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PubMed1978

Benign pneumoperitoneum following median sternotomy incision.

Because of the close anatomic relationship of the pericardium, diaphragm, and peritoneal cavity, a benign pneumoperitoneum may occur following median sternotomy incision and cardiac surgery. The pneumoperitoneum results from inadvertent opening of the peritoneal cavity during the initial surgical incision or during the subsequent cardiac surgery. It is generally of no significance to the patient, although it must be distinguished from pneumoperitoneum occuring secondary to intraabdominal pathology or to retrograde dissection of extraalveolar air in patients on ventilatory support. Two illustrative cases are presented.

Aged↗
PubMed1985

Experience with single photon emission computerized tomography (SPECT) in follow-up of sternotomy healing.

Single photon emission computerized tomography (SPECT) was performed thrice in ten patients undergoing open-heart surgery--preoperatively and 2 and 12 weeks postoperatively. The operations were done for ischemic heart disease (5), aortic valvular stenosis (2), aortic valvular insufficiency (1), leaking mitral prosthetic valve (1) and combined aortic and mitral valvular stenosis and insufficiency (1). The healing process in the longitudinally divided sternum was evaluated from the SPECT study. Four conventional static images in two dimensions were registered in anteroposterior, posteroanterior and left and right lateral projections. A tomographic study was done. Quantitative analyses were performed. The ratio of the sternal counts to the counts from a thoracic vertebra was calculated for use as a reference. The activity ratios showed a similar pattern in six cases, with initial increases and at 12 weeks slight decrease compared with the preoperative values. In two cases the activity was still increasing after 12 postoperative weeks. One patient, with sternotomy also one year previously, showed only slightly increased activity. The activity at the areas of the sternal wires was increased in six cases. The study thus revealed differing patterns of isotope uptake, although recovery was uneventful in all patients. The differences may reflect the possibility that the operative course and the preoperative clinical status can influence the healing mechanisms.

Adult↗
PubMed1986

Use of muscle flaps in the treatment of infected sternotomy.

Deep wound infection after open-heart surgery remains a major problem. In this paper potential indications and techniques for use of muscle flaps in the treatment of chronic sternal infections are discussed and the authors' early experience with such treatment is presented. A well vascularized muscle flap fills out the defect, may help to control infection, and accelerates healing. After adequate excision of infected tissue, bone and cartilage, the resulting defect is covered with a muscle flap immediately or after a period of open treatment. Coverage with a flap of pectoralis major muscle was used in five patients 3 weeks to 6 months after cardiac surgery. Primary healing occurred in two patients, secondary healing in one and healing with residual fistula in one patient. In the fifth case there was uneventful recovery with primary healing until death occurred from cerebral haemorrhage after 3 weeks. Use of muscle flaps seems to be a valuable complement in the management of severe sternotomy infections.

Aged↗
PubMed1996

Profuse mediastinal haemorrhage due to mediastinitis after sternotomy. Report of three cases and review of the literature.

Profuse spontaneous haemorrhage occurred in association with mediastinitis after median sternotomy for coronary bypass surgery in three men aged 54, 47 and 59 years. The bleeding sites were aorta, right ventricle and saphenous bypass graft. The aortic rupture occurred during closed lavage, the right ventricle ruptured during open saline mediastinal packing and the saphenous vein graft was eroded by a mediastinal drainage tube after discontinuation of closed lavage. This third patient survived and recovered, but the two others died. Previously published reports of 56 patients with 65 bleedings from this rare complication are reviewed. The outcome was fatal in 34% of cases.

Hemorrhage↗
PubMed1990

Emergency exploratory sternotomy: the nurse's role.

Emergency exploratory sternotomy (EES) is a life-saving procedure performed in the recovery room or ICU within the first 24 hours following cardiac surgery. Complications that may necessitate this procedure include: tamponade, hemorrhage, acute profound hypotension, atypical tamponade, coronary artery spasm, clotted grafts, refractory dysrhythmias, and cardiac arrest. The nurse plays an important role in the early recognition of these life-threatening situations and therefore must be able to recognize clinical signs that may preclude the need for EES. This article details the four clinical scenarios the nurse will see, which are: (1) cardiac tamponade, (2) acute profound hypotension where the etiology is unclear, (3) cardiac arrest unresponsive to standard CPR and drug therapy, and (4) acute massive hemorrhage where tamponade is not the primary presenting condition. The procedure for EES is discussed, including preprocedure preparations, the nurse's role in EES, and the post-EES nursing assessment. Nursing diagnoses appropriate to this event are outlined. There is a discussion on how to educate staff on EES as well as a discussion of the research outcomes of EES. Nurses caring for adult and pediatric cardiac surgery patients will find this information useful in establishing protocols for EES as well as in educating staff on how to respond effectively during this life-threatening event.

