Andersons pediatric cardiology 361
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enhancedrainageandneovascularization,improvingcontrolofinfectionand
enhancingeventualclosure.
Theapproachtothesternumconsideredathighriskfordehiscenceisa
subjectuntoitself.Thoughthishasnotbeenanareaofsignificantconcernin
pediatriccardiacsurgery,asourpatientpopulationages,itmaysoonbecomea
moreimportantconsideration.Thetimeisnearingwhenuptohalfofthose
undergoingsurgeryforcongenitalcardiacdiseasemaybeadults.Asignificant
portionoftheseprocedureswillnecessarilybeperformedthrougha
resternotomy.Whenthepatientisobeseordiabeticorhasundergoneprevious
chestirradiation,thissternumcanbeconsideredatincreasedriskfordehiscence.
Manyofthesepatientswillhaveundergonemultipleprevioussternotomies.Asa
result,bloodsupplytothesternummaybesignificantlyreduced.Indeed,alarge
portionofthesepatientsmayhavelostbothmajorbloodvesselstothesternum,
theinternalmammaryarteries,duringpreviousexplorations.Inadultpatients,
thelossofbothmammaryarterieshasbeenshowntoincreasetheriskofdeep
sternalwoundinfection.17Assuch,additionalmeasuresshouldbeconsidered
withsternalclosure.Doublesternalwires,steelbands,18andsternalplates,19–23
whichreducemovementanddistributestressesinthewoundoverlargerareas,
arestrategiesusedtoclosethesternumathighriskofdehiscence.
Asoutcomeshaveimprovedaftercardiothoracicsurgery,interestin
improvingthecosmesisofincisionshasemerged.Avarietyofminimally
invasivetechniqueshasbeendescribed.Thelongitudinalskinincisionhasbeen
shortenedsignificantlyinsomecases,evenwhenthesternumisdividedfully
alongitslength.Anotherefforthasinvolvedabandoningthelongitudinalskin
incisionaltogether,infavorofasubmammaryortransverseskinincisionwith
creationofskinflapstopermitafullmediansternotomyincision.24,25This
particularincisionhasnotbeenwidelyadoptedsecondarytofearofwound
complicationsandcompromisedexposure,butsomehavereportedexcellent
resultswiththisincisionandverylowratesofcomplication.26–28Itisofnote
thatthemajorityofthesensorysupplytothechestwallenterslaterally.Ifthe
submammaryincisionisappropriatelyperformed,sensorysupplytothebreast
shouldbeuninterrupted.28Itisalsoimportantthatthisincisionismadebelow
themammarytissuewithinthebreastcrease.Significantcompromiseto
developmentofthebreastshasresultedwhentheincisionhasbeenmadetoo
high.29
Thoracotomy
Thoracotomyincisionsarecommonlyusedforligationofthepatentarterial
duct,repairofaorticcoarctation,placementofapulmonaryarteryband,and
constructionofasystemic-to-pulmonaryarterialshunt.Aposterolateral
thoracotomyisshowninFig.16.4.Theskinincisionismadeinacurvilinear
fashionalongthepathoftheribs(Fig.16.4A).Inmostinstances,thelatissimus
dorsimuscleisdivided(Fig.16.4B),buttheserratusanteriorisspared(Fig.
16.4C).Theintercostalmusclesaredividedbetweentheribstobespread.At
times,eventhelatissimuscanbespared.Inthisinstance,theapproachtothe
thoraciccavityismadethroughasmallspacebetweenthemuscles,thetriangle
ofauscultation.Incaseswheregreaterexposureisnecessary,especiallyinolder
patients,itmaybenecessarytoresectaribtoobtainidealexposure.Theskin
incisioncanbelimitedcomparedtothelengthoftheincisionwithinthethoracic
cavity.Thisincisionisperformedthroughavarietyofintercostalspaces,
dependingonthelevelforwhichexposureisdesired.Thearterialductandaortic
archaretypicallyapproachedthroughthethirdorfourthintercostalspace.
Exposureforexcisionofpulmonarypathologytypicallyinvolvesanincisionin
thefourthorfifthintercostalspace.Exposurefortreatmentofesophageal
pathologycanbemadethroughtheleftfifththrougheighthintercostalspaces,or
therightfourthorfifthintercostalspaces.Exposuretothediaphragmisusually
throughtheseventhintercostalspace.
FIG.16.4 Posterolateralthoracotomy.(A)Theskinandsubcutaneous
tissuesaredividedwithacombinationoftheknifeandelectrocauteryalong
theindicatedline.Inthemostcommoniterationcurrentlyused,the
latissimusmuscleisdividedandtheserratusanteriorisspared.The
intercostalmusclesintheintercostalspaceofentryarealsodivided.(B)
Undividedlatissimusdorsi.(C)Dividedmusclewiththesparedserratus
anterior.
Thetransversethoracosternotomyincisionisusedwhenthereisneedfor
extensivethoracicexposure(Fig.16.5).Inthisincision,boththoraciccavities
areenteredthroughbilateralanterolateralthoracotomiesthatareconnected
acrossthemidlinebyatransversesternotomy.Thisincisiongivesexcellent
exposuretoallofthemediastinalstructuresanteriorly.Itismostcommonlyused
forbilateralsequentiallungtransplantationbuthasalsobeenusedfor
unifocalizationofaortopulmonarycollateralarteries.Theskinincisioncanbe
madeasindicatedinthefiguretopreservedevelopmentofthebreasts.This
incisionissometimescomplicatedbysternalmalunion,characterizedbya
malalignedsternumwithoutossification.Somehaveabandonedthisincisionfor
thisreason,andprefertoapproachthechestthroughbilateralanterolateral
thoracotomieswithoutdividingthesternum.30Theuseofalternativewiring
techniquesoralternativematerialssuchascablesforsternalapproximationhave
beenreportedandmayreducetheincidenceofcomplicationswiththetransverse
sternotomy.31–33Novelabsorbablesternalpinsforclosureofthe“clamshell”
thoracosternotomyhaverecentlybeenreportedforuseinpatientsthatmaynot
besuitableforbilateralanterolateralthoracotomieswithoutsternaldivision.34
