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Hyperinflation of Lungs During Redo-sternotomy, A Safer Technique

https://doi.org/10.1016/j.hlc.2011.07.011Get rights and content

Increasing numbers of patients are being referred for repeat cardiac procedures and redo-sternotomy is technically more arduous as well as time consuming. We describe our unique technique to overcome this challenging task by hyperinflating the lungs as a useful manoeuvre.

Introduction

Increasing numbers of patients are being referred for repeat cardiac procedures and redo-sternotomy currently estimates 16% [1] of the workload in cardiac surgery. Redo-sternotomy is technically more demanding and may be associated with increased morbidity and mortality. Incidences of morbidity including damage to the cardiac chamber/s, great vessels, and/or extracardiac grafts during redo-sternotomy range between 1 and 6% with an increase in mortality up to 38% in patients with major cardiac chamber or vessel injury [2].

Various approaches have been described to minimise injury during redo-operations. Redo-sternotomy is generally performed with an oscillating saw. Adjunctive techniques include untwisting previous sternal wires (a) but not removing them till completion of sternotomy, (b) and lifting the wires or (c) lifting the sternum by using additional sutures as well as the wires themselves. Blunt digital manipulation or dissection to free the sternum often results in injury to cardiac chambers, which may be fatal.

We describe a simple but effective technique to minimise the risk of injury to cardiac chamber/s, extra cardiac grafts as well as great vessels whilst performing redo-sternotomy. Pre-operative lateral chest X-ray or CT scan is a mandatory pre-requisite to delineate the anatomy and also assess the potential retrosternal space.

Section snippets

Technique

A standard midline incision with excision of the previous scar is performed. The skin incision is extended 2–3 cm below the previous scar to enhance the exposure of the retrosternal space for sharp and blunt dissection at the lower part of sternum. The sternal wires are then untwisted and removed. The dissection is started at the bottom under direct vision by lifting up the xiphi-sternum. Almost a lower third of sternum could be freed of adhesions.

The anaesthetist is then asked to hyperinflate

Discussion

Since the outcomes subsequent to cardiac surgery have been strikingly enhanced longer life expectancy has resulted in further cardiac patients returning for reoperations, and redo-sternotomy has become a routine for modern cardiac surgery practice. Cardiac reoperations constitute an increasing proportion of the workload in most cardiac units. These procedures are technically more arduous as well as time consuming. Preoperative CT plays a valuable role in delineating the anatomy for accurate

Acknowledgement

We are grateful to Aiza Javed for the help and effort in the preparation of this manuscript.

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Copyright © 2011 Elsevier Inc. Published by Elsevier Ltd. on behalf of The Australasian Society of Cardiac and Thoracic Surgeons and The Cardiac Society of Australia and New Zealand All rights reserved.