The idea that open heart surgery requires surgeons to “break” a patient’s ribs is a common misunderstanding. Open-heart surgery requires direct visibility and working space to perform complex repairs, such as coronary artery bypass grafting or valve replacement. Access is gained by surgically altering the breastbone, or sternum, not the ribs, to create a safe path for the operation.
The Sternotomy Procedure
Open heart surgery traditionally begins with a median sternotomy, involving a vertical incision down the center of the chest. The ribs are not fractured; instead, the sternum or breastbone is surgically divided. The sternum is split precisely down the middle using a specialized surgical saw, a controlled action that differs significantly from an uncontrolled break.
The sternum offers the most direct route to the heart and major blood vessels. Once the sternum is fully cut, the two halves of the breastbone are gently separated using a retractor. This device holds the bone edges apart, creating a wide and stable surgical window for the cardiac surgeon. The ribs remain intact, though their cartilaginous connections to the sternum are necessarily cut.
Securing the Chest Wall After Surgery
Once the cardiac repair is complete, the surgeon reapproximates the two separated halves of the sternum. The most common technique for securing the chest wall is the use of stainless steel cerclage wires. These strong, thin wires are passed through or around the bone halves and then twisted tight to hold the sternum firmly together.
This technique provides mechanical stability to the breastbone, which is crucial for the healing process. The wires are non-corrosive and remain permanently in the body, acting as an internal brace. While modern techniques like rigid plate fixation using titanium plates and screws are sometimes used, the wire cerclage remains the traditional and widely used method for sternal closure.
Recovery Healing the Breastbone
The primary focus of initial recovery is allowing the surgically divided sternum to heal, a process similar to the mending of any other bone. Initial stability is typically achieved within six to eight weeks, but full fusion can take several months. Patients must adhere to strict sternal precautions to prevent the wires from loosening or the bone edges from separating.
Precautions include avoiding activities that place strain on the chest and upper arm muscles. Patients are instructed not to lift, push, or pull anything heavier than a few pounds for the first six to eight weeks. They must also brace their chest with a pillow when coughing or sneezing to provide support and minimize sternal movement. Following these guidelines is paramount for ensuring a successful bone union.
Minimally Invasive Alternatives
Advancements in surgical technology have introduced alternatives that avoid the need for a full sternotomy. These modern approaches, grouped under minimally invasive cardiac surgery (MICS), utilize smaller incisions to access the heart. Procedures like mini-sternotomy involve a smaller vertical incision and only a partial cut to the upper sternum. A thoracotomy uses an incision between the ribs on the side of the chest.
These techniques are increasingly applied for procedures such as single-vessel coronary artery bypass grafting and some valve repairs. The primary benefit is reduced trauma to the chest wall, leading to less postoperative pain, shorter hospital stays, and a faster return to normal activities. However, these methods are not suitable for all patients or all types of complex heart surgery, making the full sternotomy necessary in many cases.