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Sternal “Notching” Improves Clamshell Incision
Sternal “Notching” Improves Clamshell Incision Vassyl
A. Lonchyna
Since its simultaneous introduction by Pasque’ and Bisson,2 the “clamshell” incision has been accepted as the best approach for bilateral single lung transplantation as well as an acceptable approach for bilateral pulmonary metastases and mediastinal tumor^.^.^ The usual technique is to transsect the sternum transversely at the level of the appropriate interspace (usually the fourth or fifth). This is accomplished with a Gigli saw (Zimmer, Warsaw, IN), Lebsche knife (Codman/J&J Co, Somerville, NJ), or more frequently, a sternal saw. In its application for bilateral single lung transplantation, the incision is taken to the anterior axillary Line bilaterally. Both internal mammary arteries are sacrificed and securely ligated before the sternum is transsected.
The sternum is closed with standard stainless steel wires (#5 or #6). Some surgeons reinforce the closure with a K-wire (Zimmer) or a Steinmann pin (Zirnmer). One bothersome complication seen with this incision is that of sternal override, ie, usually anterior displacement of the inferior portion of the sternum.4 This may cause sternal instability, pain, and may contribute to respiratory difficulty. In our experience with the clamshell incision for bilateral single lung transplantation, we encountered several patients with sternal override (Figure I). Therefore, the method of transsecting the sternum was modified to allow a more precise fit at closure, to provide stability, and to prevent overriding of the sternal ends postoperatively.
Fig I. Lateral chest radiograph showing severe anterior displacement of the lower sternum 1 year following bilateral lung transplantation using the standard clamshell incision.
176
Operative Techniques in Thoracic and Cardiovascular Surgery, vol4, N o 2 (May), 1999: pp 176-178
177
STER\ 41, "NOTCIIING" IMPROVES CLAMSIIEI,I, IKCISIO1
SURGICAL TECHNIQUE
Fourth intercostal space
Direction of saw cuts
/
Figure-ofeight wire suture
V
1
The sternum is notched at the level of transsection by aiming the sternal saw at a 45" angle and cutting toward the midpoint. On the contralateral side, the incision is carried upward at a 45" angle to complete the transection (A). Care is taken upon opening the chest to place one blade of the Finochetto retractor (one with an opening in the blade) against the pointed end of the sternum so that it does not injure the mediastinal structures. The sternal bone is very solid at this level and its pointed end has never broken off with retraction and manipulation. The resultant cut ends of the sternum fit nicely together at the time of closure with two sternal wires, each looped as a "figure of eight" (B). Special care is taken to cut the end of the twisted wire very short and bend it deeply into the bone to prevent postoperative discomfort.
178
VASSYL A. LONCHYNA
Fig 11. Lateral chest radiograph showing straight alignment of both ends of the sternum 3 months following bilateral lung transplantation using the clamshell incision with “notching” of sternum.
REFERENCES
Comments Arcidis suggested that beveling the sternum from a slightly caudal to rostra1 direction would create a bony overlap and hence add stability at the time of closure. Recently, Walterbusch6 described a technique of transsecting the manubrium in an inverted V-shaped line when performing a partial sternotomy for cardiac procedures. It is his opinion that this notch in the sternum prevents sternal dislocation. An increased incidence of sternal complications has also led Meyers7 to introduce a sternal sparing incision for bilateral lung transplantation, hut this requires resection of the costal cartilage of the fourth rib and sometimes limits the exposure within the thoracic cavity. We have performed sternal notching in 12 patients undergoing the clamshell incision with no overriding or dislocation of the sternum (Figure 11).This modification of the sternal transsection allows for excellent exposure because of a completed clamshell incision, important especially when cardiopulmonary bypass is used. Thus, the postoperative complication of sternal mal-alignment, which we observed in our early experience, has been eliminated.
1. Pasque MK, Cooper JD, Kaiser LR, et al: Improved technique for bilateral lung transplantation. Rationale and initial clinical experience. Ann Thorac Surg 49:785-791,1990 2 Bisson A, Bonnettr P : A new technique for double lung transplantation. “Bilateral single lung” transplantation. J Thorac Cardiovasc Surg 103:40-46,1992 3. Bains MS, Ginsherg RJ, Jones WG, et al: The clamshell incision: An improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg 58:30-33,1994 4. Wright C: Transverse sternothoracotomy. Chest Surg Clin N Am 6:149156,1996 5. Arcidi JM, Patterson GA: Technique of hilateral lung transplantation, in Patterson GA, Courand L (eds): Current Topics in General Thoracic Surgery: An International Series. Vol 3 Lung Transplantation. Amstrrdam, the Netherlands, Elsrvirr, 1995, pp 207-216 6 . Walterhusch G: Partial steruotomy for cardiac operations. J Thorac Cardiovasc: Surg 115:256-258, 1998 (letter) I . Meyers BF; Siindarrsan RS, Guthrie T, et al: Bilateral sequential lung transplantation without sternal division eliminates posttransplantation sternal complications. J Thorac Cardiovasr Surg 115:258-364,1999
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From Tulane Lniversit) Medical Center, Yew Orleans. L.1. Adtlre~sreprint requests to Vass! 1 A. Lonchya. MD. Di\ ision of Cartliothoracic Surgei?. Tulane University Mrtlical Crnter. 1530 Titlanr Avr. Yru Orleans. L.1 701 12-2099. Copyright 0 1999 by A:B. Sauntlers Compan! 1s92-29-12/99/0-10-”-000~~ 10.00/0
A. Lonchyna
Since its simultaneous introduction by Pasque’ and Bisson,2 the “clamshell” incision has been accepted as the best approach for bilateral single lung transplantation as well as an acceptable approach for bilateral pulmonary metastases and mediastinal tumor^.^.^ The usual technique is to transsect the sternum transversely at the level of the appropriate interspace (usually the fourth or fifth). This is accomplished with a Gigli saw (Zimmer, Warsaw, IN), Lebsche knife (Codman/J&J Co, Somerville, NJ), or more frequently, a sternal saw. In its application for bilateral single lung transplantation, the incision is taken to the anterior axillary Line bilaterally. Both internal mammary arteries are sacrificed and securely ligated before the sternum is transsected.
