior transseptal approach is thus useful in surgical removal of left atrial myxoma because it can be excised with minimum manipulation despite the mini sternotomy and small skin incision.

Adult↗

PubMed2000

Off-pump coronary artery bypass grafting via partial sternotomy. An alternative to left anterior small thoracotomy.

Four patients, who were considered to be inappropriate candidates for left anterior small thoracotomy, underwent off-pump coronary artery bypass grafting via partial sternotomy. Under a median skin incision over the lower half of the sternum, the sternum below the second rib was cut in an "inverted L" (or "C") shape. Without cardiopulmonary bypass, the left internal thoracic artery was anastomosed to the left anterior descending artery in all patients, and a saphenous vein graft was anastomosed to the right coronary artery in one of them. Partial sternotomy has some advantages as an alternative to left anterior small thoracotomy, in that it enables multiple-bypass grafting without cardiopulmonary bypass and conversion to cardiopulmonary bypass, should it be come necessary, would be relatively uncomplicated.

Aged↗

PubMed2000

Coronary surgery through partial sternotomy in a patient with tracheostoma.

We report successful coronary artery bypass grafting through a lower partial sternotomy for a patient with a tracheostoma. He required a tracheotomy for serious laryngeal edema which developed during anesthetic induction prior to elective conventional coronary surgery. A safe alternative approach, comprising a lower midline skin incision with a lower partial sternotomy distant from the stoma, facilitated coronary artery bypass grafting to the left and right coronary arteries after four weeks.

Coronary Artery Bypass↗

PubMed1996

[Partial median sternotomy in resection of metastases of the upper thoracic spine].

A modified method of access to the upper thoracic spine is presented based on a case report. The third and fourth thoracic vertebral bodies can be reached by partial upper sternotomy. This approach takes the local anatomic situation into account, thus avoiding the typical complications of complete sternotomy and reducing the postoperative pain. Closure was done using biodegradable sutures, achieving satisfactory stabilisation and a low rate of complications. In only 4 of 130 cases (3%) did a superficial wound infection occur. There was no case of deep infection, osteomyelitis or dehiscence of the sternum.

Aged↗

PubMed2005

Inframanubrial parathyroid glands in patients with primary hyperparathyroidism: alternatives to sternotomy.

Deep inframanubrial parathyroid tumors have traditionally been excised through a median sternotomy. With the advent of minimally invasive surgical access, we chose to examine the treatment options and outcomes of patients with inframanubrial mediastinal parathyroid tumors. Patients with primary hyperparathyroidism seen at a university medical center over a 12-year period were retrospectively reviewed. The utility of localization studies, methods of treatment, complications, and outcomes were examined in patients with a parathyroid tumor located in the mediastinum inferior to the manubrium. Patients with parathyroid adenomas located at the thoracic inlet were excluded. Sixteen patients with inframanubrial mediastinal tumors were treated during the study period. Altogether, 81% of the patients had undergone at least one prior neck exploration for primary hyperparathyroidism. Preoperative calcium and parathyroid hormone levels were 12.4 +/- 0.36 mg/dl and 273 +/- 70 pg/ml, respectively. Localization studies identified mediastinal parathyroid adenomas in the following locations: anterior mediastinum (n = 8), middle mediastinum (n = 7), posterior mediastinum (n = 1). Mediastinal computed tomography and technetium-sestamibi scans demonstrated the best sensitivity, 92% and 85%, respectively. Seven patients underwent successful excision of the mediastinal adenoma by transcervical mediastinal exploration with the Cooper retractor. The other patients underwent angiographic ablation (n = 4), anterior mediastinotomy (n = 3), video-assisted thoracoscopy (VATS) (n = 1), and VATS plus thoracotomy (n = 1). The mean hospital stay for the study group was 2.9 +/- 0.7 days. The complication rate was 25%. All patients were normocalcemic after a mean follow-up of 15 +/- 7 months. Most inframanubrial mediastinal parathyroid tumors can be successfully managed without median sternotomy.

Adenoma↗