In any redo cardiac surgery, it is prudent to get a lateral chest x-ray or even a CT chest to determine if there are any adhesions to the sternum
In redo-opening of the chest: ask the anaesthetist to inflate the lung in order to protect the heart (at the expense of the lungs) to minimise the risk of opening the right ventricle instead
Procedure
Preparation and draping
Prep with chlorhexidine / iodine from neck (including suprasternal notch), above clavicles to mid-axillary line; abdomen; groins (for femoral access); + legs (front and back) if contemplating venous harvesting
Drape legs; fold drape over axillary sides and affix above clavicle
Put drape over groin, exposing femoral regions
Apply adhesive "side drapes" just to expose the sternum - clear access from suprasternal notch to xiphisternum
Dry the cleaning solution
Apply adhesive over chest
Median sternotomy
Identify the suprasternal notch
Identify the xiphisterum - if difficult to feel, palpate for the inferior cartilage of the ribs and find the midpoint between the two
(Anand Agarwal technique) get a suture, align it from the suprasternal notch to the xiphisternum and make an "indentation" to guide the direction of the incision
Cut the skin, fat and dissect in the midline down to the sternum; divide the supra-sternal ligaments (care should be taken superiorly to avoid the constant vein) and expose the superior edges of the rectus abdominis
Score the sternum in the midline (this can be done by feeling laterally for the ribs)
Make an incision between the recti; place a finger into the sub-xiphisternal space and obliterate (making sure there are no adhesions)
Use heavy scissors and cut xipisternum
Test the saw to make sure it is functional
Ask the anaesthetist to deflate the lungs temporarily*
Using two hands, guide the saw from xiphisternum to suprasternal notch (and then expect blood)
Separate the ribs and apply a dry swab to the open cavity
Using diathermy, control the bleeding points on the peripheries of the sternal table; using bone wax to control bleeding from the marrow
Using a (Finochietto) spreader; open the chest cavity to expose the pericardium
