- Email: [email protected]
Superior Sternal Cleft: Repair in the Newborn
HOW TO DO IT
Superior Sternal Cleft: Repair in the Newborn Robert K. Salley, M.D., and Scott Stewart, M.D. ABSTRACT Superior sternal cleft is a rare congenital anomaly that should be repaired in the newborn while the bony thorax is still compliant. A method of approximating the U-shaped sternal defect that is applicable to the majority of patients seen as newborns is described. Disturbances of normal ventral midline fusion in the thorax can present as a spectrum of abnormalities ranging from an unusually prominent suprasternal notch to ectopia cordis [l].The less severe variations, such as superior sternal cleft, are readily amenable to surgical repair [2]. The incidence of this anomaly is not known, but it must be extremely rare; Ravitch [ l ] was able to collect only 44 cases reported between 1888 and 1977. Repair of this abnormality in the first weeks of life allows a primary approximation of the sternal defect without undue tension of the compliant thoracic cage. It has the added advantage of providing protection to the underlying structures [3, 41. A simple surgical technique is described that may be used to repair a U-shaped sternal cleft in infants soon after birth.
Fig 1. The U-shaped superior sternal cleft makes up the shaded area between the palpable sternum (nonshaded area). The dotted line marks the skin incision,
Technique A full-term male infant weighed 3.9 kg at birth. He had a U-shaped superior sternal cleft with a central area of ulcerated skin. The most cephalad portion of the cleft was separated by 2 cm. There were no other congenital abnormalities. Early repair was performed when the infant was 2 days old. The skin defect was excised, and the sternal cleft was exposed through a midline incision (Fig 1). When the sternal tables were encountered, the superficial and deep surfaces were freed laterally to the intercostal spaces. The sternal halves were fused at the caudal end by a cartilaginous xiphoid. This portion was excised by dividing its sternal attachment parallel to the defect (Fig 2). The perichondrium was elevated anteriorly and posteriorly on each sternal half to expose the underlying cartilage (Figs 3,4). The sternum was then approximated with several braided 1-0 Ethibond sutures (Figs 5, 6). To ensure that they were not compromised, cardiac and respiratory functions were observed for five minutes before these sutures were tied. The wound was then closed in layers with absorbable sutures. The remainder of the hospital course was uneventful. The infant had a normal-appearing sternum when he was seen at 6 months of age. From the University of Rochester, Division of Cardiothoracic Surgery, Rochester, NY. Accepted for publication Aug 13, 1984. Address reprint requests to Dr. Stewart, University of Rochester, 601 Elmwood Ave, Rochester, N Y 14642.
582
Fig 2. The xiphoid connecting the two sternal tables is divided in a sagittal plane. The shaded portion represents the amount of sternum excised.
Comment Since the report of a successful repair of superior sternal cleft in 1947 by Burton [5], early operative treatment of this anomaly has been advocated to ensure successful primary repair, circumvent respiratory difficulties, and gain protection for the mediastinal structures [l, 3, 41. The defect is often U shaped rather than V shaped and
583 How to Do I t Salley and Stewart: Superior Sternal Cleft Repair in the Newborn
Fig 3. Perichondrium is incised along the medial edge of the sternal half.
Fig 6. The completed repair. The elevated flaps of perichondrium have been embricated ouer the sternal halves.
Fig 4. The perichondrium is gently elevated 4 mm from its edge.
therefore requires resection of the xiphoid bridge to ensure satisfactory approximation of the sternal halves. Division of the xiphoid along a sagittal plane rather than transversely will add additional length to the final repair. The technique of elevating perichondrial flaps has the advantage of approximating cartilage to cartilage to facilitate primary union. In newborns, direct closure of the sternal defect can be routinely accomplished because of the high compliance of the chest wall 111. There is often a central ulcer or midline stripe associated with superior sternal cleft that is easily excised with the initial skin incision 111.
References
Fig 5. Heavy braided sutures are placed through the sternal halves. The defect is approximated, but the sutures are not tied until the vital signs are stable.
