[[300 Technical Outline of Coronary Artery Bypass Grafting]] [[400 Technical Outline of Aortic Valve Replacement]] [[500 Technical Outline of Mitral Valve Replacement]] [[600 Technical Outline of Mitral Valve Repair]] [[700 Technical Outline of Repair of Aortic Dissection]] # Sternotomy Skin Incision - Begin incision halfway down the length of the manubrium using 10 blade scalpel to dermal depth - Can always be extended later - End incision at end of sternum, beginning of xyphoid - Can always be extended later - Go through dermis with electrocautery on coagulate - Take incision through the sternal fat down to the periosteum with electrocautery on coagulate - Mark midline of stenum along its length by burning through periosteum down to bone with electrocautery on coagulate on high power. - Begin over xyphoid and bottom sternum - Fascial fibers inserting on to periosteum show midline very clearly here - Slowly cauterize area where xyphoid joins sternum to deliberately close large vein usually present before cutting, preventing annoying blood loss and jokes from attending about the "Vein of Oshit" - Create a line in the periostium at the midline up to the leve of the end of the insertion of the false ribs - Move to sternal notch and lightly score overlying fascia with medium power cautery - Insert finger through fascia, pull towards chin, creating space above manubrium - Look for large veins crossing midline - Double clip each side or coagulate depending on size - If bleeding difficult to control because of limited exposure, pack notch with lap while remaining steps performed. After sternotomy, this area will have much better exposure. - Continue cautery until deep cervical thoracic fascia reached, switch fingers as necessary because of heat generated - Carefully cut through deep cervical thoracic fascia with bovie inclined behind manubrium until bone is exposed - Excessive depth may injure innominate artery - Very important to [[clear cervical thoracic fascia from manubrium in preparation for sternal saw]]. - Probe for the midline at mid manubrium and mark it with bovie - Probe for the midline at prominent rib space below the angle of Louis and mark it with bovie - Connect the dots between sternal notch, mid manubrium, and prominent rib space - This line should be collinear with the line at the xyphoid. - Additional midline points can be marked by assessing midline by probing intercostal spaces on either side with a kelly clamp - Burn the midline along the length of the sternum through the periosteum with high power coagulation electrocautery