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Honolulu, HI
Dr. Murray is a cardiothoracic surgeon at Hawaii Kaiser Foundation Hospital.
Correspondence to: Kevin D. Murray, MD, FCCP, Cardiothoracic Surgery, Kaiser Foundation Hospital, 3288 Moanalua Rd, Honolulu, HI 96819; e-mail: Kevin.D.Murray{at}kp.org
This dictum pervaded surgery for decades. The explosive success of laparoscopic procedures served as a stimulus for seeking smaller windows of access to other body cavities and structures. Old techniques were resurrected, and new technologies were developed as interest surged from both physicians and patients to become minimally invasive. The field of cardiac surgery was not immune to this wave of interest in radically shrinking the size of incisions. Cardiac surgery, particularly coronary artery bypass grafting (CABG), had reached an unparalleled level of success, reliability, and acceptance through the thoughtful blending of cardiopulmonary bypass (CPB) technology, cardioplegic-induced cardiac arrest, enhanced surgical techniques, sophisticated postoperative care, and experience. However, the time was ripe for reassessing what had become the standard approach to surgical revascularization of the heart. The search was begun to seek improvements in the standard CABG operation, which included downsizing the length of the incisions.
The heart is securely guarded in the cage formed by the broad sternal plate and the encircling ribs. The advocacy of the mediansternotomy incision by Julian et al1 in 1957 provided extraordinary access to the heart. No incision has been more effective in exposing the organ targeted for surgery. Longitudinal and complete division of the sternum accomplished several tasks: exposure of the great vessels and heart for cannulation for CPB, unparalleled access to all epicardial coronary arteries, ease of closure, controllable postoperative pain, and the absence of deformity or restriction in activity when healing was completed.
Attempts to perform CABG surgery using CPB and nonsternotomy incisions met with less-than-ideal results.2 However, the coupling of CPB-supported CABG with partial sternal division has been more successful.3 This inferiorly placed longitudinal and partial sternal division, accompanied by a transverse sternal incision in the third intercostal space, provided excellent exposure for the epicardial coronary vessels. However, aortic cannulation for CPB and cross-clamping of the aorta were somewhat awkward. Also the "T"-shaped incision lead to bone instability problems. Despite its feasibility, there were sufficient complexities in this approach, when compared to a full sternotomy, that prevented this partial sternal division from becoming the standard of care.
The advent of off-pump CABG (OPCABG) surgery has again prompted interest in reducing the size of surgical incisions. The absence of CPB negated the need to expose the great vessels and atria. The singularly important goal of an incision for an OPCABG procedure was the exposure of the coronary arteries. However, for smaller incisions to replace the standard full sternotomy approach, the abbreviated incisions needed to provide not only equally effective visualization of the coronary arteries, but also demonstrate some measure of superiority: ease of performance, decreased operative time, fewer complications, decreased pain, and/or improved cosmesis.
The article by Niinami et al in this issue of CHEST (see page 47) evaluates an inferiorly placed partial longitudinal sternotomy (without a transverse component) used for single-vessel OPCABG. Although the authors were intending to compare a partial sternotomy with a small anterior thoracotomy, the marked decline in the use of the thoracotomy approach for OPCABG makes isolated evaluation of the partial sternotomy more relevant. This retrospective report indicates that the limited sternotomy provides adequate exposure for both the harvesting of the left internal thoracic artery and bypassing the left anterior descending (LAD) coronary artery. All anastomoses were patent and without angiographic abnormalities at 1 month following the operation, and no patient had a perioperative myocardial infarction. These excellent results, however, are merely equal to those expected for single-vessel OPCABG to the LAD using a full longitudinal mediansternotomy incision. Did the limited sternotomy incision for single-vessel bypass provide any advantages when compared to a full sternotomy? This answer is open to some debate. Since there were only 16 patients in this report, certain outcomes cannot be statistically analyzed: wound infection, sternal instability, atrial fibrillation, etc. However, areas reported by the authors that can be critically evaluated indicate that postoperative pain was judged to be at least moderate until postoperative day 5; the incisions averaged 8 cm in length for patients (predominantly male) who had an average body surface area of only 1.6 m2, and the ICU stay was nearly 1 day. This information would indicate equality rather than superiority to a full sternotomy.
For the infrequent patient who requires a single-vessel bypass to the LAD, the goal should be to perform the operation in a manner that provides the highest likelihood for long-term patency for the graft. Whether the incision is a full or partial sternotomy appears to be of secondary importance. An 8-cm skin incision followed by the use of a saw to divide the sternum longitudinally for nearly half of its length, followed by pain rated as moderate (1 h after oral analgesics) for nearly 5 days would be hard-pressed to be categorized as minimally invasive, except by the surgeon.
References
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