HOW TO DO IT
Modified Robicsek Technique for Complicated Sternal Closure Giuseppe Tavilla, MD, Jacques A. M. van Son, MD, PhD, A d F. Verhagen, MD, and Leon K. Lacquet, MD Department of Thoracic and Cardiac Surgery, University Hospital Nijmegen St. Radboud, Nijmegen, The Netherlands
A modification of the technique described by Robicsek and associates for treatment of sternum separation after open heart operation is described. The technique consists of placing four interlocking steel wires parasternally on both sides and then including them in the usual transverse peristernal wires. (Ann Thorac Surg 1991;52:1179-80)
T
here has been an increase in sternal wound complications since median sternotomy has become the standard approach for most cardiac and mediastinal surgical procedures. The incidence of major wound complications has been reported to range between 0.7% and 1.9% [l-51 with a mortality rate between 10.3% and 39.6% [l, %5]. To achieve maximum sternal stability, the use of the figure-of-8 suture technique has been described in various articles with good results [6-8], but this technique is in most cases not sufficient if it has previously failed to provide stable sternal approximation, which is frequently the case if the sternum is fragmented transversely at multiple locations. We describe a technique of sternal approximation that is a modification of the technique described by Robicsek and associates [9].
been reached, taking care to avoid injury of the mammary vessels. Finally, the transverse wires are tightened, thus providing lateral reinforcement to the closure (Fig 3 ) .
Comment We have used this modified Robicsek technique in 3 patients with osteoporotic sterna in whom complete sternal dehiscence with multiple transverse sternal fractures developed postoperatively owing to severe coughing. Chest roentgenograms revealed excellent sternal apposition with no detectable separation in all patients. At 5 months' follow-up there was still no evidence of sternal separation. We believe this technique should not be used routinely but seems to be useful in the stabilization of complicated sternal dehiscence, especially in the presence of multiple transverse fractures of the sternum. The described technique is easy to perform, and its advantage is that it provides good lateral stability. Once the transverse peristernal steel wires have been tightened, a cage is formed in which the tension is equally distributed over the entire sternal surface.
Technique Four stainless steel wires are placed parasternally on both sides. The first wire is passed through the manubrium and through the second intercostal space and then twisted, so that a ring is formed. The second suture is placed through the second and third intercostal spaces in an interlocking fashion with the first wire. This series of four interlocking steel wires is continued until the end of the sternum is reached, with the fourth wire through the fifth intercostal space (Fig 1).Placing all four wires creates a chain on both sides of the sternum (Fig 2). Subsequently, two transverse transmanubrial wires are placed laterally to both proximal parasternal wires. From proximal to distal, further transverse sternal wires are placed in the intercostal spaces until the fifth intercostal space has Accepted for publication July 12, 1991 Address reprint requests to Dr Tavilla, Department of Thoracic and Cardiac Surgery, University Hospital Nijmegen St. Radboud, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
0 1991 by The Society of Thoracic Surgeons
Fig 1 . Placement offour interlocking parasternal steel wires.
0003-4975/91/$3.50
1180
A n n Thorac Surg 1991;52:1179-80
HOW T O DO IT TAVILLA ET AL REFIXATION OF STERNAL DEHISCENCE
References Fig 2. A parasternal chain on both sides of the sternum has been created (sagittal view).
Fig 3 . Final aspect: the two parasternal chains are completed with the usual peristernal wires.
1. Grossi EA, Culliford AT, Krieger KH, et al. A survey (of 77 maior infectious comulications of median sternotomy: a review of 7,949 consecutive operative procedures. Ann Thorac Surg 1985;40:214-23. 2. Sarr MG, Gott VL, Townsend TR. Mediastinal infection after cardiac surgery. Ann Thorac Surg 1984;38:41523. 3. Loop FD, Lytle BW, Cosgrove DM, et al. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179-87. 4. Culliford AT, Cunningham JN Jr, Zeff RH, Isom OW, Teilto P, Spencer FC. Sternal and costochondral infections following open-heart surgery: a review of 2,594 cases. J Thorac Cardiovasc Surg 1976;72:71&26. 5 . Ottino G, De Paulis R, Pansini S, et al. Major sternal wound infection after open-heart surgery: a multivariate analysis of risk factors in 2,579 consecutive operative procedures. Ann Thorac Surg 1987;44:173-9. 6. Taber RE, Madaras J. Prevention of sternotomy wound disruptions by use of figure-of-eight pericostal sutures. Ann Thorac Surg 1969;8:367-9. 7. Goodman G, Palatianos GM, Bolooki H. Technique of closure of median sternotomy with trans-sternal figure-of-eight wires. J Cardiovasc Surg 1986;27:512-3. 8. Di Marco RF Jr, Lee MW, Bekoe S, Grant KJ, Woelfel GF, Pellegrini RV. Interlocking figure-of-8 closure of the sternum. Ann Thorac Surg 1989;47:927-9. 9. Robicsek F, Daugherty HK, Cook JW. The prevention and treatment of sternum separation following open-heart surgery. J Thorac Cardiovasc Surg 1977;73:267-8.
