© 2014 Wiley Periodicals, Inc.
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SURGICAL TECHNIQUE ___________________________________________________________
Laminectomy Retractor: A Useful Tool for Redo Sternotomy Pankaj Saxena, F.R.A.C.S., Ph.D., and Adam D. Zimmet, F.R.A.C.S. Department of Cardiothoracic Surgery, The Alfred Hospital, Melbourne, Australia ABSTRACT Sternal re-entry represents a critical step during redo cardiac surgery. We describe a simple method that relies on opening of the posterior table of the sternum with a laminectomy retractor after dividing the anterior table with an oscillating saw. doi: 10.1111/jocs.12375 (J Card Surg 2014;29:785–786) Redo cardiac surgery poses technical challenges to the surgeon. An important part of the procedure is safe sternal re-entry via sternotomy. A number of technical maneuvers have been described to assist the cardiac surgeon in performing redo sternotomy.1–4 We describe a safe and simple technique for performing redo sternotomy. This method relies on opening the posterior table of sternum with a laminectomy retractor after dividing the anterior table with an oscillating saw.
are opened. The remainder of the redo dissection is carried out in a standard fashion.
SURGICAL TECHNIQUE Skin and subcutaneous tissues are divided and the sternal wires are removed. A self-retaining retractor is used in the xiphoid area to perform limited dissection of the retrosternal tissue. An oscillating saw is used to divide the anterior table of sternum along the entire length (Fig. 1 A). A curved or a straight Mayo scissors is used to divide the lower few centimeters of the posterior table of the sternum. At this stage, a laminectomy spreader is used to open the lowermost part of divided posterior table (Fig. 1B). Ratchets of the retractor are gradually opened and the posterior table is slowly divided along the length with a Mayo scissors. Another spreader is placed more superiorly (Fig. 1C). The sternum splits along its length with traction force generated by the retraction from the spreader and is facilitated by the scissors. Ventilation is maintained during the redo sternotomy. Once the sternum is divided, rake retractors are used to perform diathermyassisted dissection in a retrosternal plane. Both pleurae
Conflict of interest: The authors acknowledge no conflict of interest in the submission. The present study was supported by the Cardiothoracic Unit of the Alfred Hospital, Melbourne, Australia. Address for correspondence: Adam D. Zimmet, F.R.A.C.S., Department of Cardiothoracic Surgery, The Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia. Fax: þ61 3 9076 2317; E-mail: [email protected]
Figure 1. (A) An oscillating saw is used to divide the outer table of the sternum. (B) A laminectomy retractor has been used to open the lowermost part of the partially divided sternum with a Mayo scissors. (C) A second laminectomy retractor helps with the exposure.
786
SAXENA AND ZIMMET LAMINECTOMY RETRACTOR FOR REDO STERNOTOMY
J CARD SURG 2014;29:785–786
DISCUSSION
REFERENCES
Outcomes in redo cardiac surgery depend on safe sternal re-entry. Injury to cardiovascular structures during redo sternotomy is associated with 25% mortality.5 A number of methods have been described in the literature to perform safe redo sternotomy. We have described the use of laminectomy spreaders in facilitating redo sternotomy. A similar technique has been used for opening plaster casts after immobilization in orthopedic surgery, using a ‘‘plaster cast spreader.’’ We have used this technique routinely in our practice. There have been no instances of injury to heart or bypass grafts during sternal re-entry in over 50 redo sternotomies performed by one of us (A.D.Z.) using the present technique.
1. Machiraju V: How to avoid problems in redo coronary artery bypass surgery. J Card Surg 2004;19:284–290. 2. Grunwald RP: A technique for direct-vision sternal reentry. Ann Thorac Surg 1985;40:521–522. 3. O’Brien MF, Harrocks S, Clarke A, et al: How to do safe sternal reentry and the risk factors of redo cardiac surgery: A 21 year review with zero major cardiac injury. J Card Surg 2001;17:4–13. 4. Mejia R, Saxena P, Tam RK: Hydrodissection in redo sternotomies. Ann Thorac Surg 2005;79:363–364. 5. Park CB, Suri RM, Burkhart HM, et al: Identifying patients at particular risk of injury during repeat sternotomy: Analysis of 2555 cardiac reoperations. J Thorac Cardiovasc Surg 2010;140:1028–1035.
