Xiphoid-sparing midline sternotomy reduces wound infection risk after coronary bypass surgery

Midline sternotomy was first described by Milton in 1897 (1). The Milton procedure remained unused until it was recommended by Julian et al. in the 1950s (2). Since then, midline sternotomy has become the most common approach for coronary artery bypass surgery (1-3). It provides full access to almost all mediastinal structures and to all branches of the coronary system. Moreover, it is easily performed and learned by younger surgeons, and is well tolerated by patients. In the last two decades, many surgeons have applied partial sternotomy (upper or lower) for minimal access cardiac surgery; however, the role of this approach in reducing sternal wound infections is unclear (4,5). Midline sternotomy is also preferred by many thoracic surgeons (6). Manubrium-sparing midline sternotomy is less utilized and is usually performed to provide better cosmetic results compared to standard sternotomy (7). Mainly due to biomechanical factors, physical activity after midline sternotomy always results in varying amounts of lateral distraction between the sternal edges. Because immobilization is mandatory for bony union, the wound healing of full midline sternotomy is likely to be less optimal compared with that of orthopaedic fractures (8). Additionally, the wound healing of this approach majorly depends on many risk factors, which may affect the stabilization or circulation state of the healing sternum (9). The cartilaginous xiphoid process (XIP) is usually avascular. Consequently, wound healing in the region of the xiphoid could be slower compared to other segments of the sternum. A study of cadaveric humans showed a greater displacement at the xiphoid region than at other segments of the sternum, with lateral distraction after midline sternotomy (10). In this study, we aimed to clarify if the preservation of XIP with its muscular attachment may play a role in improving the healing process after midline sternotomy and reducing the risk of deep sternal wound infections (DSWIs)