Has anyone heard of this incision??

[Bonbet]

Hi all. Thanks for reading this. The surgeon told me that he would use a minimally invasive incision for my AVR (not yet scheduled) that is about 3 to 4 inches long down the midline of the sternum but in the very middle of sternum leaving the sternal notch and xiphoid process intact. Has anyone heard of an incision like this? It just doesn't make sense to me that he could open it enough to provide access. At the time I was a bit overwhelmed with all the other info I was receiving so I didn't think to follow up with this specific line of questioning. He did say he's done many of these incisions and likes them because they are cosmetically beneficial. Anyway, I thought I'd see if anyone else has had experience or knowledge of this before I call his office to ask. Thanks much, Bonbet

 

[Paleowoman]

Hi Bonbet - My surgeon said she would do a minimally invasive incision for my AVR. I understood that to be around a 2 to 3 inch incision mid sternotomy, but turns out mine is 4 1/2 inches long. The full length of my sternum is 6 inches. My sternal notch and xiphoid process are intact, yes ! I posted a photo of the scar here: http://www.valvereplacement.org/for...the-tawdry-shirt-toots/44053-my-incision-scar They can get full access, it's just more fiddly, but I think it's often done these days if the person is just having AVR. I only found out the reason why the surgeon couldn't do the smaller 2 to 3 inch incision about a month ago - she said she couldn't access my aortic valve between the 3rd and 4th intercostal space so couldn't do a "mini-sternotomy"….but still my incision is shorter than a full sternotomy. I wouldn't say that cosmetically it is particularly beneficial but I don't mind my scar at all, it shows clearly since it starts just at the point where the sternal notch begins.

 

[cldlhd]

I had the full sternotomy 4.5 months ago . I inquired about minimally invasive but my surgeon said he wanted full access. Made sense to me , the analogy in my mind would be the difference between working under the hood ,or bonnet , of a 55 Chevy compared to a modern car stuffed full of electronics and turbos. However I'm not a surgeon so my my analogy is bunk. I'd ask the advantages of a mini weighed against possible negatives. My ribs feel pretty well healed up ,back to doing whatever I want to, went swimming yesterday an played some baseball with my son. I guess it depends on what surgery you're having but I felt that the mini sternotomy may make for quicker recovery but if the operation was compromised at all the convenience isn't worth it. I don't look at surgery as totally black and white as in " was it a success or a failure" .I'm sure in something that complex there's shades of gray,

 

[epstns]

I think there are a lot of variations on this technique. In my case, the surgeon opened my complete sternum, but only cut skin for about 4 inches. Somehow he/they gained enough access to my chest to do the valve and a bypass without a larger incision through the skin. He also cut the skin on a slight angle so that the scar isn't visible if I leave the top button of my shirt open.

When we were discussing the incision technique to be used, I told him to "go ahead and do whatever you need to do in order to have the best chance at the best outcome." The rest really didn't matter to me. I'm now almost 4 1/2 years out, and you really have to look hard to find the scars. My pacemaker, on the other hand, is a real "stand-out."

 

[Paleowoman]

I I guess it depends on what surgery you're having but I felt that the mini sternotomy may make for quicker recovery but if the operation was compromised at all the convenience isn't worth it.

Mine definitley didn't make for quicker recovery - but maybe that was because they started out with the aim of doing a "mini-sternotomy" but ended up having to do a longer sternotomy, though not a full sternotomy. I didn't ask for the "mini", it was the surgeon who decided on it, I never found out it was supposed to be "mini" till nearer the time…. I would leave the technicalities to the surgeon !

 

[cldlhd]

Hi Bonbet - My surgeon said she would do a minimally invasive incision for my AVR. I understood that to be around a 2 to 3 inch incision mid sternotomy, but turns out mine is 4 1/2 inches long. The full length of my sternum is 6 inches. My sternal notch and xiphoid process are intact, yes ! I posted a photo of the scar here: http://www.valvereplacement.org/for...the-tawdry-shirt-toots/44053-my-incision-scar They can get full access, it's just more fiddly, but I think it's often done these days if the person is just having AVR. I only found out the reason why the surgeon couldn't do the smaller 2 to 3 inch incision about a month ago - she said she couldn't access my aortic valve between the 3rd and 4th intercostal space so couldn't do a "mini-sternotomy"….but still my incision is shorter than a full sternotomy. I wouldn't say that cosmetically it is particularly beneficial but I don't mind my scar at all, it shows clearly since it starts just at the point where the sternal notch begins.

I admit that before your post I'd never heard of the xiphoid process but then again I don't get out as often as I used to. That's the exact area where I occasionally feel a little click as if something is moving. There is no pain and it's less frequent than it was but I still wonder what it is.

