How to Do It
A novel modified Robicsek technique for sternal closure: ‘‘Double-check’’
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(6) 758–760 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313497207 aan.sagepub.com
Gokhan Lafci1, Emre Yasar1, Omer Faruk Cicek1, Ahmet Irdem1, Alper Uzun2 and Adnan Yalcinkaya3
Abstract A median sternotomy is the most common approach for cardiac and great vessel surgery. After a median sternotomy, healing complications such as instability, nonunion, and infection, are rare but devastating. Predisposing factors for sternal complications are old age, diabetes, steroid treatment, postmenopause state, obesity, reoperation, and the use of bilateral internal mammary arteries. Patients with sternal dehiscence frequently require reoperation to maintain optimum sternal stability. The technique chosen for sternal closure must provide excellent sternal approximation. We describe a modified Robicsek procedure reinforced with figure-of-8 sternal wires. We named this technique ‘‘double-check’’.
Keywords Bone wires, fracture fixation, internal, sternotomy, sternum, thoracic surgical procedures
Introduction A median sternotomy is the most common approach for cardiac and great vessel surgery. After a median sternotomy, healing complications such as instability, nonunion, and infection are rare, ranging between 0.3% and 5%, but devastating.1 Predisposing factors for sternal complications are old age, diabetes, steroid treatment, postmenopause state, obesity, reoperation, and the use of bilateral internal mammary arteries.2 Patients with sternal dehiscence frequently require reoperation to maintain optimum sternal stability. The technique chosen for sternal closure must provide excellent sternal approximation. In this article, we describe a modified Robicsek procedure reinforced with figure-of8 sternal wires. We named this technique ‘‘doublecheck’’.
Technique We begin at the lowermost aspect of the sternal wound with no 7. stainless steel wires and proceed longitudinally upward. Uninterrupted suture is inserted outside-in through an intercostal space and inside-out through the cephalad intercostal space. Wires are placed through the manubrium at the upper sternum. The suturing is
then reversed and led caudally in a similar fashion and tied. This procedure is applied to both sternal halves. Four figure-of-8 wires were passed lateral to the longitudinal wires, aiming to reinforce them. The first figureof-8 wire is passed through the manubrium, and the other wires are passed through the intercostal spaces. A second pair of longitudinal wires were placed 2 cm lateral to the first Robicsek line on both halves of the sternum. In contrast to the first medial longitudinal wires, the lateral wires were passed only through the costae. In this manner, we prevent the sternal wires from cutting through the intercostal space and becoming loose. Thus we maximize the strength of the first modified Robicsek line. Four additional figure-of-8 1 Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey 2 Department of Cardiovascular Surgery, Ankara Research and Education Hospital, Ankara, Turkey 3 Department of Cardiovascular Surgery, Corum State Hospital, Corum, Turkey
Corresponding author: Omer Faruk Cicek, MD, Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Sihhiye 06100, Ankara, Turkey. Email: [email protected]
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Figure 1. Intraoperative step-by-step view of the technique.
Figure 3. Postoperative 3-dimensional computed tomography showing an inside wire through the cephalad intercostal space (A), an inside figure-of-8 wire (B), an outside wire through the cephalad intercostal space (C), and an outside figure-of-8 wire (D).
Figure 2. Final appearance of the ‘‘double-check’’ technique.
wires are placed lateral to the second pair of longitudinal wires to support them (Figures 1 and 2).
