- Request Bone Saw - Inspect to make sure it has been assembled properly - Test with two quick applications of trigger or foot pedal - Serves as audio cue to team to be prepared for sternotomy - Ask anesthesia to drop lungs - If patient is a smoker and has known COPD, wait for a longer interval before starting the saw. This will reduce unwanted entry into right pleural space as much as possible. Keep an eye on saturation, but you have plenty of time - Saw through sternum, manubrium to xyphoid, following line of burned periosteum at a controlled deliberate pace - Assistant uses two army-navy retractors on skin and sternum to expose inner table periosteum on left sternal edge - Avoid retracting on sternum anywhere other than Angle of Louis or Sternal-xyphoid junction to avoid fracture of more delicate sterna, or expression of marrow - Move from xyphoid to manubrium - At manubrium, use longer blade of army-navy to pull skin up and away from the top of manubrium - Surgeon uses high power coagulation electrocautery continuously along inner table periosteum - Underneath sternal-xyphoid junction, look for diaphragmatic muscular attachments to sternum and cut these with bovie. When they are substantial, they can interfere with sternal retraction. - Use Olive Tip Plastic Yankauer hooked up to cell saver in other hand to clear blood and to push away the pleura-covered lung that may interfere with visualization - Angle bovie so that 2-3 mm of periosteum coagulated - Devote special attention to the soft tissue on the cephalad surface of the manubrium as it has some tenaciously vascularized tissue. - Surgeon and assistant switch roles to repeat process for right sternal edge. - Assistant lifts left sternal edge with single army-navy at sternal-xyphoid junction while surgeon lightly sprays marrow with thrombin spray and vigorously rubs gelfoam (half a sheet cut lengthwise and rolled up) into marrow as a substitute for bonewax. Pay particular attention to top half of sternum and manubrium. - Gelfoam rub repeated for right sternal marrow, assistant and surgeon switch roles - Surgeon and assistant each retract sternum open with army-navy retractor at sternal-xyphoid junction while surgeon slides Cooley sternal retractor into position, from xyphoid up. - Ensure sternal edges are within the curved portion of Cooley sternal retractor - Cooley retractor should be positioned primarily over caudal two thirds of the sternum - Slowly crank retractor open - Swip dry lap from manubrium to xyphoid and leave bunched up at xyphoid, providing dry exposure of cervico-thoracic fascia and muscle at manubrium - Intermittently crank retractor further open so that full retraction does not occur at one time but allows an interval for resisting fibers to relax - Probe tension of cervicothoracic fascia with finger and carefully cut with medium power electrocautery until thymus exposed and resistance to spread of sternal retractor has been relieved - Remove lap sponge - Probe tension of linea alba with finger and use medium power electrocautery to incise along lineal alba until desired spread of retractor achieved. - Linea alba can be incised further than the skin - If the skin opposes spread of retractor, cut skin as necessary with cut setting electrocautery.