 

[Northernlights]

I had a full sternotomy but with minimal skin incision. I asked my surgeon to keep the scar as low as possible and basically he made the incision in the middle and then cut the sternum all the way but leaving the skin intact at either end. My scar is 4 1/2 inches like Palaeogirl's, but because it starts lower it isn't visible wearing an open shirt or most scoop necks. It seemed to me to have the best of both worlds, with full access for my surgeon- and I had a Ross procedure , ie 2 valves, together with an aortoplasty. I think this is the sort of incision your surgeon is suggesting, and I do recommend it. My incision healed very quickly. A lot of surgeons don't bother about the cosmetic result, or do a minimally invasive surgery through the top half of the sternum.

 

[Bonbet]

Thanks for the responses. Currently I only have a slightly enlarged ascending, and my aortic root is 4.1 so they are not planning on doing anything but the aortic valve replacement. (We'll see how the aorta progresses by the time I go in but they predict that it won't get bigger.) More complex surgeries ie: multiple valves, CABG etc. require more legroom, and a full sternotomy is often a better choice. Your comments remind me that the surgeon also told me that he likes this mid sternal incision because if he runs into something unanticipated it is very simple to extend the incision without having to prep and open an entirely new site, as would be the case with the minimal incisiion between the ribs.
I am very comforted to hear Paleogirl say you've had this incision, I was starting to wonder about the surgeon! I still cannot get my head around how they stretch the bone/cartilage enough to get in there, but then there is alot about this surgery I can't imagine. Paleogirl, mind if I ask where you had the surgery and who did it?
Is that within forum protocol?

 

[Paleowoman]

Your comments remind me that the surgeon also told me that he likes this mid sternal incision because if he runs into something unanticipated it is very simple to extend the incision without having to prep and open an entirely new site, as would be the case with the minimal incisiion between the ribs.

Ah, now I understand what my surgeon did ! She just extended the incision like your surgeon says he does. Because my surgeon couldn't access my aortic valve where she expected it to be at a level between the 3rd and 4th intercostal space, all she had to do was extend the incision. I wish she'd explain things to me like your surgeon does Bonbet !

I am very comforted to hear Paleogirl say you've had this incision, I was starting to wonder about the surgeon! I still cannot get my head around how they stretch the bone/cartilage enough to get in there, but then there is alot about this surgery I can't imagine.

If you're up to it here's a couple of Youtube videos showing 'highlights' of mini sternotomy. You will see they really stretch, or rather pull apart, the bone, cartilage, skin etc at the incision site. Looks like they have a metal gadget to do this and hold it all in place apart so they can get on with the work. You will ache for quite a while after due to this stretching, but that happens even with a full sternotomy as obviously everything has to be stretched apart to gain access. Your back and shoulders also ache after surgery as I guess they 'contort' your body somewhat to help with the access.

https://www.youtube.com/watch?v=0WeeyKaF3J0
https://www.youtube.com/watch?v=ybG4O_VCKq0

They also use a transoseophageal echocardiogram during minimally invasive surgery so that they can see things from the inside. I note from my Operation Note that my anaesthetist was doing the transoseophageal echo. How do they get everything down a person's throat ? The ventilator and the transoseophageal echo ? How do they do that with little children who have smaller throats ? My throat never hurt afterwards.

I also found, before I had surgery, a YouTube video showing how they cut the sternum as I was always worried they'd nick my pericardium cutting through as my heart sits right snug behind my sternum, even when lying on my back, as I have a slightly depressed sternum. I can't find the link right now, but basically they don't cut right the way through the sternum, they just cut into it so much and then'crack' it open...I was relieved to find that out.

Paleogirl, mind if I ask where you had the surgery and who did it?Is that within forum protocol?

No problem, it's in my signature below. I had it at St Anthony's Hospital in London, UK, and it was done by Professor Marjan Jahangiri.

 

[Bonbet]

Thanks Anne for the links. Hopefully the minimized incision will provide enough room, if not, he can extend. At this point in life I am not so worried about "cosmetics." There is plenty else to be concerned about. Early on I watched the entire video of Lars Svensson performing AVR on the Cleveland Clinic website. So I'm not too squeamish. I did appreciate the pix of your scar. It looks like we are similar ages and it sounds like you are pretty active and you got a bovine bio prosthesis.
My current cardio and surgeon are recommending mechanical for me becasue they think that if I am as active as I am now, and hopefully plan to be after rehab, that I would wear out a bio valve faster. I will post something about this on a new thread for general feedback because frankly, I was surprised. I thought I was a total candidate for bio valve and never even researched mechanicals. I am now though!

 

[pellicle]

... At this point in life I am not so worried about "cosmetics."

yeah, I know how you feel. I am pretty much over my bikini modelling career ...

