Median sternotomy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]

Overview

Median sternotomy is a type of surgical procedure in which a vertical inline incision is made along the sternum, after which the sternum itself is divided, or cracked. This procedure provides access to the heart and lungs for surgical procedures such as heart transplant, corrective surgery for congenital heart defects (CHD's), or coronary artery bypass surgery.

Median sternotomy is often mistakenly referred to as open heart surgery; however, open heart involves incision of the pericardium, and many median sternotomy procedures do not require this. Open heart usually involves the use of a cardiopulmonary bypass, also known as a heart-lung machine.

Complications

Complications of median sternotomy are infrequent but are very grave. Complications are seen usually in the time frame of 1-2 weeks after the surgery. They can be categorized into

• Sterile serosanguineous discharge with stable sternum
• Unstable sternum with or without sterile discharge
• Sternal dehiscence without mediastinitis
• Superficial wound infection without mediastinitis
• Subcutaneous infection, unstable sternum
• Retrosternal extension
• Mediastinitis with or without sternal separation.

Diagnosis

Symptoms

• Pain
• Fever

Physical Examination

• Tenderness
• Erythema
• Sternal discharge
• Sternal separation

Chest X Ray

• Mediastinal widening
• Large or enlarging air collections - suggestive of mediastinitis

CT Scan

• Progressive widening of the lucency in the sternum post operatively indicate sternal separation.
• Retrosternal, soft circumscribed mass - hematoma

Treatment

Prevention

• Sternal wound support
• Lifting restrictions
  • Weight restriction on unilateral lifting
  • Weight restriction on bilateral lifting
  • Restricting the height an object can be lifted, and the size of the object being lifted
• Weight restrictions specified initially to prevent sternal dehiscence
• No overhead lifting
• Transfer precautions
  • Unilateral pushing and unilateral pulling are movements most commonly restricted during hospitalization and at discharge.
  • The use of bilateral upper-limb movements, producing a symmetrical load on the sternum, may be more beneficial for sternal healing compared with the asymmetrical loads produced by unilateral upper limb movements.
• Mobility aid restriction
  • When the use of mobility aid restrictions is considered in combination with lifting and transfer restrictions, it is evident that there is immense potential to have a detrimental impact on patient recovery, including functional capacity and ability to perform necessary activities of daily living(ADL) tasks.
  • Time required to attain independent mobility can also could be affected, potentially leading to an increased length of stay and greater resource utilization.

Rationale for restrictions

• Prevention of incision dehiscence
• Prevention of sternal instability
• Prevention of sternal breakdown and infection
• Pain management

See also

• Sternal saw