Discussion We first used this technique in a 68-year-old diabetic and severely obese patient who underwent eventless 3vessel coronary artery bypass surgery. Four figure-of-8 sternal wires were used for sternal closure in the primary surgery. He was readmitted due to sternal motion
and instability on the 27th day after discharge. Sternal dehiscence was confirmed by physical examination and chest radiography. There was no evidence of infection, but the wires had cut into the sternum on both sternal halves transversally. We performed double-check technique to the patient. There was no sternal complication detected at the 2-month routine follow-up. Computed tomography verified satisfactory sternal union (Figure 3). The success of this case encouraged us to perform the same procedure on 3 more cases. At the 1-month follow-up, sternal infection had developed in one patient who has already been operated on for
Downloaded from aan.sagepub.com at University of Manchester Library on March 26, 2015
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Asian Cardiovascular & Thoracic Annals 22(6)
repair of deep sternal infection-related sternal dehiscence. All other patients healed uneventfully with no need for a sternal corset. Throughout the years various techniques and materials have been described and used for sternal closure.3 Transsternal-peristernal intermittent wiring and the figure-of-8 technique are among the most commonly used. In 1977, Robicsek and colleagues4 described an alternative method with bilateral and longitudinal running wires that stabilize the fragile and broken sternum. Several modifications of the Robicsek technique have been reported in the subsequent decades. Sharma and colleagues5 placed continuous wire suture on both side of the sternum and tied the lines cranially and caudally. Besides the commonly used simple techniques, the Robicsek procedure and its modifications still remain the gold standard for high-risk patients.6 Our technique includes the double line of the modified Robicsek procedure applied longitudinally to both sides of the sternum combined with a double row of figure-of-8 sutures reinforcing each pair of longitudinal suture lines. It doubles the strength of the sternum with excellent sternal apposition and no additional cost, unlike titanium plates and thermoreactive clips which both require additional cost and might be unavailable at the time of surgery. In our technique, reinforcing sutures contribute to the resistance of the sternum and abolish the requirement for a sternal corset, which restricts breathing. On the other hand, several studies have suggested that excessive usage of sternal wires, as in our technique, might be associated with sternal wound infections and bleeding.7 Using our technique, we detected sternal infection in only one patient, who had already been operated on for repair of deep sternal infection-related sternal dehiscence, but we did not observe any bleeding complication. Another point to consider is that sternal reentry might be challenging in emergency situations due to our procedure’s complexity. The ideal sternal closure technique should be easily applicable, cost-effective, and reliable, but proper patient selection is as crucial as the technique itself.
We propose that our double-check technique should be used especially for repair of the sternal dehiscence or broken sternum of a previous surgery. However, in patients with multiple risk factors for sternal complications (older patients with osteoporosis, diabetes, steroid treatment, obesity, bilateral internal mammary artery use) or in those with chronic cough, it could be performed as a prophylactic approximation technique against sternal dehiscence. This technique is not only simple and cost-effective but also beneficial in the case of lack of advanced alternative materials. Declaration of conflicting interest The authors declare that there is no conflict of interest.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Losanoff JE, Collier AD, Wagner-Mann CC, et al. Biomechanical comparison of median sternotomy closures. Ann Thorac Surg 2004; 77: 203–209. 2. Al Ebrahim K. Reinforced sternal closure: the bilateral straight longitudinal wire technique. Asian Cardiovasc Thorac Ann 2003; 11: 90–91. 3. Tasoglu I and Lafci G. Novel longitudinal plate-fixation technique after gross resection of the sternum. Tex Heart Inst J 2012; 39: 215–217. 4. Robicsek F, Daugherty HK and Cook JW. The prevention and treatment of sternum separation following open heart surgery. J Thorac Cardiovasc Surg 1977; 73: 267. 5. Sharma R, Puri D, Panigrahi BP and Virdi IS. A modified parasternal wire technique for prevention and treatment of sternal dehiscence. Ann Thorac Surg 2004; 77: 210–213. 6. Schimmer C, Sommer SP, Bensch M, Bohrer T, Aleksic I and Leyh R. Sternal closure techniques and postoperative sternal wound complications in elderly patients. Eur J Cardiothorac Surg 2008; 34: 132–138. 7. Casha AR, Yang L, Kay PH, Saleh M and Cooper GJ. A biomechanical study of median sternotomy closure techniques. Eur J Cardiothorac Surg 1999; 15: 365–369.
