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[Sternal re-entry using the retractor for harvesting internal thoracic artery]
1Department of Cardiovascular Surgery, Daini Hospital, Tokyo Women's Medical University, Tokyo, Japan.
Insights
Redo cardiac surgery, particularly coronary artery bypass grafting (CABG), faces challenges with sternal re-entry due to adhesions. A novel retractor technique safely facilitates sternal division, aiding in cardiac adhesion dissection during redo sternotomy.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Surgical Techniques
Context:
- Increasing rates of redo cardiac operations, especially coronary artery bypass grafting (CABG), are linked to saphenous vein graft failure.
- Re-opening a median sternotomy poses risks due to potential adhesions between the heart and sternum.
- Preoperative computed tomography aids in assessing cardiac and aortic adhesion severity.
Purpose:
- To present a safe and effective technique for sternal re-entry during redo median sternotomy.
- To describe the use of an internal thoracic artery (ITA) retractor for improved sternal division and adhesion management.
Summary:
- A novel technique utilizes an ITA retractor with attached rake retractors for controlled sternal elevation during re-entry.
- The method involves cutting sternal wires, retracting the sternum, and using an oscillating saw for precise division of the anterior and posterior sternal tables.
- Slight elevation of the left sternum confirms complete division, facilitating dissection of adhesions without additional assistance.
Impact:
- This technique enhances safety and efficiency in redo cardiac surgeries, particularly for patients requiring left ITA harvesting.
- It offers a valuable approach for managing sternal adhesions in any patient undergoing repeat median sternotomy.
- Improved visualization and access reduce the risk of injury during redo sternotomy procedures.
Abstract:
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.
