The Median Sternotomy: The Unkindest Cut of All? Pearls, Pitfalls, Aphorisms, & Myths.

While some have claimed that a median sternotomy is an 'unkind cut,' when this incision is performed, closed, and managed optimally, it can be one of the 'most kind cuts' used for major operations. The median sternotomy is the most commonly used incision for coronary artery bypass surgery, which is the most common operation performed in the United States at the current time. This approach is, of course, used for many other cardiac and thoracic operations, as well. It is, however, also one of the most misunderstood procedures in Surgery. Because it is an incision that even a novice surgical resident can perform, with proper supervision, the subtleties and nuances of not only opening but also of closing sternotomies are not often conveyed optimally to our trainees. In this treatise we will attempt to comprehensively address these subtleties, nuances, and misunderstandings, both for the benefit of our younger learners, but also, and more importantly, for the benefit of our patients.

Right ventricular function and left ventricular assist device placement: clinical considerations and outcomes.

The HeartMate II is an axial-flow left ventricular assist device that is approved for the treatment of advanced heart failure as a bridge to transplant or destination therapy. Despite the success of this device, right ventricular failure remains a persistent problem in most studies. Right ventricular dysfunction is usually defined as the need for right heart mechanical support or the persistent requirement for inotropes to support right heart function beyond 14 days. Over 21 months, 45 patients with end-stage heart disease underwent placement of the HeartMate II at our institution. This continuous cohort of patients underwent a retrospective review to evaluate the incidence of right heart failure. The perioperative survival was 91% with no incidents of mechanical support for the right ventricle and no requirements for inotropes beyond 14 days. This survival was consistent to beyond 1 year at the time of the study, and 18% of patients underwent heart transplant with 100% survival.

Laparoscopic gastric bypass complicated by gastric pouch necrosis: considerations in gastroesophageal reconstruction.

Gastric pouch necrosis and intraabdominal sepsis is an uncommon complication following laparoscopic gastric bypass. The intraoperative management of this complication centers on resection of the necrotic pouch, esophageal diversion, drainage, and enteral access for nutrition. Reestablishing gastrointestinal continuity at a later surgery following this complication can be challenging. We present a case in which the colon was found to be unacceptable for use in reconstruction; the remaining stomach was used as the conduit for a transhiatal reconstruction of gastrointestinal continuity instead.