Copyright of Journal of Cardiac Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
785
SURGICAL TECHNIQUE ___________________________________________________________
Laminectomy Retractor: A Useful Tool for Redo Sternotomy Pankaj Saxena, F.R.A.C.S., Ph.D., and Adam D. Zimmet, F.R.A.C.S. Department of Cardiothoracic Surgery, The Alfred Hospital, Melbourne, Australia ABSTRACT Sternal re-entry represents a critical step during redo cardiac surgery. We describe a simple method that relies on opening of the posterior table of the sternum with a laminectomy retractor after dividing the anterior table with an oscillating saw. doi: 10.1111/jocs.12375 (J Card Surg 2014;29:785–786) Redo cardiac surgery poses technical challenges to the surgeon. An important part of the procedure is safe sternal re-entry via sternotomy. A number of technical maneuvers have been described to assist the cardiac surgeon in performing redo sternotomy.1–4 We describe a safe and simple technique for performing redo sternotomy. This method relies on opening the posterior table of sternum with a laminectomy retractor after dividing the anterior table with an oscillating saw.
are opened. The remainder of the redo dissection is carried out in a standard fashion.
SURGICAL TECHNIQUE Skin and subcutaneous tissues are divided and the sternal wires are removed. A self-retaining retractor is used in the xiphoid area to perform limited dissection of the retrosternal tissue. An oscillating saw is used to divide the anterior table of sternum along the entire length (Fig. 1 A). A curved or a straight Mayo scissors is used to divide the lower few centimeters of the posterior table of the sternum. At this stage, a laminectomy spreader is used to open the lowermost part of divided posterior table (Fig. 1B). Ratchets of the retractor are gradually opened and the posterior table is slowly divided along the length with a Mayo scissors. Another spreader is placed more superiorly (Fig. 1C). The sternum splits along its length with traction force generated by the retraction from the spreader and is facilitated by the scissors. Ventilation is maintained during the redo sternotomy. Once the sternum is divided, rake retractors are used to perform diathermyassisted dissection in a retrosternal plane. Both pleurae
Conflict of interest: The authors acknowledge no conflict of interest in the submission. The present study was supported by the Cardiothoracic Unit of the Alfred Hospital, Melbourne, Australia. Address for correspondence: Adam D. Zimmet, F.R.A.C.S., Department of Cardiothoracic Surgery, The Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia. Fax: þ61 3 9076 2317; E-mail: [email protected]
Figure 1. (A) An oscillating saw is used to divide the outer table of the sternum. (B) A laminectomy retractor has been used to open the lowermost part of the partially divided sternum with a Mayo scissors. (C) A second laminectomy retractor helps with the exposure.
786
SAXENA AND ZIMMET LAMINECTOMY RETRACTOR FOR REDO STERNOTOMY
J CARD SURG 2014;29:785–786
DISCUSSION
REFERENCES
Outcomes in redo cardiac surgery depend on safe sternal re-entry. Injury to cardiovascular structures during redo sternotomy is associated with 25% mortality.5 A number of methods have been described in the literature to perform safe redo sternotomy. We have described the use of laminectomy spreaders in facilitating redo sternotomy. A similar technique has been used for opening plaster casts after immobilization in orthopedic surgery, using a ‘‘plaster cast spreader.’’ We have used this technique routinely in our practice. There have been no instances of injury to heart or bypass grafts during sternal re-entry in over 50 redo sternotomies performed by one of us (A.D.Z.) using the present technique.
1. Machiraju V: How to avoid problems in redo coronary artery bypass surgery. J Card Surg 2004;19:284–290. 2. Grunwald RP: A technique for direct-vision sternal reentry. Ann Thorac Surg 1985;40:521–522. 3. O’Brien MF, Harrocks S, Clarke A, et al: How to do safe sternal reentry and the risk factors of redo cardiac surgery: A 21 year review with zero major cardiac injury. J Card Surg 2001;17:4–13. 4. Mejia R, Saxena P, Tam RK: Hydrodissection in redo sternotomies. Ann Thorac Surg 2005;79:363–364. 5. Park CB, Suri RM, Burkhart HM, et al: Identifying patients at particular risk of injury during repeat sternotomy: Analysis of 2555 cardiac reoperations. J Thorac Cardiovasc Surg 2010;140:1028–1035.
Copyright of Journal of Cardiac Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