Cardiac Surgical Procedures↗
PubMed1987

Sternotomy infections with Mycoplasma hominis.

Mycoplasma hominis caused sternal wound infections with mediastinitis in three patients. One infection occurred in a nonimmunocompromised man after coronary artery bypass grafting. The wound did not heal after repeated debridement, closed irrigation of the mediastinum with povidone-iodine solution, and antimycoplasmal chemotherapy; muscle flap grafting was eventually required. Two infections occurred in recipients of heart-lung transplants after the isolation of mycoplasma from bronchial secretions. Although no Mycoplasma species were isolated after specific antimycoplasmal therapy was begun, the wounds still did not heal. Both patients died of other complications. Infection of wounds after sternotomy is another of an increasing number of infections caused by M. hominis in the normal and immunocompromised host. Familiarity with the morphologic characteristics of M. hominis on bacteriologic culture media may increase the recognition of this pathogen in atypical clinical settings.

Adult↗
PubMed1998

[Plastic surgery of the thoracic wall as a method of thoracic wall reconstruction after complete surgical wound disintegration after sternotomy].

During the period between January 1996 and July 1998 in our department 1920 patients were operated on account of heart disease from median sternotomy. In 17 patients, i.e. in 0.9% during the early postoperative period the surgical wound disintegrated incl. dehiscence of the sternum and the development of postoperative mediastinitis. In 14 of these patients the authors reconstructed the defect of the thoracic wall by their own modification of Jurkiewicz plastic operation using the pectoral muscles. One patient from this group died, in the remaining 13 patients the wound healed without deformity of the chest and without signs of instability, without restriction of movement and function.

Aged↗
PubMed1999

[Surgical treatment of septicemia after pacemaker implantation: a case report of removal of infected lead under median sternotomy].

A 73-year-old woman was admitted to our hospital because of septicemia associated with infection of an old retained pacemaker lead and a reimplanted pacemaker system. After general condition was recovered, the pacemaker system was removed and then the retained pacemaker lead was removed through median sternotomy. Then a new pacemaker system was implanted using myocardial leads. The postoperative course was uneventful.

Aged↗
PubMed1999

Comparison of post-operative pain, stress response, and quality of life in port access vs. standard sternotomy coronary bypass patients.

OBJECTIVE: Although it has been postulated that minimally invasive cardiac surgery using the port access method would reduce operative stress and postoperative pain and accelerate postoperative recovery to a good quality of life, few data are currently available to document this intuitively appealing claim. Therefore, this study was designed to examine differences in stress response, postoperative pain, rapidity of recovery, and quality of life after port access (PA) isolated coronary artery bypass surgery compared with standard sternotomy (STD) isolated coronary bypass surgery. METHODS: Fourteen PA and 15 STD coronary bypass patients were studied postoperatively for pain score, FEV, catecholamine and cortisol levels, resumption of activity, and Duke Activity Scale ratings. The surgical approach was based on the surgeon's preference. Although the PA patients were younger, there were no other differences between the groups in gender or preoperative risk factors. RESULTS: There were no operative deaths and no differences between the groups in perioperative complications. Repeated measures analysis of variance showed lower pain scale ratings over the first 4 postoperative weeks in the PA group (P < 0.001). The PA patients also had less muscle soreness, shortness of breath, fatigue, and poor appetite at 1, 2, 4, and 8 weeks (P < 0.05), better FEV at 1 day (1.59 vs. 0.97 l/s; P < 0.02) and 3 days (2.20 vs. 1.49 l/s; P < 0.03), and lower norepinephrine levels at days 1, 2, and 3 (P = 0.005). The Duke Activity Scale questionnaire results demonstrated that more PA patients were able to walk 1-2 blocks at 1 week, climb stairs at 1 and 2 weeks, perform light or moderate housework at 1 and 2 weeks, and engage in moderate recreational activities and perform heavy housework at 4 and 8 weeks (P < 0.05). CONCLUSIONS: These results show that compared with STD coronary bypass patients PA patients enjoyed significant postoperative physiologic and quality of life advantages with less pain, less early stress response, better pulmonary function, and superior Duke Activity scores during the first 2 postoperative months.

Aged↗
PubMed1999

Minimally aortic valve surgery avoiding sternotomy.

