[HSF] Image of the week Hemisternotomy

Thu May 1 09:52:05 EDT 2008

You must.Ratcheting the sternum slowly allows it to stretch. If the sternum
is brittle give a small lead cut. It will allow a fulcrum to turn instead of
randomly fracturing.
Prasanna

On Thu, May 1, 2008 at 8:21 AM, Edward Bender <ebender001 at charter.net>
wrote:

> I seem to remember Tirone David saying that when he does a partial
> sternotomy, he just makes a vertical cut (usually upper) and allows the
> sternum to fracture "naturally." I have yet to try it.
>
> Ed Bender, MD
>
>
> On 4/30/08 9:31 PM, "Prasanna Simha M" <prasannasimha at gmail.com> wrote:
>
> > 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