Modified Robicsek Technique for Complicated Sternal Closure Giuseppe Tavilla, MD, Jacques A. M. van Son, MD, PhD, A d F. Verhagen, MD, and Leon K. Lacquet, MD Department of Thoracic and Cardiac Surgery, University Hospital Nijmegen St. Radboud, Nijmegen, The Netherlands
A modification of the technique described by Robicsek and associates for treatment of sternum separation after open heart operation is described. The technique consists of placing four interlocking steel wires parasternally on both sides and then including them in the usual transverse peristernal wires. (Ann Thorac Surg 1991;52:1179-80)
T
here has been an increase in sternal wound complications since median sternotomy has become the standard approach for most cardiac and mediastinal surgical procedures. The incidence of major wound complications has been reported to range between 0.7% and 1.9% [l-51 with a mortality rate between 10.3% and 39.6% [l, %5]. To achieve maximum sternal stability, the use of the figure-of-8 suture technique has been described in various articles with good results [6-8], but this technique is in most cases not sufficient if it has previously failed to provide stable sternal approximation, which is frequently the case if the sternum is fragmented transversely at multiple locations. We describe a technique of sternal approximation that is a modification of the technique described by Robicsek and associates [9].
been reached, taking care to avoid injury of the mammary vessels. Finally, the transverse wires are tightened, thus providing lateral reinforcement to the closure (Fig 3 ) .
Comment We have used this modified Robicsek technique in 3 patients with osteoporotic sterna in whom complete sternal dehiscence with multiple transverse sternal fractures developed postoperatively owing to severe coughing. Chest roentgenograms revealed excellent sternal apposition with no detectable separation in all patients. At 5 months' follow-up there was still no evidence of sternal separation. We believe this technique should not be used routinely but seems to be useful in the stabilization of complicated sternal dehiscence, especially in the presence of multiple transverse fractures of the sternum. The described technique is easy to perform, and its advantage is that it provides good lateral stability. Once the transverse peristernal steel wires have been tightened, a cage is formed in which the tension is equally distributed over the entire sternal surface.
Technique Four stainless steel wires are placed parasternally on both sides. The first wire is passed through the manubrium and through the second intercostal space and then twisted, so that a ring is formed. The second suture is placed through the second and third intercostal spaces in an interlocking fashion with the first wire. This series of four interlocking steel wires is continued until the end of the sternum is reached, with the fourth wire through the fifth intercostal space (Fig 1).Placing all four wires creates a chain on both sides of the sternum (Fig 2). Subsequently, two transverse transmanubrial wires are placed laterally to both proximal parasternal wires. From proximal to distal, further transverse sternal wires are placed in the intercostal spaces until the fifth intercostal space has Accepted for publication July 12, 1991 Address reprint requests to Dr Tavilla, Department of Thoracic and Cardiac Surgery, University Hospital Nijmegen St. Radboud, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
0 1991 by The Society of Thoracic Surgeons
Fig 1 . Placement offour interlocking parasternal steel wires.
0003-4975/91/$3.50
1180
A n n Thorac Surg 1991;52:1179-80
HOW T O DO IT TAVILLA ET AL REFIXATION OF STERNAL DEHISCENCE
References Fig 2. A parasternal chain on both sides of the sternum has been created (sagittal view).
Fig 3 . Final aspect: the two parasternal chains are completed with the usual peristernal wires.
1. Grossi EA, Culliford AT, Krieger KH, et al. A survey (of 77 maior infectious comulications of median sternotomy: a review of 7,949 consecutive operative procedures. Ann Thorac Surg 1985;40:214-23. 2. Sarr MG, Gott VL, Townsend TR. Mediastinal infection after cardiac surgery. Ann Thorac Surg 1984;38:41523. 3. Loop FD, Lytle BW, Cosgrove DM, et al. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179-87. 4. Culliford AT, Cunningham JN Jr, Zeff RH, Isom OW, Teilto P, Spencer FC. Sternal and costochondral infections following open-heart surgery: a review of 2,594 cases. J Thorac Cardiovasc Surg 1976;72:71&26. 5 . Ottino G, De Paulis R, Pansini S, et al. Major sternal wound infection after open-heart surgery: a multivariate analysis of risk factors in 2,579 consecutive operative procedures. Ann Thorac Surg 1987;44:173-9. 6. Taber RE, Madaras J. Prevention of sternotomy wound disruptions by use of figure-of-eight pericostal sutures. Ann Thorac Surg 1969;8:367-9. 7. Goodman G, Palatianos GM, Bolooki H. Technique of closure of median sternotomy with trans-sternal figure-of-eight wires. J Cardiovasc Surg 1986;27:512-3. 8. Di Marco RF Jr, Lee MW, Bekoe S, Grant KJ, Woelfel GF, Pellegrini RV. Interlocking figure-of-8 closure of the sternum. Ann Thorac Surg 1989;47:927-9. 9. Robicsek F, Daugherty HK, Cook JW. The prevention and treatment of sternum separation following open-heart surgery. J Thorac Cardiovasc Surg 1977;73:267-8.
