A Preliminary Argument for the Selective Use of the Robicsek
Weave
John S. Ikonomidis MD, PhD
Division of Cardiothoracic Surgery, University of North Carolina at
Chapel Hill
Word Count: 886
References: 4
Address correspondence to:
John S. Ikonomidis MD, PhD
Professor and Chief,
Division of Cardiothoracic Surgery
University of North Carolina at Chapel Hill
3034 Burnett Womack Building
160 Dental Circle,
Chapel Hill, NC
27599
e-mail: john_ikonomidis@med.unc.edu
Tel: (919) 966-3381
Proper execution of median sternotomy and its subsequent closure are
critical to the success of cardiac surgical outcomes. It is essential
that the sternum be divided directly in the midline, and table fractures
must be avoided if at all possible by avoiding excessive spreading if
the sternum for exposure of the heart. Multiple methods have been
described regarding primary sternal closure technique, but the
conventional technique of wire circlage, either linear or
figure-of-eight, has endured and is also the most cost-effective.
Sternal wound complications have an incidence of 0.8% to 1.5%
patients, and this number rises to as high as 8% when bilateral
internal mammary artery harvest is undertaken. Further established risk
factors for deep sternal wound complications include breaches in
sterility in the operating room, lengthy operations, re-exploration for
bleeding, undrained retrosternal hematoma, incomplete wound closure,
obesity, advanced age, diabetes, chronic obstructive pulmonary disease,
hospital acquired pneumonias, renal failure, requirement for dialysis,
and prolonged mechanical ventilation. Mortality from sternal dehiscence
and related complications ranges from 6% to 70%. It is generally felt
that early treatment reduces mortality.1
Deep sternal wound complications and dehiscence were once thought to be
highly feared and challenging complications of cardiac surgery. Modern
primary closure techniques, tissue flap coverage options, and negative
pressure wound therapy have made these complications more manageable.
Nevertheless, it behooves surgeons to avoid this complication due to its
considerable negative clinical impact.
There are many methods currently available for reconstruction of the
sternum after its dehiscence, the most common of which is the sternal
weave first described by Robicsek and colleagues in
1977.2 This technique is often used to reinforce the
sternum with primary sternal closure in instances where the sternotomy
was off the midline leaving a thin weak section of sternum on one side
or where some fracturing has occurred, but has also been used as a first
line for sternal reconstruction after its dehiscence from primary
closure. Data are not available regarding the overall success rate of
reinforcement using the Robicsek weave, but at least one multicenter,
randomized controlled trial showed that in patients with an increased
risk for sternal instability and wound infection after cardiac surgery,
sternal reinforcement using the Robicsek technique prior to primary
sternal closure did not reduce dehiscence rate.3
In addition to the above, antecedent sternal weaving weave may
complicate further attempts at sternal closure should dehiscence recur.
In this issue of the Journal of Cardiac Surgery,4Seyrek et al. conducted a retrospective review of patients at a single
institution with noninfectious sternal dehiscence (NISD) after median
sternotomy who received thermoreactive nitinol clips (TRNC) for sternal
closure. The authors studied 34 cases who received TRNC treatment
between December 2009 and January 2020 out of 283 patients with NISD who
underwent sternal refixation. These cases were divided into two groups:
patients who had a previously failed Robicsek procedure before TRNC
treatment (group A, n=11) and patients who had been directly referred to
TRCN treatment (group B, n= 23). The results showed that the
postoperative complication rate and length of hospital stay was
significantly higher with use of the Robicsek weave. Further, operative
time was significantly shorter and blood loss was significantly lower in
patients referred for sternal refixation without having first undergone
a Robicsek weave.
Part of the reason for the above results may lie with the surgical
requirements for performance of the Robicsek weave. Substernal and
lateral dissection is required to define the margins of the sternum
before placing the weave. This increases the technical difficulty of the
reclosure operation and puts the patient at risk for inadvertent injury
to the heart, great vessels, and other mediastinal structures. This
dissection may also compromise blood flow to the sternal half. Further,
intercostal arteries may be squeezed by weave as it runs anteriorly and
posteriorly around the ribs, which may occlude blood supply to the
sternum. This could worsen pre-existing ischemia, which would delay
sternal healing, promote bacterial colonization, and cause bone necrosis
and additional sternal fragmentation, thus complicating any additional
closure attempts.
Use of TRNC may represent an advance in sternal reconstruction therapy
due to the simplicity of use and lack of requirement for a complex
mediastinal dissection prior to application. The authors contend that a
previously failed Robicsek procedure caused significantly higher
morbidity, additional operative risk and lower success rate in later
TRNC treatment of high-risk cases and hence speculate that patients at
high risk for sternal separation should proceed directly to TRNC
treatment. In the light of the above study, this approach seems
reasonable, but a prospective trial should be considered to provide the
definitive answer.