Benefits and complications of total sternotomy and ministernotomy in cardiac surgery

Ministernotomy (MS) is a well-known procedure developed in the past ten years along with the rise of minimally invasive cardiac surgery. Upper, mid, or inferior partial sternotomies allow coronary surgery, as well as aortic and mitral valve approaches. Contrary to anterior thoracotomy, access to the great vessels is sometimes easy, which renders central cannulation possible. In opposition to total sternotomy (TS), MS could procure better postoperative stability that would aide in reduction of wound infections. Nevertheless, upper MS can be responsible for the lesion of the internal thoracic arteries (ITAs). Moreover, little evidence exists regarding blood sparing in MS approaches. MS presents the problem of hiding a part of the cardiac structures. For example, in the case of aortic surgery by way of upper sternotomy for example, left venting is risky or even impossible. However, partial inferior sternotomy can be interesting for aortic valve surgery in patients with in situ right ITA passing in front of the aorta, protecting the grafts during dissection. In coronary surgery, inferior T sternotomy and C sternotomy allow perfect access to the coronary network. Some authors also have described inferior "T" sternotomy for various congenital lesions. If mini-invasive cardiac surgery can offer reduced postoperative morbidity and faster rehabilitation, the advantages of MS upon TS--except for cosmetic aspects--remain to be defined. Thus, this approach should be reserved for selected patients and lesions.