[HSF] Image of the week Hemisternotomy

Fri May 2 23:52:40 EDT 2008

Maybe but so far I have succeeded; but then I don't operate 80 and 90 year
olds !!
Prasanna

On Fri, May 2, 2008 at 7:36 PM, Dr. Roberto Battellini <
battr at medizin.uni-leipzig.de> wrote:

> It seems like the fractures in children compared to adults, like the young
> trees and the old ones...
> 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: Donnerstag, 1. Mai 2008 03:31
> An: OpenHeart-L at lists.hsforum.com
> Betreff: Re: [HSF] Image of the week Hemisternotomy
>
> 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