Sternotomy:

1. Identify landmarks

   • Midline approximated by feeling costal cartilage on each side.
   • Jugular notch and xiphoid should be identified as the superior and inferior points respectively.

2. Incision single midline incision from the jugular notch to the xiphoid

3. Subcutaneous dissection with scalpel till we reach peristernum.

4. Carefully visualize the avascular plane between muscles to ensure you are on the midline

5. Prepare the jugular notch and use the finger to retract the soft tissue.

6. Divide the interclavicular ligament and slip a finger under the sternum.

7. Prepare the xiphisternum, divide linea alba and use straight mayo to split the cartilaginous portion of the xiphoid. Slip finger under the sternum here as well.

8. Using an oscillating saw from the bottom-up or the other way around in a single motion.

9. Always pull the saw upwards to avoid injury to underlying structures.

10. Retractor placed not too cranially to avoid innominate vein and brachial plexus tension or damage.

11. Langenbeck retractors could be used to help slide the blades of the chest retractors in place

12. The sternum is retracted slowly and progressively to avoid fractures.

13. J-shaped pericardiotomy to expose the heart and vessels.

Abbreviated Aortic Cannulation

The aortic area selected for cannulation must be soft and nonatherosclerotic. A single purse-string suture is placed into the aorta using 2-0 silk sutures, and the aortic adventitia is divided within the diameter of the purse-string suture. An aortotomy is performed with a scalpel, the cannula is placed, and the purse-string suture is tightened around it.

Please note that this procedure different for what is done in cardiothoracic surgery.