Curvilinear Paramedian Sternotomy

Curvilinear Paramedian Sternotomy Myles Edwin Lee, M.D., and Carlos Blanche, M.D. ABSTRACT A modification of the classic straight midline sternotomy incision is described. The technique involves performing the sternotomy in a curvilinear manner along both sides of the midline to create two sternal halves that interdigitate with one another. With such a configuration, malalignment is virtually impossible. Median sternotomy, described in 1957by Julian and colleagues [l],is the standard incision used for most cardiac surgical procedures. The sternum is usually divided in a straight line placed equidistant from its lateral edges from manubrium to xiphoid (Fig 1A). Unless the sternal wires are placed at equal levels, malalignment and instability of the sternal halves are possible (Fig 1B). The modeling required by the healing process may result in a cosmeticallyunsatisfactory lump at the upper part of the incision and cause discomfort to the patient. This report describes a slight modification of the sternotomy incision that eliminates malalignment and reduces the potential for subsequent instability.

A B Fig I. (A) Standard median sternotomy incision. (B)Malalignment of the sternal halves may result from the standard sternotomy.

Technique The sternum is divided in a curvilinear manner with the incision extending to both sides of the midline for several millimeters (lazy S) (Fig 2A). This results in a line of closure which, of necessity, can be approximated only one way, with the two sternal halves fitting together like the pieces of a jigsaw puzzle (Fig 2B).

Comment This modification of the traditional straight-line median sternotomy incision facilitates closure of the sternotomy without malalignment or instability. The method ensures precise, automatic reduction of the sternotomy without relying solely on estimated parallel placement of the sternal closure wires. The paramedian deviation of the incision from the midline is a few millimeters, no more than a slight exaggeration of the normal tendency to vary slightly off the midline while making any incision. In no instance have we deviated so far from the midline as to leave only a thin cortex of bone on one edge. Were this to happen, closure could be accomplished with Parham stainless steel bands rather than wires to prevent the closure material from cutting through the bone.

From the Section of Cardiac Surgery, Department of Thoracic and Cardiovascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA. Accepted for publication Mar 2, 1984. Address reprint requests to Dr. Lee, Cedars-Sinai Medical Center, Department of Thoracic and Cardiovascular Surgery, Room 6215, 8700 Beverly Blvd, Los Angeles, CA 90048.

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Fig 2. (A) Modified curvilinear paramedian sternotomy incision (lazy S). (B)Closure of the modified curvilinear sternotomy incision demonstrating perfect apposition of the sternal halves.

Over the last two years, we have used this incision routinely in at least a hundred patients with no incidence of wound complications related to the method itself. Curvilinear paramedian sternotomy ensures precise open reduction and internal fixation conforming to well-established orthopedic principles.

Reference 1. JulianOC,Lopez-Belio M, Dye WS, et al: The median sternal incision in intracardiac surgery with extracorporeal circulation: a general evaluation of its use in heart surgery. Surgery 42:753, 1957