[HSF] Image of the week Hemisternotomy

Thu May 1 09:01:19 EDT 2008

I have done it even in older patients. The thing is to open the sternum in
stages and not rapidly. If the sternum appears rigid, I give a small partial
sternal cut (an incomplete T or L that gives an axis for sternal torque. The
key is to ratchet the sternum in stages. First open it to an extent, hold
open the pericardium, open a bit more release the pericardium over SVC and
IVC , open a bit more  and so on and so forth.
The thing that I have noticed in older people is some have a springy sternum
and some have a rigid rock like sternum. The springy ones open easily. The
rigid rock like ones need to be opened slower or need a partial T or a lead
cut if you want to open it faster.
Prasanna

On Thu, May 1, 2008 at 1:06 AM, V. Aldrete, M.D. <valdretemd at shaw.ca> wrote:

> Hi Prassanna,
>
> With the lower hemisternotomy.  Do I understand that there is no
> transverse division at the upper end of the sternotomy?
> If this is so, what is the average age of patients that can tolerate this
> without sternal fracture?
>
> Remember than in North America our patients' average age is much higher.
> Over half of my patients that had open heart surgery were over the age of
> 60, and I hear that the average age is only getting higher.
>
> Cheers,
>
> Victor
>
>
> On Apr 30, 2008, at 9:11 AM, Prasanna Simha M wrote:
>
>  Roberto,
> > I have shown how the exposure is good with a hemisternotomy. We have to
> > use
> > a small bit of trickery as is obvious  in the two views. With a lttle
> > head
> > low you can see how the view dramatically improves. You can also use a
> > rultract retractor  to hook up the manubrial segment to get a better
> > exposure. I use a towel clip /Langenbeck which can be ratcheted up to
> > another towel clip or a attached to the ether screen instead of a
> > rultract.
> > Once  aortic cannulation is done the head low is unecessary. Another
> > thing
> > is that the cross clamp must preferably not be like an L but mor of an
> > oblique angle instead of a right angle .This prevents the clamp impeding
> > the
> > operative field. If that is not available it can be placed in reverse
> > but
> > will overlie the RV.
> >
> > Prasanna
> > On Wed, Apr 30, 2008 at 8:39 PM, Prasanna Simha M <
> > prasannasimha at gmail.com>
> > wrote:
> >
> >  Yes the exposure is not a problem for surgery . In fact it can be made
> > > smaller by actually using the drain site as the site for the IVC
> > > cannulae
> > > and you can do the whole procedure with conventional instruments.and
> > > direct
> > > vision. Photography is a little bit problematic  as the sternal
> > > spreader
> > > appears unaesthetic  (though vision is not hampered. I think the only
> > > thing
> > > that one has to be careful is the ascending aortic cannulation which
> > > is
> > > actually not much of a problem. My resident and lecturer do these
> > > cannulations under my supervision so it is doable. Actually I do not
> > > do an L
> > > or a T but give a small cut to act as a fulcrum for opening. In
> > > children and
> > > young adults even that is not necessary. The key is to stagewise and
> > > slowly
> > > open the spreader. If opened slowly it is surprising how the sternum
> > > can be
> > > opened adequately without fracturing it.I even do AVR's with  the same
> > > incision. though the bone cut may be slightly higher (depends on the
> > > verticality of the heart and root position as seen on the Chest X Ray.
> > > When
> > > done for cosmessis an upper sternotomy is not acceptable. Also keeping
> > > the
> > > manubrium intact seems to help quick recovery. I was initially
> > > skeptical but
> > > patients do seem to feel better.
> > > Prasanna
> > >
> > >
> > > On Wed, Apr 30, 2008 at 7:47 PM, Dr. Roberto Battellini <
> > > battr at medizin.uni-leipzig.de> wrote:
> > >
> > >  Prasanna,
> > > > Did you have a good view and comfortable from that approach?
> > > > Better than mitral MIC as you saw by Mohr?
> > > > Was the incision in L or in T?
> > > > Roberto
> > > >
> > > >
> > > > -----Ursprüngliche Nachricht-----
> > > > Von: openheart-l-bounces at lists.hsforum.com
> > > > [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von
> > > > Prasanna
> > > > Simha
> > > > M
> > > > Gesendet: Mittwoch, 30. April 2008 09:38
> > > > An: OpenHeart-L; <ccm-l at ccm-l.org>
> > > > Betreff: [HSF] Image of the week Hemisternotomy
> > > >
> > > > Havent got any exiting photos from some time so posting a postop
> > > > photo.
> > > > Mitral valve repair done in a 20 year old patient via a
> > > > hemisternotomy
> > > > at
> > > > his 6 month follow up.Not as small as the robots but getting
> > > > somewhere
> > > > there
> > > > :). Patient is very happy with the cosmesis despite a hypertrophied
> > > > scar
> > > > as
> > > > the scar is not seen even when his second shirt button is left open.
> > > > Prasanna
> > > >
> > > > --
> > > > Prasanna Simha M
> > > >
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> > >
> > >
> > > --
> > > Prasanna Simha M
> > >
> >
> >
> >
> >
> > --
> > Prasanna Simha M
> > <hemisternotomy
> > vieweml.jpg>_______________________________________________
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-- 
Prasanna Simha M