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Mini-Bentall Procedure and Hemiarch Replacement: Mini-Sternotomy

Tuesday, April 18, 2017

In this video, the first in a seven-part series, Tristan Yan demonstrates how to perform a mini-sternotomy via a 5 cm access incision.

  1. The body surface anatomy is clearly marked with a marking pen, depicting the positions of the supra-sternal notch, sterno-manubrial junction, second to fourth intercostal spaces, the inferior extent of xiphoid cartilage, and bilateral femoral arteries.
  2. A midline skin incision is performed from 1 cm above the manubrio-sternal junction to the level of the third intercostal space. A cutaneous flap is developed with a diathermy hand-piece along the prepectoral fascia.
  3. A 14 Fr Jackson Pratt drain (Cardinal Health, McGaw Park, IL, USA) is inserted through the skin at the level of fourth parasternal space on the left side and positioned in the subcutaneous space. This is used for CO2 inflow during the case and as a subcutaneous drain at the completion of the operation.
  4. A mini-sternotomy is performed using a hand-held electrical saw from the superior extent of the manubrium. In this case, a left-sided, reversed “J” hemi-sternotomy is performed to maximize exposure of the aortic arch.
  5. The pericardium is opened longitudinally to the pericardial reflection superiorly and the level of fourth intercostal space inferiorly. Three pericardial traction sutures are placed on each side. They are hitched up and tied securely to the edges of the skin incision.
  6. A minimally invasive sternal retractor is placed over the pericardial edges and opened up gradually. In doing so, the sternum is spread open, together with the pericardium, which anteriorizes the ascending aorta. The access would adequately expose the aorta from the level of the sinotubular junction to that of the distal ascending aorta. It is possible to perform aortic valve replacement, aortic root replacement, ascending aortic replacement, and/or hemi-arch replacement through this 5 cm access incision.

View all videos in this series here.


Interesting technique to protect the Mammary artery. I used to make a left-to right- mini-sternotomy to replace the aortic valve and had to sacrifice both mammaries. Makes me curios to see how the procedure goes on ! How do you avoid breaking the saw-blade?
You will see how it goes next week ! We are doing a weekly series of 7 videos. I hope I am not giving anything away by saying that there is a happy ending for the last episode !!
I usually perform a mini-sternotomy using a hand-held electrical saw from the superior extent of the manubrium. The division follows a curvilinear path, more like a “⎭’, rather than an “L”, and is terminated either to the right or left para-sternal space. One advantage to the right (a “⎭” mini-sternotomy) is gaining easier access to the right superior pulmonary vein for venting. The main advantage of doing a mini-sternotomy to the left (a “⎩” mini-sternotomy) is increasing the exposure of the proximal arch, especially if a concomitant hemi-arch or total arch replacement is anticipated. In addition, the minor sternal block is lifted slightly on the left side, so the exposure is better for the operating surgeon and it is easier to put in the annular sutures along the right coronary annulus. If you follow a curvilinear path and not force the saw to create a sharp turn, the saw blade should not break and the sternal integrity is better. I think that an “L” shaped division may weaken the main sternal plate at its turning point.

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