[Sternal re-entry using the retractor for harvesting internal thoracic artery]

The number of redo cardiac operations, especially coronary artery bypass grafting (CABG), has recently been increasing mainly due to the failure of saphenous vein grafts. Re-opening a median sternotomy is troublesome, because of possible adhesion of the heart to the sternum. Preoperative computed tomography is quite useful and helpful in determining the degree of the adhesion of the heart and ascending aorta to the back of the sternum. We report here a safe and useful technique for sternal re-entry using a retractor for harvesting the internal thoracic artery (ITA). When re-opening a median sternotomy the incision is made to the sternal wires; the wires are then cut and removed. Small rake retractors, which are connected to the ITA retractor, are hooked to both ends of the left side of the sternum. The ITA retractor is gently wound up to lift up the sternum. An oscillating saw is then applied to divide the anterior table of the sternum. When the posterior table of the sternum is carefully divided, the left side of the sternum is automatically elevated slightly. Complete division of the sternum can be confirmed by this slight elevation. If the left side of the sternum is elevated a little bit more by the ITA retractor, the dissection of the adhesion between the sternum and the heart can be performed without assistance. This technique is most beneficial for a case of redo CABG with the use of the left ITA, but it can be applied in any patients who previously underwent median sternotomy.