[HSF] Image of the week Hemisternotomy

Thu May 1 10:24:14 EDT 2008

Yes.When I did T cuts I noted that patients complained of pain when a T was
done . This is strikingly absent when you do not do a cut. Maybe related to
the final interlocking of the ends and stbilty too.
Prasanna

On Thu, May 1, 2008 at 9:08 AM, Edward Bender <ebender001 at charter.net>
wrote:

> Do you think there is a difference in pain or healing compared to an "L"
> or a "T" sternotomy?
>
> Ed Bender, MD
>
>
>
> On Apr 30, 2008, at 10:22 PM, Prasanna Simha M wrote:
>
>  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
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-- 
Prasanna Simha M