Downloaded from aan.sagepub.com at University of Manchester Library on March 26, 2015
A novel modified Robicsek technique for sternal closure: ‘‘Double-check’’
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(6) 758–760 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313497207 aan.sagepub.com
Gokhan Lafci1, Emre Yasar1, Omer Faruk Cicek1, Ahmet Irdem1, Alper Uzun2 and Adnan Yalcinkaya3
Abstract A median sternotomy is the most common approach for cardiac and great vessel surgery. After a median sternotomy, healing complications such as instability, nonunion, and infection, are rare but devastating. Predisposing factors for sternal complications are old age, diabetes, steroid treatment, postmenopause state, obesity, reoperation, and the use of bilateral internal mammary arteries. Patients with sternal dehiscence frequently require reoperation to maintain optimum sternal stability. The technique chosen for sternal closure must provide excellent sternal approximation. We describe a modified Robicsek procedure reinforced with figure-of-8 sternal wires. We named this technique ‘‘double-check’’.
Keywords Bone wires, fracture fixation, internal, sternotomy, sternum, thoracic surgical procedures
Introduction A median sternotomy is the most common approach for cardiac and great vessel surgery. After a median sternotomy, healing complications such as instability, nonunion, and infection are rare, ranging between 0.3% and 5%, but devastating.1 Predisposing factors for sternal complications are old age, diabetes, steroid treatment, postmenopause state, obesity, reoperation, and the use of bilateral internal mammary arteries.2 Patients with sternal dehiscence frequently require reoperation to maintain optimum sternal stability. The technique chosen for sternal closure must provide excellent sternal approximation. In this article, we describe a modified Robicsek procedure reinforced with figure-of8 sternal wires. We named this technique ‘‘doublecheck’’.
Technique We begin at the lowermost aspect of the sternal wound with no 7. stainless steel wires and proceed longitudinally upward. Uninterrupted suture is inserted outside-in through an intercostal space and inside-out through the cephalad intercostal space. Wires are placed through the manubrium at the upper sternum. The suturing is
then reversed and led caudally in a similar fashion and tied. This procedure is applied to both sternal halves. Four figure-of-8 wires were passed lateral to the longitudinal wires, aiming to reinforce them. The first figureof-8 wire is passed through the manubrium, and the other wires are passed through the intercostal spaces. A second pair of longitudinal wires were placed 2 cm lateral to the first Robicsek line on both halves of the sternum. In contrast to the first medial longitudinal wires, the lateral wires were passed only through the costae. In this manner, we prevent the sternal wires from cutting through the intercostal space and becoming loose. Thus we maximize the strength of the first modified Robicsek line. Four additional figure-of-8 1 Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey 2 Department of Cardiovascular Surgery, Ankara Research and Education Hospital, Ankara, Turkey 3 Department of Cardiovascular Surgery, Corum State Hospital, Corum, Turkey
Corresponding author: Omer Faruk Cicek, MD, Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Sihhiye 06100, Ankara, Turkey. Email: [email protected]
Downloaded from aan.sagepub.com at University of Manchester Library on March 26, 2015
Lafci et al.
759
Figure 1. Intraoperative step-by-step view of the technique.
Figure 3. Postoperative 3-dimensional computed tomography showing an inside wire through the cephalad intercostal space (A), an inside figure-of-8 wire (B), an outside wire through the cephalad intercostal space (C), and an outside figure-of-8 wire (D).
Figure 2. Final appearance of the ‘‘double-check’’ technique.
wires are placed lateral to the second pair of longitudinal wires to support them (Figures 1 and 2).
