Needle-holder – heavy for wires and wire-twisting, other for skin
Sutures – steel wire for sternum, absorbable for skin
Procedure
Haemostasis in the pericardial cavity is achieved before closing the sternum. Pericardial and pleural drains placements are checked and unclamped.
Pericardial stay sutures are removed.
The sternal retractor is removed.
A large swab is inserted over the pericardium.
The assistant lifts the hemi-sternum on one side using double-hook retractors (Brompton Erector Spinae retractor) to allow visualisation and haemostasis on the underside. This is repeated on the other hemi-sternum.
Diathermy (with or without forceps, also using ball-tip diathermy) or transfixing sutures may be required to achieve haemostasis.
Heavy needle-holders are used to drive steel wire needles through the sternum starting superiorly in the manubrium, from starting from outside to inside. The bites are placed approximately >1-1.5cm from the edge of the wound.
The needle is grasped closer to its tip to push it through the bone without bending it.
The free end of the wire is protected and grasped by Kocher’s forceps or similar.
Driving the needle into the sternum from outside can lead to a jerk that causes the needle to advance further than intended and cause damage to the beating heart. The sternum is therefore lifted and the needle visualised at all times to avoid this from happening.
Depending on the length of the wires, a continuous suture-line is undertaken, with the bites about 1.5-2cm apart.
The needle is then cut and the cut end of the wire wrapped around forceps.
This is repeated through the whole length of the sternum.
If continuous suture are placed, they are cut to make interrupted sutures and the free ends protected as before.
After wire placement, the large swab is removed.
Ask the scrub nurse to check that all swab and instrument counts are correct before closing the chest.
Double hooks are again used to lift each side of the sternum to achieve haemostasis, particularly in the wire sites under the sternum and in the neck. Bone wax may be used again if needed. Other surgical haemostatic agents may also be used.
After haemostasis of the sternal surfaces, the ends of each pair of wires are crossed over individually.
With the help of the assistant, the bottom and top groups of wires are pulled tight.
While the assistant maintains tension, each pair of wires is twisted tight.
Wire-cutters (Muller Claus) are used to cut the twisted ends leaving approximaly 1-1.5cm tall ends.
Wire-twisters (Berry sternal needle holder) are used to grasp the twisted ends, lift up the sternum to pull the wire tight and twist more to further tighten the wire.
The tightened ends are then bent to bury them flat with the sharp ends pointing deep.
Final haemostasis, particularly in the neck, is checked.
The skin is closed in at least 3 layers. The deepest layer grabs the periosteum and muscle in a continuous manner.