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J Thorac Cardiovasc Surg 1997;113:810-811
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

Mini-T sternotomy for cardiac operations

Department of Cardiovascular Surgery
Sharp Memorial Hospital
8010 Frost St., Suite 501
San Diego, CA 92123

To the Editor:

A wave of enthusiasm has recently arisen for the use of minimally invasive techniques for cardiac surgery. Some of these techniques include small incisions that have the disadvantage of providing limited exposure. ¹ I initially used a T-shaped low sternotomy on a patient who had a tracheostomy, and I have extended its use to other patients after appreciating its multiple advantages compared with other "mini" incisions.

The vertical skin incision extends from the xiphoid to below the angle of Louis. The midline sternotomy starts just to the side of the xiphoid and extends to the level of the second intercostal space, where it is "T'd" to the left and right, care taken to avoid injury to the intercostal pedicles (Fig. 1).

View larger version (23K): [in this window] [in a new window]   Fig. 1. Mini-T sternotomy follows the dotted line from the xiphoid to the second intercostal spaces. The incision is closed with peristernal and manubrium-to-sternum wires.

View larger version (43K): [in this window] [in a new window]   Fig. 2. Exposure for aortic cannulation is enhanced by lifting the sternum with the Rultrac retractor. A Favaloro or Thompson type retractor could be similarly used. The internal thoracic artery (inset, small arrow) is easily taken down through this approach.

The mini-T sternotomy has the advantage of providing better exposure than parasternal and transverse "mini" incisions. It also preserves the internal thoracic arteries, which are sacrificed with transverse incisions. In addition, direct cannulation is simple, and this approach offers versatility for combined procedures such as coronary bypass and mitral or aortic valve replacement.

Both internal thoracic arteries can be taken down completely through the T sternotomy, and maneuvers for deairing and myocardial protection are straightforward.

Arom, Emery, and Nicoloff ² recently described a vertical mini-sternotomy with extension to the left for takedown of the left internal thoracic artery. However, exposure with only a left extension is still limited. The simple T extension to the right with lifting of the manubrium, as described here, avoids full sternotomy and offers good exposure for most cardiac procedures. A disadvantage is poor exposure of the aortic arch, but if this is needed the incision can be simply converted to a full sternotomy by dividing the manubrium.

A distinct advantage of the mini-T sternotomy is less postoperative discomfort, because the clavicle and the first and second ribs are undisturbed when the manubrium is left intact.

References

1. Acuff TE, Landreneau RJ, Griffith BP, Mack MJ. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;61:135-7.[Abstract/Free Full Text]
   
2. Arom KV, Emery RW, Nicoloff DM. Mini-sternotomy for coronary artery bypass grafting Ann Thorac Surg 1996;61:1271-2.[Abstract/Free Full Text]
   

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ricardo J. Moreno-Cabral Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Moreno-Cabral, R. J. Search for Related Content PubMed PubMed Citation Articles by Moreno-Cabral, R. J.