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Sternotomy
Diane C. Strollo, MD, FACR
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KEY FACTS

  • Terminology

    • Imaging

      • Clinical Issues

        TERMINOLOGY

        • Abbreviations

          • Median sternotomy (MS)
          • Clamshell sternotomy (CS)
        • Synonyms

          • CS: Transverse sternotomy, cross-bow incision
        • Definitions

          • MS: Vertical incision through manubrium & sternum
            • Access to heart & anterior mediastinum
              • Limited access to hila, lungs, pleura
            • Indications
              • Ascending aortic aneurysm or dissection
              • Coronary artery bypass graft (CABG)
              • Cardiac valve repair or replacement
              • Repair of congenital heart disease
              • Orthotopic heart transplant
              • Placement of cardiac support devices
                • Ventricular assist device
                • Extracorporeal membrane oxygenation
              • Chest trauma exploration
              • Pulmonary embolectomy
              • Resection of anterior mediastinal mass
              • Pericardial stripping
              • Double lung transplant in some cases
            • Closure with cerclage or "figure 8" steel sutures
              • 2-3 wires in manubrium, 4-5 in sternum body
              • Heals quickly with stable closure & minimal pain
          • CS: Broad transverse incision across sternum & 4th anterior intercostal spaces
            • Excellent access to heart & both hemithoraces
              • Disrupts sternal pericardial attachments
                • Pleural spaces may communicate anteriorly
                • Chest tube may cross midline anteriorly
              • Indications
                • Double lung or heart-lung transplantation
                • Resection of large mediastinal or cardiac mass
                • Resection of bilateral lung metastases (rare)
            • Closure with steel "figure 8" sternal sutures
              • Extensive disruption of chest wall musculature
              • Increased risk of sternal complications
              • Extended painful recovery

        IMAGING

        • General Features

          • Radiographic Findings

            • CT Findings

              • Imaging Recommendations

                CLINICAL ISSUES

                • Presentation

                  • Natural History & Prognosis

                    • Treatment

                      DIAGNOSTIC CHECKLIST

                      • Consider

                        • Image Interpretation Pearls

                          Selected References

                          1. Losanoff JE et al: Primary closure of median sternotomy: techniques and principles. Cardiovasc Surg. 10(2):102-10, 2002
                          2. Macchiarini P et al: Clamshell or sternotomy for double lung or heart-lung transplantation? Eur J Cardiothorac Surg. 15(3):333-9, 1999
                          3. Bains MS et al: The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg. 58(1):30-2; discussion 33, 1994
                          Related Anatomy
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                          Related Differential Diagnoses
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                          References
                          Tables

                          Tables

                          KEY FACTS

                          • Terminology

                            • Imaging

                              • Clinical Issues

                                TERMINOLOGY

                                • Abbreviations

                                  • Median sternotomy (MS)
                                  • Clamshell sternotomy (CS)
                                • Synonyms

                                  • CS: Transverse sternotomy, cross-bow incision
                                • Definitions

                                  • MS: Vertical incision through manubrium & sternum
                                    • Access to heart & anterior mediastinum
                                      • Limited access to hila, lungs, pleura
                                    • Indications
                                      • Ascending aortic aneurysm or dissection
                                      • Coronary artery bypass graft (CABG)
                                      • Cardiac valve repair or replacement
                                      • Repair of congenital heart disease
                                      • Orthotopic heart transplant
                                      • Placement of cardiac support devices
                                        • Ventricular assist device
                                        • Extracorporeal membrane oxygenation
                                      • Chest trauma exploration
                                      • Pulmonary embolectomy
                                      • Resection of anterior mediastinal mass
                                      • Pericardial stripping
                                      • Double lung transplant in some cases
                                    • Closure with cerclage or "figure 8" steel sutures
                                      • 2-3 wires in manubrium, 4-5 in sternum body
                                      • Heals quickly with stable closure & minimal pain
                                  • CS: Broad transverse incision across sternum & 4th anterior intercostal spaces
                                    • Excellent access to heart & both hemithoraces
                                      • Disrupts sternal pericardial attachments
                                        • Pleural spaces may communicate anteriorly
                                        • Chest tube may cross midline anteriorly
                                      • Indications
                                        • Double lung or heart-lung transplantation
                                        • Resection of large mediastinal or cardiac mass
                                        • Resection of bilateral lung metastases (rare)
                                    • Closure with steel "figure 8" sternal sutures
                                      • Extensive disruption of chest wall musculature
                                      • Increased risk of sternal complications
                                      • Extended painful recovery

                                IMAGING

                                • General Features

                                  • Radiographic Findings

                                    • CT Findings

                                      • Imaging Recommendations

                                        CLINICAL ISSUES

                                        • Presentation

                                          • Natural History & Prognosis

                                            • Treatment

                                              DIAGNOSTIC CHECKLIST

                                              • Consider

                                                • Image Interpretation Pearls

                                                  Selected References

                                                  1. Losanoff JE et al: Primary closure of median sternotomy: techniques and principles. Cardiovasc Surg. 10(2):102-10, 2002
                                                  2. Macchiarini P et al: Clamshell or sternotomy for double lung or heart-lung transplantation? Eur J Cardiothorac Surg. 15(3):333-9, 1999
                                                  3. Bains MS et al: The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg. 58(1):30-2; discussion 33, 1994