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Jaishankar Raman, MBBS MMed, FRACS, PhD

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© 2017 Jaishankar Raman

 

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Not splitting the chest!

August 11, 2018

The late Dr Louis Cohen was a delightful man, and an incredibly caring cardiologist with a passion for squash, who was very well known at the University of Chicago for his dedication to his patients.  A large, luxuriant and very prominent white beard graced his face. As a fortunate collaborator of his, I was the beneficiary of many entertaining stories and some interesting, high profile Chicago faculty members as patients. His refrain about the sternum - "every one of these white hair in my beard is a reminder of a sternal wound problem in one of my patients".  It was a gross exaggeration, but you get the idea. This wonderful access incision, the sternotomy has been plagued over the years with a bad reputation. Some of the negatives -

1. A big bone-breaking incision

2. Issues with pain and limitation afterwards

3. Problems with slow healing and wound infections.

4. Restrictions in terms of activity.

5. Sternal dehiscence and/or infections of the sternum & underlying structures.

 

The impetus to  minimize these potential complications have been two-fold -

Avoid the sternum if possible

If the sternum needs to be split, the closure can be helped along with plates and screws (as I mentioned in a previous post).

Lets imagine these alternate approaches -

Less invasive approaches which include 

1. Minithoracotomy

2. Ministernotomy

3. Percutaneous, trans-catheter approaches.

4. Robotic cardiac surgery

5. Hybrid approaches - which include a combination of percutaneous and less invasive surgical procedures.

 

The growth in percutaneous, trans-catheter approaches have been remarkable in many ways. The primary driver for growth has been the avoidance of a big, bone-breaking sternotomy or "cracking of the chest". Many of these percutaneous strategies have been able to overcome sub-optimal medium and long-term outcomes, mainly because they preclude the need for a sternotomy.

 

We can through each of these alternate approaches to a sternotomy in detail - in the next few blog posts.

 

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