On the subject of research:

some posts of recent experiences from people here:

7 years
http://www.valvereplacement.org/for...on-Open-to-opinions-and-suggestions=&p=793746

5.5 years

http://www.valvereplacement.org/for...ave-4-days-to-decide-help?p=801568#post801568''


6 months
http://www.valvereplacement.org/for...hs?39503-Tissue-valve-failing-after-6-months=

so its not always like it is in the sales brochure. I always recommend people are informed in their decision making. The only certainty is that there is no certainty: only probability. All the current evidence leans towards tissue prosthetic valves having reduced durations (compared to the makers claims) in younger and more active people.

There is equally no certainty with a mechanical valve that you will require no further surgery. It can happen and for reasons that are not related to the valve. The point is that if you are younger and you are active and you choose a tissue valve you will need a replacment, with a mechanical you probably won't.

Much here on warfarin and the misinformation on that topic too.

Make your choice but please, make your research dispassionate and look for reliable and verifable sources.

Best Wishes

 

[Paleowoman]

My current cardio and surgeon are recommending mechanical for me becasue they think that if I am as active as I am now, and hopefully plan to be after rehab, that I would wear out a bio valve faster.!

YOU'RE KIDDING ! Sorry for the shout ! I just looked back at your threads and find you say:

" I am 62 and both the cardiologist and the surgeon recommended I go with a mechanical valve.(Of course exactly one year ago another "faciltiy of excellence" recommended bio-prothesis/bovine. ) The rational, according to them, is that I have a "physiologic age" which is less than my biologic age IE,I exercise regularly and am in relatively good shape for a 62 year old female….They said they thought I would wear out a tissue valve too rapidly.."

I'm the same age as you, 62. I was 60 when I had my aortic vavle replaced with a bovine bioprosthesis and I am exceptionally active ! I do weight lifting three times a week, not girlie Hollywood weight ifting, but heavy weight lifting, here's a link to a previous thread where I posted some photos of me lifting weights two months ago: http://www.valvereplacement.org/foru...451#post855451 I also walk around five miles each day ! When the surgeon met me first time she was astonished that I was 60 ! She thought I was much younger and even said "remarkable" !

No one ever said that a bioprosthetic valve would wear out quickly due to my active lifestyle, and no one ever recommended a mechanical valve for me (not that I would have wanted one due to the ticking and the warfarin). I know I'll need a "re-do" one day, and I am quite okay with that.....…umm maybe sooner would be better for the "re-do" than later since if my current valve lasts too long and I'm very old I would find surgery harder….

 

[river-wear]

Hi Bonbet, I wondered for a long time about how they get enough access with a shorter incision too. Then I realized they cut the sternum and then notch over to the space between the ribs - they can then pry open enough space to work because your rib cage will give. (It's not as bad as it sounds, honest!)

Most of my scar is nearly invisible after a year, but I have about a 1-inch keloid at the top. I'm not sure if it's because the wires under the skin irritate it (I can feel the bumps) or because the incision was supposed to be lower and the skin tore during surgery. My skin is pretty delicate. Going to see a dermatologist next week to see if we can smooth it out a bit.

 

[dab]

I got my bovine aortic valve in 2005. For most of the years since, I have done well. I am now 61 and having fatigue and chest discomfort. See my cardiologist Friday for a 6 month follow up. In the past follow up was always at a year. So maybe at the 10 year mark they watch it closer? I have a high stress job and sit too much at work. I even got a treadmill desk to try and get more walking in. Have had a few setbacks with that idea due to fatigue and other GI related issues. I am wondering what the signs are when the valve starts to wear out. Is it suddenly or gradually?

 

[Bonbet]

River-wear: sounds like you may have the J incision, which isn't what this surgeon was describing. Although I was kinda thinking that's what they would be offering.
I'll be interested to her what the dermatologist recommends.
Dab: I hear porcine valves, if they fail, do so precipitously. Bovines are a more gradual decline, kind of mimicking the slow demise of our native valves. Symptom wise it's similar, decreased exertion tolerance, SOB, dizziness, chest pain. Usually they do 6 month checks when your hemodynamics are in the "severe" range.
Sitting too much-bad! Walking- good : ) unless you are uncomfortable. Bonbet

 

[Paleowoman]

River-wear: sounds like you may have the J incision, which isn't what this surgeon was describing.

I didn't have the J incision either.

 

[river-wear]

I didn't have a J incision. The "cross cut" to the space between ribs is in the bone, but the sternotomy incision is the same but shorter. (My cardiologist considers my case a full sternotomy, but the 6" scar indicates they didn't cut my sternum all the way to the notch at the top. The skin incision doesn't give up all of the secrets of what happened inside. For example, I have a sternal wire bump under my skin about an inch above the top of my incision.