Manubrium–Sparing Median Sternotomy as a Uniform Approach for Cardiac Operations

Editorial Commentary

Since the introduction of less-invasive or minimal-access surgical techniques for intra-abdominal procedures a decade ago, cardiovascular surgeons have been challenged to reduce the extent of incisions used for cardiac operations. Although minimizing the extent of the incision is certainly a worthy objective, contemporary surgeons must not overlook the principles established for performing a safe and precise operation.

The standard median sternotomy, which was adopted several decades ago for access to the heart and great vessels, generally provides excellent results. Unfortunately, many surgeons over-expose the surgical field, often disregarding the postoperative course and comfort of the patient. In our hospital, surgeons are aware of the problems associated with maximum exposure and use only a single-blade, self-retaining retractor, which is applied in the lower third of the sternum. ¹

Changing the shape of the exposure from rectangular or square (Fig. 1A) to pyramidal (Fig. 1B) displaces minimally the sternoclavicular joints and upper ribs and avoids some of the complications mentioned by the authors. The transverse incision across the manubrium described by the authors may injure the internal thoracic artery, and the presence of the manubrial segment during the operation may interfere with aortic cannulation and vein anastomoses during coronary bypass. Finally, repair of a heavy manubrium may be difficult.

Fig. 1 A) Square exposure of the surgical field B) Pyramidal exposure of the surgical field

The authors are to be commended, however, for their effort to improve patients' recovery and to achieve some cosmetic improvement over conventional techniques.