Diathermy – monopolar, setting 7, ball and short spatula ends
Forceps – non-toothed
Swabs – large and small, large towels
Sucker – Yankauer
Sternal reciprocating saw
Sternal retractor
Bone wax
Procedure
Marking the midline.
Find the sternal notch, angle of Louis and the xiphisternum and visualise a straight line joining them. Place a finger each on the lateral edges of the sternum at both second intercostal spaces to find the midline.
If the xiphisternum is difficult to feel, follow the costal margins up to come to the middle.
A marking pen, the closed tips of the forceps, or a heavy silk tie stretched across the skin, may be used to mark the midline.
Skin incision
Use a curved scalpel blade to cut the skin from just below the sternal notch to below the xiphisternum. Lift up the wrist to see the direction taken.
Use diathermy (setting 8) with a short blade to cut the subcutaneous fat and achieve haemostasis. Use a swab and non-toothed forceps to assist in haemostasis.
Jugular notch dissection
Lift up the skin above the jugular notch and use the diathermy to dissect down. Stay close to the bone, and do not delve blindly into the notch with the diathermy blade.
The anterior jugular bridging veins are liga-clipped and ligated using the diathermy.
Use a finger to sweep under the manubrium to clear and soft tissue under the posterior table.
Identify the interclavicular ligament and pull it up with a finger which protects the underlying structures as diathermy is applied to it.
Xiphoid dissection
Identify the superior attachment of the rectus muscles and the linea alba. Create a space just at the tip of the xiphoid to pass a finger or scissors.
A thorough finger sweep is performed to clear any sterno-pericardial or pleural soft tissue.
Use a Mayo straight scissors to bisect the cartilaginous xiphoid. This space is for passing the sternal saw.
Identify the periosteum of the sternum and make a marking cut in the midline using the diathermy. Find the space in the midline where there are no muscle fibres. At this point the intercostal spaces are easier to palpate.
Dividing the sternum
Ask the anaesthetist to deflate the lungs.
Test the saw before using by flicking the safety off. Ensure the air supply hose for the saw does not get kinked as it will stop working.
Insert the reciprocating saw at the sternal notch in the midline. Ensure it is flush against the bone and its bottom edge against the posterior table of the sternum.
Make a cutting motion forwards 4-5cm and move the saw backwards to clear the soft tissue. Carry on forwards again with another cutting motion and backwards the same amount until the sternum is cut, pulling up on the saw along the line previously marked on the periosteum.
Ask the anaesthetist to resume ventilation.
Haemostasis of the sternum
Insert a large swab into the wound pushing down the pericardium.
Haemostasis is methodical from superficial to deep, inferior to superior, using diathermy and forceps, at the superificial and deep sternal periosteal edges. Each sternal edge may be exposed by lifting it with left index and middle fingers. Bone wax is applied to the sternal bone marrow space.
Towels are placed on either side of the incision with their edges covering the sternal marrow space, but not further in.
Exposure and haemostasis of the neck and pericardium
The sternal retractor is placed with its handle on the left inferiorly, and the blades on the lower third of the incision and opened, such that the angle superiorly is smaller than the inferior part.
Pericardial and thymic vessels are coagulated using diathermy.
The fatty remnants of the thymus is also divided, blood vessels may be encountered here as well. They may be bluntly pushed away from the pericardium.
Pericardial dissection
Divide the pericardium by lifting it up with forceps and incising it gently with the diathermy to create a hole.
Continue dissecting the pericardium inferiorly in a straight line parallel to the aorta with the diathermy. At the inferior extent, 1-2cm above the diaphragmatic surface, dissect left and right in an inverted-T manner.
The superior portion of the pericardium is opened using McIndoe’s scissors to avoid thermal injury to the aorta. The pericardium is opened directly over the ascending aorta to the pericaridal reflection.
Pericardial traction sutures
Using silk sutures, take two bites of the pericardium and approximate it against the skin.