Discussion We first used this technique in a 68-year-old diabetic and severely obese patient who underwent eventless 3vessel coronary artery bypass surgery. Four figure-of-8 sternal wires were used for sternal closure in the primary surgery. He was readmitted due to sternal motion
and instability on the 27th day after discharge. Sternal dehiscence was confirmed by physical examination and chest radiography. There was no evidence of infection, but the wires had cut into the sternum on both sternal halves transversally. We performed double-check technique to the patient. There was no sternal complication detected at the 2-month routine follow-up. Computed tomography verified satisfactory sternal union (Figure 3). The success of this case encouraged us to perform the same procedure on 3 more cases. At the 1-month follow-up, sternal infection had developed in one patient who has already been operated on for
Downloaded from aan.sagepub.com at University of Manchester Library on March 26, 2015
760
Asian Cardiovascular & Thoracic Annals 22(6)
repair of deep sternal infection-related sternal dehiscence. All other patients healed uneventfully with no need for a sternal corset. Throughout the years various techniques and materials have been described and used for sternal closure.3 Transsternal-peristernal intermittent wiring and the figure-of-8 technique are among the most commonly used. In 1977, Robicsek and colleagues4 described an alternative method with bilateral and longitudinal running wires that stabilize the fragile and broken sternum. Several modifications of the Robicsek technique have been reported in the subsequent decades. Sharma and colleagues5 placed continuous wire suture on both side of the sternum and tied the lines cranially and caudally. Besides the commonly used simple techniques, the Robicsek procedure and its modifications still remain the gold standard for high-risk patients.6 Our technique includes the double line of the modified Robicsek procedure applied longitudinally to both sides of the sternum combined with a double row of figure-of-8 sutures reinforcing each pair of longitudinal suture lines. It doubles the strength of the sternum with excellent sternal apposition and no additional cost, unlike titanium plates and thermoreactive clips which both require additional cost and might be unavailable at the time of surgery. In our technique, reinforcing sutures contribute to the resistance of the sternum and abolish the requirement for a sternal corset, which restricts breathing. On the other hand, several studies have suggested that excessive usage of sternal wires, as in our technique, might be associated with sternal wound infections and bleeding.7 Using our technique, we detected sternal infection in only one patient, who had already been operated on for repair of deep sternal infection-related sternal dehiscence, but we did not observe any bleeding complication. Another point to consider is that sternal reentry might be challenging in emergency situations due to our procedure’s complexity. The ideal sternal closure technique should be easily applicable, cost-effective, and reliable, but proper patient selection is as crucial as the technique itself.
We propose that our double-check technique should be used especially for repair of the sternal dehiscence or broken sternum of a previous surgery. However, in patients with multiple risk factors for sternal complications (older patients with osteoporosis, diabetes, steroid treatment, obesity, bilateral internal mammary artery use) or in those with chronic cough, it could be performed as a prophylactic approximation technique against sternal dehiscence. This technique is not only simple and cost-effective but also beneficial in the case of lack of advanced alternative materials. Declaration of conflicting interest The authors declare that there is no conflict of interest.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Losanoff JE, Collier AD, Wagner-Mann CC, et al. Biomechanical comparison of median sternotomy closures. Ann Thorac Surg 2004; 77: 203–209. 2. Al Ebrahim K. Reinforced sternal closure: the bilateral straight longitudinal wire technique. Asian Cardiovasc Thorac Ann 2003; 11: 90–91. 3. Tasoglu I and Lafci G. Novel longitudinal plate-fixation technique after gross resection of the sternum. Tex Heart Inst J 2012; 39: 215–217. 4. Robicsek F, Daugherty HK and Cook JW. The prevention and treatment of sternum separation following open heart surgery. J Thorac Cardiovasc Surg 1977; 73: 267. 5. Sharma R, Puri D, Panigrahi BP and Virdi IS. A modified parasternal wire technique for prevention and treatment of sternal dehiscence. Ann Thorac Surg 2004; 77: 210–213. 6. Schimmer C, Sommer SP, Bensch M, Bohrer T, Aleksic I and Leyh R. Sternal closure techniques and postoperative sternal wound complications in elderly patients. Eur J Cardiothorac Surg 2008; 34: 132–138. 7. Casha AR, Yang L, Kay PH, Saleh M and Cooper GJ. A biomechanical study of median sternotomy closure techniques. Eur J Cardiothorac Surg 1999; 15: 365–369.
Downloaded from aan.sagepub.com at University of Manchester Library on March 26, 2015
