Peristernal Closure of Median Stemotomy Using Stainless Steel Bands Samuel L. Kalush, M.D., and Lawrence I. Bonchek, M.D. ABSTRACT Peristernal closure of median ster- patients with severe chronic obstructive pulmonotomy incisions with interrupted stainless steel nary disease who are undergoing median sterbands has proved to be a rapid and safe method for notomy. Figure 1A shows the Parham band with achieving solid internal fixation in approximation of the approximator necessary for its application. the sternum. The method is particularly useful for The remaining instruments needed for band obese patients undergoing sternotomy. closure are a Kocher and a long tonsil clamp There have been no instances of wound dehiscence in addition to a wire cutter. For effective closure, using this technique, and several other advantages three bands easily suffice and are placed penover standard forms of sternal closure are apparent. sternally in the second, third, and fourth intercosThe method is a useful addition to the cardiac sur- tal spaces. Using blunt dissection and remaining geon’s armamentarium. on the lateral bony margins of the sternum, one
With increasing numbers of median sternotomies being performed for open-heart operations, effective sternal closure is essential. As with any surgical wound, secure internal fixation and approximation are required for primary wound healing. Poor reconstruction of the sternum can result in extensive dehiscence and possibly major wound sepsis, leading to a prolonged, morbid postoperative course. Although several techniques of sternal closure have been described [l, 4, 6, 71 and are successful in the vast majority of cases, heavy patients and those with chronic obstructive pulmonary disease are especially prone to sternal dehiscence using these methods. Peristernal approximation of the sternum using interrupted stainless steel bands* has proved to be a most effective method that results in several advantages in sternal closure, especially in heavy patients. This report describes the technique of sternal closure using stainless steel bands.
Method Stainless steel band closure of the sternum is utilized most frequently for heavy patients or From the Division of Cardiopulmonary Surgery, University of Oregon Health Sciences Center, Portland, OR. Accepted for publication Apr 3, 1975. Address reprint requests to Dr. Kalush, 3181 SW Sam Jackson Park Rd, Portland, OR 97201. *Parham bands, Richards Manufacturing Co, 1450 Brooks Rd, Memphis, TN 38116.
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places the band so as to encircle the sternum completely. The band is then closed. Care is taken to avoid injury to the internal mammary artery. With the band connected to the approximator as shown in Figure l B , the band is tightened to close the sternum. The band “buckle” is interlocked, the approximator is removed, and excess band is cut with the wire cutter. The final appearance of the band is as shown in Figure2. The remainder of the sternum is closed in routine fashion.
Results No sternal dehiscences have occurred following closure with stainless steel bands. Operating time is not prolonged, and there have been no major complications related to the use of steel bands. In addition, patients who have had band closure seem to complain less of postoperative pain, which may be due to the solid internal sternum fixation.
Comment Several methods of sternal closure are in use [l, 2,4,71 and, in general, achieve satisfactory fixation and approximation of the sternum for effective wound healing. A notable exception, however, has been peristernal closure using nylon bands as described by LeVeen and Piccone [31. Sanfelippo and Danielson 151, in their follow-up of patients who had nylon band closure, dem-
173 How to Do It: Kalush and Bonchek: Sternotomy Closure with Steel Bands
A
B Fig 1 . ( A ) The Parham band (below) and the approximator. ( B ) The Parham band is connected to the approximator (arrow).
onstrated an unacceptable incidence of major wound dehiscence in addition to breakage and slippage of the nylon bands, resulting in prolonged morbidity due to wound sepsis. Steel, in contrast to nylon, provides solid internal fixation of the sternum for wound healing. There has been no instance of sternal dehiscence
utilizing stainless steel bands. Peristernal steel bands are particularly suitable for obese patients and for those with chronic obstructive pulmonary disease, in whom secure sternal closure may be difficult by other means. Steel band closure eliminates wire or suture knots that might project into the subcutaneous layer of the wound. This not only facilitates wound closure but also eliminates a possible source of discomfort to the patient. For patients who subsequently require reoperation, the steel bands are easily divided with a wire cutter to gain access to the sternum. In addition, patients who have had steel band closure and who require reoperation through the previous median sternotomy have some degree of protection from traumatic cardiotomy since the bands provide a partial layer of steel between the inner table of the sternum and the heart.
References 1. Cabrol C, Le Picard P, Laughlin L: A new sternal
2. 3.
4. 5. 6.
Fig2. Simulation of the band in place with the interlocking joint secured.
