Accidental pleurotomy during sternotomy.

BACKGROUND : Accidental pleurotomy has been noted during sternotomy for various cardiothoracic surgical procedures. Importance of pleural integrity has been noted in various studies and various methods have been proposed to reduce the incidence of pleurotomy. INTRODUCTION : Sternotomy is the commonest access route for the surgeries performed on heart and other various mediastinal structures. Although the principles of Sternotomy were known and described by Milton in 1897, it was not widely practiced till 1957. It was Julian and colleagues who proved it to be less painful and useful than a bilateral anterior thoracotomy which was practiced during the early era of open cardiac surgery. During sternotomy we notice that pleura many a times get opened inadvertently. Although accidental pleurotomy does not interfere with the progression of the intended surgery, it may lead to insertion of chest tube and its related morbidity. Avoiding a chest tube may be prudent in patients with poor pulmonary reserve and will help them in post operative recovery and in early mobilization. To avoid accidental pleurotomy, various methods has been postulated and none have been found to be effective in reducing its incidence. One of the most common methods employed by cardiothoracic surgeons is to deflate the lung just before commencing the sternotomy and to dissect the retrosternal tissues bluntly using a finger. Direction of sternotomy has been found to be a factor in few studies in reducing the pleurotomy. AIMS AND OBJECTIVES ; 1. To evaluate the practice of lung deflation in reducing the incidence of pleurotomy. 2. To evaluate whether delaying the sternotomy after lung deflation reduces pleurotomy. 3. To understand the various factors which may contribute to the pleurotomy. METHOD : This study was a prospective randomized single blinded study conducted at department of cardiothoracic surgery in Madras medical college during the period of March 2013 to March 2014.A total of 101 cases undergoing sternotomy for various cardiothoracic surgical procedures were included in the study. Randomization was done by anaesthesiolgist drawing a lot. Group A [n=34] underwent sternotomy without lung deflation, Group B [n=40] underwent after 5 seconds of lung deflation and Group C [n=27] underwent sternotomy after 10 seconds of lung deflation. Observations were recorded,tabulated and analyzed. CONCLUSIONS : 1. Age and sex are not a factor determining the accidental pleurotomy during sternotomy. 2. Smoking and COPD also are not found to be a risk factor for pleurotomy. 3. Surgeons experience in doing sternotomy is not a factor determining pleurotomy. 4. Accidental pleurotomy rate in the study is acceptable when compared to similar studies. 5. Right side is involved in all accidental pleurotomies in this study. 6. Direction of sternotomy as a risk factor could not be analysed in this study. 7. Deflating or inflating the lung during the sternotomy did not influence the rate of accidental pleurotomy. 8. Drain site pain is similar in intercostal pleural drain and sub xiphoid mediastinal/pericardial drain. Deflating or ventilating the lung during sternotomy did not influence the rate of accidental pleurotomy [p-0.13 not significant]