OBJECTIVES: Minimally invasive valve surgery, although still in its pioneer era, can open new horizons in cardiac surgery. Following that trend we started aortic valve surgery through a right anterior minithoracotomy using a novel approach under 3-D video-assistance in most of the cases. METHODS: Aortic valve replacement avoiding sternotomy through a right thoracotomy was performed in seven patients (14% were female, average age: 58 years) There were five aortic stenoses and two aortic insufficiencies. In four patients we employed central aortic and right atrium cannulation and in three, femoral artery returns. Antegrade cardioplegia was used in all patients. RESULTS: The operative mortality was 0%, four patients received a mechanical aortic valve, two patients received a biological valve, and in one patient a decalcification of the valve was performed. The mean pump time was 110 min (70-146), the mean cross-clamp time was 72 min (52-95), the mean hospital stay was 7.7 days (4-11 days). One patient died 7 months after the operation of pulmonary insufficiency, the rest of the patients are alive and improved the clinical situation. CONCLUSIONS: This access produces an operative view adequate to safely perform aortic valve surgery. Therefore, removal of ribs or cartilage fragments is not necessary, which results in a less traumatic and less painful approach. Within this is a potential good approach for patients with sternal problems (radiation), redo in certain situations (example previous coronary surgery with LIMA open to LAD). Young patients are potential candidates for future coronary surgery as well as patients with long thoracic cavity and deep aortic plane.

Adult↗
PubMed1975

Interrupted aortic arch and ventricular septal defect. Direct repair through a median sternotomy incision in a 13-day-old infant.

A type B interrupted aortic arch was successfully repaired in a 13-day-old infant during profound hypothermia and circulatory arrest. Through a median sternotomy incision it was possible to resect a patent ductus arteriosus and mobilize the descending thoracic aorta for anastomosis to the side of the ascending aorta. At the same time a large ventricular septal defect (VSD) and a small atrial septal defect were closed through the right atrium. Cardiac catheterization 5 months after operation showed a small persistent VSD with a pulmonary to systemic blood flow ratio of 1.1/1. The systolic gradient between the ascending and descending aorta was 20 mm. Hg.

Angiography↗
PubMed2001

Arch-first reconstruction via median sternotomy. Short retrograde cerebral perfusion.

In December 1998, we introduced arch-first reconstruction for total aortic arch replacement via conventional median sternotomy in order to shorten the duration of retrograde cerebral perfusion (RCP). We used a separate straight graft for an elephant trunk, which allowed an easy subsequent distal anastomosis. The average RCP duration in this series was 32.1+/-5.8 min (mean+/-SD, range, 24-40 min, n=12), which was significantly shorter (p<0.05) than that of the conventional procedure (45.6+/-12.4 min, range, 34-65 min, n=8), in which we first perform a distal anastomosis. No significant differences in cardiopulmonary bypass time (268+/-81 min vs 258+/-42 min) nor operation time (518+/-213 min vs 517+/-82 min) between the two groups were observed. There was no hospital death in either group. One patient in the second series (conventional method) suffered temporary neurological disturbance. For acceptable RCP duration, total aortic arch replacement is currently the standard procedure in our institution for Stanford A type aortic dissection.

Anastomosis, Surgical↗
PubMed2002

[A case report of bilateral multiple pulmonary arteriovenous fistulas treated surgically at one-stage procedure by median sternotomy].

A 40-year-old female was admitted because of abnormal chest shadows. Chest CT and pulmonary angiography revealed bilateral multiple arteriovenous fistulas in the right S5a, S5b and left S5, S9. Fistula excision and bilateral partial resection of lung were performed through median sternotomy in one stage. This surgical options allows entire removal of the fistulas as well as preservation of lung function.

Adult↗
PubMed2001

[Surgical treatment of sternal dehiscence after sternotomy using Ley prosthesis].

Median sternotomy is still the most commonly used approach in cardiac surgery. Closure of the sternal halves is usually performed with stainless wires. Usually this method proves efficient to achieve proper sternal stability without postoperative wound complications. On the other hand in a small number of patients this simple method is not efficient to resist the great spreading forces on the sternal halves leading to sternal instability and other serious complications. We describe successful application of a newly introduced device, the Ley-prosthesis, which may be a very useful treatment for postoperative sternal dehiscence even in complicated cases.

Bone Plates↗
PubMed2002

[Is minimal skin incision and partial sternotomy approach for congenital heart defects less invasive?; evaluation of SIRS on ventricular septal defect].

OBJECTIVES: Minimally invasive cardiac surgery (MICS) has been developed to offer patients the benefits of open heart operations with limited skin incision. But it is unclear whether this procedure is less invasive. We evaluate postoperative duration of systemic inflammatory response syndrome (SIRS) on ventricular septal defect (VSD). METHODS: From August 1997 to March 2000, 47 patients VSD underwent total repair by the minimal skin incision and lower partial median sternotomy (MICS group). We compared duration of SIRS between MICS and conventional method group (n = 14) and between early MICS and recent MICS group. We also evaluated the relationship between MICS and postoperative clinical course. RESULTS: Duration of SIRS of MICS group were obviously shorter than that of conventional method group (p < 0.05). That of recent MICS group is also significantly shorter than that of early MICS group (p < 0.05). Operative time, bypass time, postoperative intubation time and length of skin incision were related duration of SIRS. CONCLUSIONS: The results of this study indicate that MICS for VSD may be less invasive method.

