Partial median sternotomy as a minimal access for off-pump coronary artery bypass grafting: feasibility of the lower-end sternal splitting approach

Background. Off-pump coronary artery bypass grafting (OPCAB) can be performed in several ways using a minimally invasive approach (MIDCAB). Using the left anterior small thoracotomy (LAST) approach, only the LAD can be grafted. To expand the indications for MIDCAB from single-vessel disease to double-vessel disease, we have used a partial sternotomy without a transverse cut, namely, the lower-end sternal splitting (LESS) approach. Through this approach, the LAD and RCA can be revascularized by means of a single small incision without the risk of damaging the tissue around the intercostal space during harvesting of ITA when the sternum is transversely divided. The purpose of this study was to demonstrate the feasibility and safety of this technique. Methods. Between November 1999 and November 2000, a total of 22 patients underwent MIDCAB through a lower midline skin incision from the fourth intercostal space to the xiphoid process with longitudinal division of the lower half sternum up to the 3rd rib, without either a T- or reversed L-shaped division of the sternum. Of the patients, 14 had LAD disease only, 5 had both LAD and RCA disease, 2 had RCA disease only, and 1 had left main trunk disease. Two of the operations were of redo coronary artery bypass grafting. The mean age was 69.5 ± 6.1 years (range 58 to 77 years). Results. The mean length of the skin incision was 8.5 ± 1.4 cm (range 7 to 12 cm). No hospital death or morbidity was observed. All patients had arterial conduits: LIMA in 20 patients, RIMA in 3, RGEA in 4, and RA in 1. The mean number of grafts per patient was 1.3 ± 0.6 (range 1 to 3). No blood transfusion was required perioperatively. The patency rate was 96%. All patients were in New York Heart Association class I and no wound complications or postoperative pain occurred during follow-up. Conclusions. Our experience demonstrates that the LESS approach for MIDCAB is technically feasible for revascularizing not only the LAD but also the RCA system, with the same small incision using IMA and GEA. It can be used with excellent cosmetic results and safety. Although our experience is limited, we conclude that this less invasive surgical technique can be used as an alternative approach for MIDCAB in patients with LAD or RCA disease.