AW: [HSF] Image of the week Hemisternotomy
David Harris
drdharris at yahoo.co.uk
Sat May 3 23:21:41 EDT 2008
An upper sternal split, as for AVR can still be done
with a lower skin incision, about 8 cm (or more) below
the sternal notch. And excellent exposure can be
obtained with a 10 cm skin incision. So the cosmesis
is still good with this approach.
Regarding the aortic clamp when a lower split is
used:A conventional cross clamp is clumsy, and in the
reverse position gets in the way. We use the flexible
Cosgrove clamp from Edwards Lifesciences, and it works
brilliantly, and costs only US$ 1000.
The lower stenal split has lost its flavour for me. It
always appears to be a messy affair, and there appears
to be more bleeding at the top where an L or a T has
been done, as the muscle is thicker here. It is
difficult to get hemostasis at the top cut or split as
you can get venous bleeding there, and can`t get the
diathermy into the space, and likeways bleeding from
the bone at the top is difficult to control as its
difficult to get bone wax in.
The last one I did was for a single vessel CABG to the
RCA in a young female. She had to go back to the OR
for bleeding, and also had a lot of postoperative
pain. This I presume is disruption of the costal
cartilages on the side of the L split. Now I rather do
a small thoracotomy.
A small thoracotomy for CABG or MVR is in my opinion
the best minimally invasive incision. For an MVR you
can do it all under direct vision (without robot or
VATS) with excellent exposure. These patients also
have less bleeding than sternotomy, and less pain if
you use an indwelling paravertebral catheter, and
close using sutures which are placed through drill
holes in the lower ribs, instead of around the lower
ribs. In the past we have shied away from the
thoracotomy approach thinking that there is more pain,
without tackling the causes of pain. The return to
activity is faster, and now the only patients I see
with chronic pain are the occasional ones who`ve had a
full sternotomy (usually by old school colleagues who
spread the chest very wide)
Dave
--- "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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=== message truncated ===
Dr. David G. Harris, FCS, MMED,
Cardiothoracic Surgeon
Suite 207
Kuils River Private Hospital,
PO Box 1200, Kuils River, 7579, Cape Town, South Africa.
Tel +27-21-9006411
Fax +27-21-9006412 Mobile +27-83-3309587
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