The common fear that surgeons must break a person’s ribs to perform open heart surgery is understandable, given the heart’s protected location inside the chest. In reality, modern cardiac surgery utilizes precise methods of entry that generally leave the ribs intact. Open heart surgery, defined as any procedure requiring the chest to be opened to directly access the heart, depends on careful surgical techniques to create the necessary working space.
Sternotomy: The Standard Surgical Entry
The standard approach for most complex cardiac procedures is a technique called a median sternotomy. This procedure does not involve breaking the ribs; instead, it focuses on the breastbone, or sternum, which lies in the center of the chest. The sternum is a flat, narrow bone that runs vertically and connects to the ribs via cartilage.
To begin, a surgeon makes a vertical incision down the middle of the chest. A specialized, powered sternal saw is then used to carefully cut the sternum lengthwise from top to bottom, dividing the bone into two halves.
Once divided, a surgical retractor is used to gently spread the two halves of the sternum apart. This creates a wide opening to the chest cavity, providing surgeons with the maximum visibility and working room needed to perform intricate repairs.
How the Heart Is Accessed During Surgery
After the chest cavity is opened, the heart is exposed, but the surgery requires a still, bloodless field. For many open heart procedures, the patient is placed on a heart-lung machine, or cardiopulmonary bypass. This machine temporarily takes over the function of the heart and lungs, circulating and oxygenating the blood outside the body.
The heart is then intentionally stopped using a chilled solution called cardioplegia, introduced into the coronary arteries. Operating on a non-beating heart allows the surgeon to perform delicate tasks, such as coronary artery bypass grafting or valve repair, with high precision. The large opening created by the sternotomy is necessary to facilitate the complex connections and visibility required for the bypass machine and the subsequent repair.
Minimally Invasive Approaches
Not all heart surgeries require a full median sternotomy, as technology has introduced less invasive options. Minimally invasive cardiac surgery utilizes smaller incisions, resulting in less trauma and a faster recovery for selected patients. These techniques are suitable for single-vessel coronary bypass or certain valve procedures.
One approach is the partial sternotomy, where only a small section of the sternum is divided. Other techniques avoid the breastbone entirely by making a small incision between the ribs on the side of the chest, known as a minithoracotomy.
Surgeons use specialized instruments and high-definition cameras to operate through these small openings. This intercostal approach gently separates the ribs without cutting them, which reduces pain and shortens the recovery period.
Healing and Recovery After Chest Entry
Regardless of the entry method, the chest cavity must be securely closed to begin recovery. Following a full median sternotomy, the two halves of the sternum are brought back together and secured using several stainless steel wires. These wires are passed around the bone and twisted tight, acting like internal sutures that hold the bone in place. The wires remain permanently in the body to maintain stability while the bone heals.
Initial healing for the sternum typically takes about six to eight weeks to achieve primary stability. During this time, patients are given specific sternal precautions to prevent movement that could disrupt the healing bone. Restrictions often include avoiding lifting, pushing, or pulling anything heavier than five to ten pounds. Full bone strength may take several months, but adhering to these physical limits is important to ensure the sternum fuses correctly.