Cardiac Surgical Procedures↗
PubMed1976

Chylothorax after median sternotomy for intrapericardial cardiac surgery.

Chylothorax following cardiovascular surgery occurs with an incidence of 0.25 to 0.5 per cent. We are aware of only 5 reported cases in the literature following intrapericardial procedures. This report includes the forth documented case following ventricular septal defect closure and the first 4 reported cases following median sternotomy for intrapericardial acquired cardiac disease. The fistula in all cases occurred in the anterior mediastinum in the region of the thymic tissue. This problem can be prevented by surgical ligation of the thymic vascular structures at the time of dissection rather than the use of electrocautery. The treatment recommended is a 2 week trial of conservative therapy with a diet of medium-chain triglycerides and closed-chest suction. If this fails, surgical division of the fistula is recommended.

Adult↗
PubMed2002

Treatment of tuberculous spondylitis at the cervicothoracic junction. Clinical impact of surgery by means of a sternotomy.

The operative treatment of tuberculous spondylitis remains a challenge with regard to the surgical approach to the cervicothoracic junction. In addition, it is difficult to restore the resected vertebral bodies. Two cases of tuberculous spondylitis in this area are presented. The first case concerns a 25-year-old African patient suffering from the effects of tuberculous spondylitis: Destruction of vertebral bodies dorsal (D)1, D2, and D3, kyphosis coupled with compression of the spinal cord, as well as incomplete motor and sensory paraplegia (Frankel grade C). The operative treatment of tuberculous spondylitis that is described, approached the cervicothoracic junction by means of a sternotomia. Corpectomy of vertebral bodies D1 through D3 were followed by their restoration with the help of a titanium cage. As a result, the paraplegia disappeared. Ventral decompression was followed by dorsal instrumentation. The results of the operation are decompression of the spinal cord, correction of the kyphosis, and stable fusion followed by restitution of the paraplegia. Primary stability was provided by the use of a titanium cage and dorsal instrumentation. There was no need for an external brace. There was no loss of correction 3 years after the operation. The 2nd case concerns a 49-year-old European patient suffering from thoracic pain radiating around the chest. A partial destruction of D2 and D3 with kyphosis and compression of the spinal cord because of a tuberculous spondylitis were detected, neurological deficits were not found. The corpectomy of D2 and D3 were proceeded by means of a sternotomy, the defect was restored with the help of a titanium cage. Due to the use of a ventral Morscher plate an additional dorsal instrumentation was not necessary. The patient was fixed in a minerva plaster for 3 months. There was no loss of correction 2 years after the operation. Both patients are manual workers and postoperatively adapted to their former work.

Adult↗
PubMed2003

[Use of the skin-closure system Medizip in median sternotomy in oncological patients. Evaluation of results obtained in 30 patients].

BACKGROUND: The authors evaluate effectiveness, safety and cosmetic results obtained using the new skin closing system Medizip. METHODS: At the Thoracic Surgery Department of the National Cancer Institute (Milan) between June 1999 and March 2001, in 30 patients who underwent median sternotomy for bilateral pulmonary wedge resections, Medizip a new skin-closing system to suture the sternal wounds has been used. Twenty patients were under 30 (66%) and 6 of the 10 remaining were females. The average age was 34.25+/-21.60 years, (median: 25, range: 12-72). It took about half a minute (average time: 30.00+/-10.54 seconds) to perform all the application manoeuvres. In order to better evaluate the cosmetic results obtained, a scale of three levels was created: level 1: very good, level 2: satisfactory, level 3: inadequate. RESULTS: Twenty-eight 20 cm-long zippers, one 25 cm-long and one 30 cm-long were employed. Medizip has been kept in site for 9.88+/-2.12 days on average (median: 9; range: 8-12). The time employed for each dressing was on average 70.00+/-21.35 seconds (median: 70, range: 46-128). No wound infections were observed even if all the patients were affected by neoplastic diseases and were immunocompromised because of lots of antiblastic treatments. The quick removal (few seconds) and the non-invasiveness of the disposal constitutes remarkable advantages. Using the criteria previously described, 26 patients at level 1 (87%), and 4 (13%) at level 2 were classified. CONCLUSIONS: Medizip is considered to be an effective skin-closure system easy and quick to handle, assuring very good cosmetic results, with non-invasive removal, particularly useful in pediatric patients and in young adults affected by neoplastic diseases undergone to a lot of combined treatments.

Adolescent↗