7.
perforator for closure of midline sternotomy. J Cardiovasc Surg (Torino) 14:547, 1973 Lambert CJ, Mitchel BF, Adam M, et al: A modified technic for secure median sternotomy closure. Surgery 69:393, 1971 LeVeen HL, Piccone VA: Nylon band chest closure. Arch Surg 9636, 1968 Martin A, Ross A, Braimbridge M V : Peristemal wiring in closure of median stemotomy. J Thorac Cardiovasc Surg 66:145, 1973 Sanfelippo I'M, Dani-elson GK: Nylon bands for closure of median sternotomy incisions: an unacceptable method. Ann Thorac Surg 13:404, 1972 Santos G, Cook WA, Frater RWM: Reclosure of sternotomy disruption produced by hiccups. Chest 66:189, 1974 Timmes JJ, Wolvek S, Fernando M, et al: A new method of sternal approximation. Ann Thorac Surg 15:544, 1973
With increasing numbers of median sternotomies being performed for open-heart operations, effective sternal closure is essential. As with any surgical wound, secure internal fixation and approximation are required for primary wound healing. Poor reconstruction of the sternum can result in extensive dehiscence and possibly major wound sepsis, leading to a prolonged, morbid postoperative course. Although several techniques of sternal closure have been described [l, 4, 6, 71 and are successful in the vast majority of cases, heavy patients and those with chronic obstructive pulmonary disease are especially prone to sternal dehiscence using these methods. Peristernal approximation of the sternum using interrupted stainless steel bands* has proved to be a most effective method that results in several advantages in sternal closure, especially in heavy patients. This report describes the technique of sternal closure using stainless steel bands.
Method Stainless steel band closure of the sternum is utilized most frequently for heavy patients or From the Division of Cardiopulmonary Surgery, University of Oregon Health Sciences Center, Portland, OR. Accepted for publication Apr 3, 1975. Address reprint requests to Dr. Kalush, 3181 SW Sam Jackson Park Rd, Portland, OR 97201. *Parham bands, Richards Manufacturing Co, 1450 Brooks Rd, Memphis, TN 38116.
172
places the band so as to encircle the sternum completely. The band is then closed. Care is taken to avoid injury to the internal mammary artery. With the band connected to the approximator as shown in Figure l B , the band is tightened to close the sternum. The band “buckle” is interlocked, the approximator is removed, and excess band is cut with the wire cutter. The final appearance of the band is as shown in Figure2. The remainder of the sternum is closed in routine fashion.
Results No sternal dehiscences have occurred following closure with stainless steel bands. Operating time is not prolonged, and there have been no major complications related to the use of steel bands. In addition, patients who have had band closure seem to complain less of postoperative pain, which may be due to the solid internal sternum fixation.
Comment Several methods of sternal closure are in use [l, 2,4,71 and, in general, achieve satisfactory fixation and approximation of the sternum for effective wound healing. A notable exception, however, has been peristernal closure using nylon bands as described by LeVeen and Piccone [31. Sanfelippo and Danielson 151, in their follow-up of patients who had nylon band closure, dem-
173 How to Do It: Kalush and Bonchek: Sternotomy Closure with Steel Bands
A
B Fig 1 . ( A ) The Parham band (below) and the approximator. ( B ) The Parham band is connected to the approximator (arrow).
onstrated an unacceptable incidence of major wound dehiscence in addition to breakage and slippage of the nylon bands, resulting in prolonged morbidity due to wound sepsis. Steel, in contrast to nylon, provides solid internal fixation of the sternum for wound healing. There has been no instance of sternal dehiscence
utilizing stainless steel bands. Peristernal steel bands are particularly suitable for obese patients and for those with chronic obstructive pulmonary disease, in whom secure sternal closure may be difficult by other means. Steel band closure eliminates wire or suture knots that might project into the subcutaneous layer of the wound. This not only facilitates wound closure but also eliminates a possible source of discomfort to the patient. For patients who subsequently require reoperation, the steel bands are easily divided with a wire cutter to gain access to the sternum. In addition, patients who have had steel band closure and who require reoperation through the previous median sternotomy have some degree of protection from traumatic cardiotomy since the bands provide a partial layer of steel between the inner table of the sternum and the heart.
References 1. Cabrol C, Le Picard P, Laughlin L: A new sternal
2. 3.
4. 5. 6.
Fig2. Simulation of the band in place with the interlocking joint secured.
7.
perforator for closure of midline sternotomy. J Cardiovasc Surg (Torino) 14:547, 1973 Lambert CJ, Mitchel BF, Adam M, et al: A modified technic for secure median sternotomy closure. Surgery 69:393, 1971 LeVeen HL, Piccone VA: Nylon band chest closure. Arch Surg 9636, 1968 Martin A, Ross A, Braimbridge M V : Peristemal wiring in closure of median stemotomy. J Thorac Cardiovasc Surg 66:145, 1973 Sanfelippo I'M, Dani-elson GK: Nylon bands for closure of median sternotomy incisions: an unacceptable method. Ann Thorac Surg 13:404, 1972 Santos G, Cook WA, Frater RWM: Reclosure of sternotomy disruption produced by hiccups. Chest 66:189, 1974 Timmes JJ, Wolvek S, Fernando M, et al: A new method of sternal approximation. Ann Thorac Surg 15:544, 1973