1. Ravitch MM: Congenital Deformities of the Chest Wall and Their Operative Correction. Philadelphia, Saunders, 1977 2. Jewett TC, Butsch WL, Hug HR: Congenital bifid sternum. Surgery 52:932. 1962 3. Billig DM, Immordino PA: Congenital upper sternal cleft: a case with successful surgical repair. J Pediatr Surg 5:257, 1970 4. Bernhardt LC, Meyer T, Young WP: Bifid sternum. J Thorac Cardiovasc Surg 55:758, 1968 5. Burton JF: Method of correction of ectopia cordis: two cases. Arch Surg 54:79, 1947
Superior Sternal Cleft: Repair in the Newborn Robert K. Salley, M.D., and Scott Stewart, M.D. ABSTRACT Superior sternal cleft is a rare congenital anomaly that should be repaired in the newborn while the bony thorax is still compliant. A method of approximating the U-shaped sternal defect that is applicable to the majority of patients seen as newborns is described. Disturbances of normal ventral midline fusion in the thorax can present as a spectrum of abnormalities ranging from an unusually prominent suprasternal notch to ectopia cordis [l].The less severe variations, such as superior sternal cleft, are readily amenable to surgical repair [2]. The incidence of this anomaly is not known, but it must be extremely rare; Ravitch [ l ] was able to collect only 44 cases reported between 1888 and 1977. Repair of this abnormality in the first weeks of life allows a primary approximation of the sternal defect without undue tension of the compliant thoracic cage. It has the added advantage of providing protection to the underlying structures [3, 41. A simple surgical technique is described that may be used to repair a U-shaped sternal cleft in infants soon after birth.
Fig 1. The U-shaped superior sternal cleft makes up the shaded area between the palpable sternum (nonshaded area). The dotted line marks the skin incision,
Technique A full-term male infant weighed 3.9 kg at birth. He had a U-shaped superior sternal cleft with a central area of ulcerated skin. The most cephalad portion of the cleft was separated by 2 cm. There were no other congenital abnormalities. Early repair was performed when the infant was 2 days old. The skin defect was excised, and the sternal cleft was exposed through a midline incision (Fig 1). When the sternal tables were encountered, the superficial and deep surfaces were freed laterally to the intercostal spaces. The sternal halves were fused at the caudal end by a cartilaginous xiphoid. This portion was excised by dividing its sternal attachment parallel to the defect (Fig 2). The perichondrium was elevated anteriorly and posteriorly on each sternal half to expose the underlying cartilage (Figs 3,4). The sternum was then approximated with several braided 1-0 Ethibond sutures (Figs 5, 6). To ensure that they were not compromised, cardiac and respiratory functions were observed for five minutes before these sutures were tied. The wound was then closed in layers with absorbable sutures. The remainder of the hospital course was uneventful. The infant had a normal-appearing sternum when he was seen at 6 months of age. From the University of Rochester, Division of Cardiothoracic Surgery, Rochester, NY. Accepted for publication Aug 13, 1984. Address reprint requests to Dr. Stewart, University of Rochester, 601 Elmwood Ave, Rochester, N Y 14642.
582
Fig 2. The xiphoid connecting the two sternal tables is divided in a sagittal plane. The shaded portion represents the amount of sternum excised.
Comment Since the report of a successful repair of superior sternal cleft in 1947 by Burton [5], early operative treatment of this anomaly has been advocated to ensure successful primary repair, circumvent respiratory difficulties, and gain protection for the mediastinal structures [l, 3, 41. The defect is often U shaped rather than V shaped and
583 How to Do I t Salley and Stewart: Superior Sternal Cleft Repair in the Newborn
Fig 3. Perichondrium is incised along the medial edge of the sternal half.
Fig 6. The completed repair. The elevated flaps of perichondrium have been embricated ouer the sternal halves.
Fig 4. The perichondrium is gently elevated 4 mm from its edge.
therefore requires resection of the xiphoid bridge to ensure satisfactory approximation of the sternal halves. Division of the xiphoid along a sagittal plane rather than transversely will add additional length to the final repair. The technique of elevating perichondrial flaps has the advantage of approximating cartilage to cartilage to facilitate primary union. In newborns, direct closure of the sternal defect can be routinely accomplished because of the high compliance of the chest wall 111. There is often a central ulcer or midline stripe associated with superior sternal cleft that is easily excised with the initial skin incision 111.
References
Fig 5. Heavy braided sutures are placed through the sternal halves. The defect is approximated, but the sutures are not tied until the vital signs are stable.
1. Ravitch MM: Congenital Deformities of the Chest Wall and Their Operative Correction. Philadelphia, Saunders, 1977 2. Jewett TC, Butsch WL, Hug HR: Congenital bifid sternum. Surgery 52:932. 1962 3. Billig DM, Immordino PA: Congenital upper sternal cleft: a case with successful surgical repair. J Pediatr Surg 5:257, 1970 4. Bernhardt LC, Meyer T, Young WP: Bifid sternum. J Thorac Cardiovasc Surg 55:758, 1968 5. Burton JF: Method of correction of ectopia cordis: two cases. Arch Surg 54:79, 1947