The sternum is closed with standard stainless steel wires (#5 or #6). Some surgeons reinforce the closure with a K-wire (Zimmer) or a Steinmann pin (Zirnmer). One bothersome complication seen with this incision is that of sternal override, ie, usually anterior displacement of the inferior portion of the sternum.4 This may cause sternal instability, pain, and may contribute to respiratory difficulty. In our experience with the clamshell incision for bilateral single lung transplantation, we encountered several patients with sternal override (Figure I). Therefore, the method of transsecting the sternum was modified to allow a more precise fit at closure, to provide stability, and to prevent overriding of the sternal ends postoperatively.
Fig I. Lateral chest radiograph showing severe anterior displacement of the lower sternum 1 year following bilateral lung transplantation using the standard clamshell incision.
176
Operative Techniques in Thoracic and Cardiovascular Surgery, vol4, N o 2 (May), 1999: pp 176-178
177
STER\ 41, "NOTCIIING" IMPROVES CLAMSIIEI,I, IKCISIO1
SURGICAL TECHNIQUE
Fourth intercostal space
Direction of saw cuts
/
Figure-ofeight wire suture
V
1
The sternum is notched at the level of transsection by aiming the sternal saw at a 45" angle and cutting toward the midpoint. On the contralateral side, the incision is carried upward at a 45" angle to complete the transection (A). Care is taken upon opening the chest to place one blade of the Finochetto retractor (one with an opening in the blade) against the pointed end of the sternum so that it does not injure the mediastinal structures. The sternal bone is very solid at this level and its pointed end has never broken off with retraction and manipulation. The resultant cut ends of the sternum fit nicely together at the time of closure with two sternal wires, each looped as a "figure of eight" (B). Special care is taken to cut the end of the twisted wire very short and bend it deeply into the bone to prevent postoperative discomfort.
178
VASSYL A. LONCHYNA
Fig 11. Lateral chest radiograph showing straight alignment of both ends of the sternum 3 months following bilateral lung transplantation using the clamshell incision with “notching” of sternum.
REFERENCES
Comments Arcidis suggested that beveling the sternum from a slightly caudal to rostra1 direction would create a bony overlap and hence add stability at the time of closure. Recently, Walterbusch6 described a technique of transsecting the manubrium in an inverted V-shaped line when performing a partial sternotomy for cardiac procedures. It is his opinion that this notch in the sternum prevents sternal dislocation. An increased incidence of sternal complications has also led Meyers7 to introduce a sternal sparing incision for bilateral lung transplantation, hut this requires resection of the costal cartilage of the fourth rib and sometimes limits the exposure within the thoracic cavity. We have performed sternal notching in 12 patients undergoing the clamshell incision with no overriding or dislocation of the sternum (Figure 11).This modification of the sternal transsection allows for excellent exposure because of a completed clamshell incision, important especially when cardiopulmonary bypass is used. Thus, the postoperative complication of sternal mal-alignment, which we observed in our early experience, has been eliminated.
1. Pasque MK, Cooper JD, Kaiser LR, et al: Improved technique for bilateral lung transplantation. Rationale and initial clinical experience. Ann Thorac Surg 49:785-791,1990 2 Bisson A, Bonnettr P : A new technique for double lung transplantation. “Bilateral single lung” transplantation. J Thorac Cardiovasc Surg 103:40-46,1992 3. Bains MS, Ginsherg RJ, Jones WG, et al: The clamshell incision: An improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg 58:30-33,1994 4. Wright C: Transverse sternothoracotomy. Chest Surg Clin N Am 6:149156,1996 5. Arcidi JM, Patterson GA: Technique of hilateral lung transplantation, in Patterson GA, Courand L (eds): Current Topics in General Thoracic Surgery: An International Series. Vol 3 Lung Transplantation. Amstrrdam, the Netherlands, Elsrvirr, 1995, pp 207-216 6 . Walterhusch G: Partial steruotomy for cardiac operations. J Thorac Cardiovasc: Surg 115:256-258, 1998 (letter) I . Meyers BF; Siindarrsan RS, Guthrie T, et al: Bilateral sequential lung transplantation without sternal division eliminates posttransplantation sternal complications. J Thorac Cardiovasr Surg 115:258-364,1999
-
From Tulane Lniversit) Medical Center, Yew Orleans. L.1. Adtlre~sreprint requests to Vass! 1 A. Lonchya. MD. Di\ ision of Cartliothoracic Surgei?. Tulane University Mrtlical Crnter. 1530 Titlanr Avr. Yru Orleans. L.1 701 12-2099. Copyright 0 1999 by A:B. Sauntlers Compan! 1s92-29-12/99/0-10-”-000~~ 10.00/0