• Theodoor D Koster, Faiz Z Ramjankhan, Ed A van de Graaf, Bart Luijk, Diana A van Kessel, Ronald C A Meijer, and Johanna M Kwakkel-van Erp.
• Department of Respiratory Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands. Electronic address: th.d.koster@gmail.com.
• J. Thorac. Cardiovasc. Surg. 2013 Oct 1; 146 (4): 901-5.

ObjectiveBilateral transverse thoracosternotomy (clamshell incision) is a widely used approach in bilateral sequential lung transplantation, but the closure technique is associated with sternal dehiscence. This study compares the incidence of sternal dehiscence between the crossed and uncrossed closure techniques.MethodsIn 129 patients who underwent transplantation through a clamshell incision, the sternum was closed using either the crossed or the uncrossed method based on the surgeon's preference. The position of the sternal parts was evaluated on lateral chest radiographs and scored as normal, override, or separation.ResultsWe observed sternal override in 38 patients and separations in 18 patients. The sternum was closed using the uncrossed method in 79 patients and the crossed method in 50 patients. There were significantly fewer overrides (n = 6, 12.0%) and separations (n = 6, 12.0%) of the sternal parts using the crossed closure technique compared with the uncrossed technique (32 overrides, 41.0%; and 12 separations, 15.1%; P < .001). Reconstructive surgery was only performed in patients with separation of the sternal parts (n = 10).ConclusionsUsing the crossed closure technique for the sternum after bilateral sequential lung transplantation reduces the incidence of sternal dehiscence compared with the uncrossed closure technique and, therefore, reduces the necessity of reconstructive surgery.Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

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