TWilliam2019
Guru
Procedure:
1. Repair of sternal nonunion with rigid fixation of the sternum
2. Rigid fixation of right rib fracture
3. Lysis of adhesions
4. Removal of sternal hardware (sternal wires and sternal cables)
5. Cardiopulmonary bypass standby
The previous sternotomy scar was opened with a 10 blade scalpel. The deep dermis and subcutaneous tissues were divided with electrocautery. The sternum was identified at its superior portion, as this area was known to be well-healed based on CT scan imaging. The dissection was carried cephalad to the manubrium. A crossing vein was sewn off with interrupted 3-0 silk sutures. Dissection was then carried inferiorly and the sternal none union/dehiscence and sternal fractures were identified. Using a bone hook, the inferior left sternal edge was gently retracted by Mr. B. Electrocautery was then used to free the scarring from the medial edge of the bone extending posteriorly and freeing the left sternal table from the cardiac structures. This was carried up to approximately the level of the third rib. Once this was completed, the soft tissues and fibrous tissue was removed from the medial border of the right inferior hemisternum. Again, the scar tissue was released from posteriorly extending up to the third rib. The third and fourth rib were evaluated. At this area, a free-floating portion of sternum was identified which did been fractured by previous wiring. The free-floating portion of sternum was resected and submitted to pathology. This left the third or fourth rib free-floating and unattached to the sternum. At this point, electrocautery was used to clear the soft tissue from the anterior portion of the sternum. Curettes were used to remove any scar tissue from the medial portion overlying the bone marrow. The same was done for the rib and then attention was turned to the left inferior Hemi sternal, again curetting and removing any scar tissue.
Once this was completed, a single sternal wire was placed from the left inferior hemisternum to the anterior free-floating rib. The inferior hemisternum was reapproximated with 2 double wires. The midportion of the inferior sternum was reapproximated with a single cable sternal plate. Once the double wires were reapproximated, the cable plate was tightened and crimped into place. The plate was then secured to the sternum using a total of 6 anchoring screws. The rib was then reapproximated with a single wire in order to provide more rigidity, a 4 hole straight rib plate was also placed and secured with 14 mm anchoring screws. In order to provide reinforcement to the upper sternum which also had fractured wires and cables, decision was made to place a total of 2 separate 4-hole square sternal plates. Prior to doing so, the sternal table pieces were cut and removed. The first 4-hole plate was placed at the superior manubrium and secured with 14 mm anchoring screws x 4. The second 4-hole plate was placed near the angle of Louis and secured with 14 mm anchoring screws x 4.
I am unsure how many portions of cable and sternal wires were removed, but these were removed out the entirety of the sternal length. The repair was then irrigated with saline and suctioned out. Prior to complete closure, a 19 French round Jackson-Pratt was placed through the anterior mediastinum. The superior abdominal fascia was reapproximated with interrupted 0 Ethibond. The soft tissues were reapproximated with 0 Vicryl in a running fashion. Skin was closed with 4-0 Monocryl in a running subcuticular manner. Dermabond was placed over the wound.
The patient tolerated the procedure well, was extubated, then transferred to recovery.
1. Repair of sternal nonunion with rigid fixation of the sternum
2. Rigid fixation of right rib fracture
3. Lysis of adhesions
4. Removal of sternal hardware (sternal wires and sternal cables)
5. Cardiopulmonary bypass standby
The previous sternotomy scar was opened with a 10 blade scalpel. The deep dermis and subcutaneous tissues were divided with electrocautery. The sternum was identified at its superior portion, as this area was known to be well-healed based on CT scan imaging. The dissection was carried cephalad to the manubrium. A crossing vein was sewn off with interrupted 3-0 silk sutures. Dissection was then carried inferiorly and the sternal none union/dehiscence and sternal fractures were identified. Using a bone hook, the inferior left sternal edge was gently retracted by Mr. B. Electrocautery was then used to free the scarring from the medial edge of the bone extending posteriorly and freeing the left sternal table from the cardiac structures. This was carried up to approximately the level of the third rib. Once this was completed, the soft tissues and fibrous tissue was removed from the medial border of the right inferior hemisternum. Again, the scar tissue was released from posteriorly extending up to the third rib. The third and fourth rib were evaluated. At this area, a free-floating portion of sternum was identified which did been fractured by previous wiring. The free-floating portion of sternum was resected and submitted to pathology. This left the third or fourth rib free-floating and unattached to the sternum. At this point, electrocautery was used to clear the soft tissue from the anterior portion of the sternum. Curettes were used to remove any scar tissue from the medial portion overlying the bone marrow. The same was done for the rib and then attention was turned to the left inferior Hemi sternal, again curetting and removing any scar tissue.
Once this was completed, a single sternal wire was placed from the left inferior hemisternum to the anterior free-floating rib. The inferior hemisternum was reapproximated with 2 double wires. The midportion of the inferior sternum was reapproximated with a single cable sternal plate. Once the double wires were reapproximated, the cable plate was tightened and crimped into place. The plate was then secured to the sternum using a total of 6 anchoring screws. The rib was then reapproximated with a single wire in order to provide more rigidity, a 4 hole straight rib plate was also placed and secured with 14 mm anchoring screws. In order to provide reinforcement to the upper sternum which also had fractured wires and cables, decision was made to place a total of 2 separate 4-hole square sternal plates. Prior to doing so, the sternal table pieces were cut and removed. The first 4-hole plate was placed at the superior manubrium and secured with 14 mm anchoring screws x 4. The second 4-hole plate was placed near the angle of Louis and secured with 14 mm anchoring screws x 4.
I am unsure how many portions of cable and sternal wires were removed, but these were removed out the entirety of the sternal length. The repair was then irrigated with saline and suctioned out. Prior to complete closure, a 19 French round Jackson-Pratt was placed through the anterior mediastinum. The superior abdominal fascia was reapproximated with interrupted 0 Ethibond. The soft tissues were reapproximated with 0 Vicryl in a running fashion. Skin was closed with 4-0 Monocryl in a running subcuticular manner. Dermabond was placed over the wound.
The patient tolerated the procedure well, was extubated, then transferred to recovery.