REDO STERNATOMY

We have been greatly concerned with the incidence of injury to the heart during re-do cardiac surgery.  Global statistics shows about approximately 10% of the patients who are undergoing re-do cardiac surgery sustain cardiac injury and 30% of them die because of these complications.  Since we are doing large number of re-do surgeries for the last six years, we have been trying to develop a safe and a simple technique to do re-do sternotomy, which can be done by moderately experienced heart surgeons.  Large number of patients, who had heart surgeries in the past in India, are coming back for a re-do operation either for re-do bypass, valve re-replacement or conduit replacement in congenital heart disease.  Over a period of time we developed a safe technique of doing re-do sternotomy using Gigli saw.  This technique has been used in 50 consecutive sternotomies in the last 4 months with no complications at all and the whole procedure of re-do sternatomy takes less than ten minutes.  Younger patient who had REDO sternatomy by this technique was 3year old with gross cardiomegly due to mitral regurgitation, all the remaining patients are adults.

Description of the procedure of re-do sternotomy with the Gigli Saw: 

Fundamental principle of using Gigli Saw for re-do sternatomy is based on the fact that right plural cavity is a safe passage for the Gigli saw to go inside the chest from below and emerge at the suprasternal space.  Unlike traditional technique of using Gigli saw under the sternum for a primary sternotomy in the good old days, in this technique Gigli saw does not go under the sternum.  This goes into the right plural cavity and then emerges at the suprasternal space.

Step: - 1.  After anesthesia and draping scar of the previous incision was excised and all the wires are removed then a space below the xiphisternum is created using diathermy always dissecting under the bone and Rectus sheath incision is extended by two inches and Rectus sheath is dissected away from the abdominal fat using the diathermy.  Using a tough scissors xiphisternum was cut in the middle to create a groove. Two Towel clips are attached to the two edges of the xiphisternum to lift the xiphisternum and part the chest wall.  Dissection is carried out only in the right side under the xiphisternum and the right chest.  Then the right index finger in inserted into the right plural cavity constantly in touch with the rib cage.   It is very important to keep the finger very close to the rib cage, since finger can create a false passage in between several tissue layers and it will not be possible to enter the right plural cavity.  If required at this stage, again the diathermy can be used to dissect the right pleura from the rib cage.  Right index finger can easily sense entering empty right pleural cavity.

Step: - 2. Left index finger is passed under the manubrium again into the right pleural cavity.  Surgeons do develop the space under the manubrium in the midline in the event of doing primary sternotomy with Oscillating saw.  In this technique finger is not directed in the midline.  THE LEFT INDEX FINGER IS DIRECTED UNDER THE MANUBRIUM AT RIGHT ANGLES TO THE MIDLINE INTO THE RIGHT PLEURAL CAVITY.  Lot of the time finger may not enter into the right plural cavity totally because of some adventitial tissue along with mediasternal pleura.  That is acceptable.

Step: -3. A special curved instrument with blunt tip and a hole at the end is chosen.  A thick long thick thread is passed through the hole and the one end of the thread is fixed to a mosquito forceps to prevent it from getting lost.  This curved special instrument is now inserted into the right plural cavity below the right edge of Rectus sheath.  Once the tip of the instrument goes into the right pleural cavity, sometimes it is difficult to know where the tip of the instrument is.  There is a marker in the handle of the instrument to show the direction of the tip and then the instrument is rotated so that the tip of the instrument touches the chest wall.  A slight nudge on the instrument will lift the chest wall and the left hand on the chest wall can clearly feel where the tip of the instrument is then the instrument is directed towards the manubrium.  At this stage left index finger is inserted into the right plural cavity through the manubrium.  With the little manipulation of the curved instrument, the left index finger can feel the round tip of the special introducer.  Then the instrument is advanced directed by the left index finger into the suprasternal space.  If required diathermy can be used to cut the adventitial tissues on the bulb of the special introducer.  Using a hook thick thread is retrieved and the introducer is withdrawn from below the xiphisternum. 

Step: 4.  Now we have a thick thread below the xiphisternum into right plural cavity and emerged to the suprasternal space.  A Gigli saw is tied to the xiphisternal end of the thick thread and thick thread is pulled from the top end near the manubrium.  This in turn introduces the Gigli saw under the xiphisternum into the right pleural cavity and emerges from the suprasternal space.  Handles are fixed to the Gigli saw and anesthetists brings down the blood pressure to systolic of 50 mm of mercury. When this blood pressure level is reached, ventilator is turned off and the assistant standing on the left side of the patient uses the Gigli saw to cut through the sternum.  This gives a perfect midline sternotomy and cats paw is used to retract the left sternal edge and a diathermy is used to dissect the heart under the left sternal edge.  In this technique right sternal edge is totally clear from the heart, so a metal retracter can be used without any difficulty.

Gigli saw is used by the assistance standing on the left side of patient, not by the main surgeon

We are unhappy with the concept of using the oscillating saw for performing the redo sternotomy. Oscillating saw will never cut the bone unless you press the sternum down.  Pressing the sternum with the oscillating saw obliterates the existing the space between tense right ventricle in patients with Mitral valve disease and tense aorta, which is stuck to the sternal wall in case of a re-do arch replacements.  Using this technique, we have done several re-do aneurysms with aneurysm virtually pressing on the sternum.  Gigli saw when it moves from the right pleural cavity towards the center takes along with it mediasternal pleura and several adventitial tissues, which pushes the cardiac structures towards the midline there by making enough space for the Gigli saw to cut through the midline of the sternum.  This is essentially a cunning way of getting under the sternum with the Gigli saw via right pleural cavity.  The resulting sternotomy is absolute midline 100% of the time, since a tensed Gigli saw is always straight and never crucked.  I am sending some pictures and I will try to send the video of the operation.  If you cannot see the video you can observe it on our website i.e. www.mail.narayanahospitals.com or if you like the procedure, please let me know and I will courier the instrument to you at the earliest. 

Publication: - we have submitted this article for publication in Annals of cardiac surgery.
Important: it is extremely important create a space with the left index fingure under the manubrium towards the right pleural cavity. Introducer should be advanced touching the chest wall towards the tip of the left index finger then the introducer should be pushed into the supra strenal space. If the introducer is pushed towards the supra sternal space without the guidance of the left index finger, in nominate and SVC can get injured.

We recommend that you do this procedure for primary sternatomy not REDO sternatomy initially to familiarize with every step. Once you are comfortable with primary sternatomy you can embark on REDO sternatomy.

Thanking you

Yours sincerely

Dr. Devi Shetty
Chairman
Narayana Hrudayalaya
Bangalore

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