The Median Sternotomy: The Unkindest Cut of All? Pearls, Pitfalls, Aphorisms, & Myths


  • Curt Tribble, MD Division of Cardiac Surgery, University of Virginia, Charlottesville, VA, USA
  • Walter Merrill, MD Department of Cardiothoracic Surgery, Vanderbilt University, Nashville, TN, USA
  • Stephen Derryberry, MD Mercy Hospital, Youngstown OH, USA
  • Gene Parrino, MD Department of Cardiothoracic Surgery, Ochsner Medical Center, New Orleans, LA, USA



The Median Sternotomy


While some have claimed that a median sternotomy is an ‘unkind cut,’ when this incision is performed, closed, and managed optimally, it can be one of the ‘most kind cuts’ used for major operations. The median sternotomy is the most commonly used incision for coronary artery bypass surgery, which is the most common operation performed in the United States at the current time. This approach is, of course, used for many other cardiac and thoracic operations, as well. It is, however, also one of the most misunderstood procedures in Surgery. Because it is an incision that even a novice surgical resident can perform, with proper supervision, the subtleties and nuances of not only opening but also of closing sternotomies are not often conveyed optimally to our trainees. In this treatise we will attempt to comprehensively address these subtleties, nuances, and misunderstandings, both for the benefit of our younger learners, but also, and more importantly, for the benefit of our patients.


Tribble C. Reoperative Cardiac Surgery: Part I – Preoperative Planning. The Heart Surgery Forum 2018; 21: E63-9

Tribble C. Reoperative Cardiac Surgery: Part II. The Heart Surgery Forum 2018; 21: E124-131.

Julian O, Lopez-Belio M, Dye W, Javid H, Grove W. The median sternal incision. Surgery 1957; 42: 753-61.

Dalton M, Connally S, Sealy W. Julian’s Reintroduction of Milton’s Operation. Ann Thorac Surg 1992; 53: 532-3.

Edwards F, Engelman R, Houck P, Shahian D, Bridges C. The STS Practice Guideline Series: Prophylaxis in Cardiac Surgery. 2006; 81: 397-404.

Hong J, Saraswat M, Ellison T, Magruder J, Crawford T, Gardner, J, Padula W, Whitman G. Staphylococcus Aureus Prevention Strategies in Cardiac Surgery: A Cost-Effectiveness Analysis. Ann Thorac Surg 2018; 105: 47–53.

Lazar H, McDonald M, Chipkin S, Furnary A, et al. The Society of Thoracic Surgeons Practice Guideline Series: Blood Glucose Management during Adult Cardiac Surgery. Ann Thorac Surg 2009; 87: 663-9.

Tribble C, Merrill W. The Way We Talk is the Way We Teach. J Thorac Cardiovasc Surg. 2014; 147: 1155-9.

Lee ME, Blanche Carlos. Curvilinear Paramedian Sternotomy. Ann Thorac Surg 1984; 38: 414.

Williams CD. Curved Sternotomy Incision. Tex Heart Inst J; 2000: 27: 419.

Lazar H. The use of vancomycin paste to reduce sternal wound infections after cardiac surgery - why is this still a “sticky” subject? J Thorac Cardiovasc Surg. October 2017; 154: 1324-5.

Vestergaard R, Jensen H, Vind-Kezunovic S, Jakobsen T, Søballe K, Hasenkam J. Bone healing after median sternotomy: A comparison of two hemostatic devices. J Cardiothorac Surg 2010; 5: 17–27.

Wellisz T, Armstrong J, Cambridge J, Wen X, Hill C, Fisher T. The Effects of a Soluble Polymer and Bone Wax on Sternal Healing in an Animal Model. Ann Thorac Surg 2008; 85: 1776-80.

Flege J. Pericardial incision for internal mammary artery coronary bypass. Ann Thorac Surg 1987; 44: 424.

Tribble C. The Skeleton in the Closet: Harvesting a Skeletonized IMA. The Heart Surgery Forum 2017; 20: E178-83.

Kalso E, Mennander S, Tasmuth T, Nilsson E. Chronic Post-sternotomy Pain. Acta Anaesthesiologica Scandinavia 2001; 45: 935-9.

Khonsari S, Sintek C. Cardiac Surgery: Safeguards and Pitfalls in Operative Technique. 4th Edition. 2007. Lippincott Williams & Wilkins. Philadelphia, PA.

Loor G, Vivacqua A, Sabik J, Li L, Hixson E, Blackstone E, Koch C. Process improvement in cardiac surgery: Development and implementation of a reoperation for bleeding checklist. J Thorac Cardiovasc Surg 2013; 146: 1028-32.

Dasika U, Trumble D, Magovern J. Lower Sternal Reinforcement Improves the Stability of Sternal Closure. Ann Thorac Surg 2003; 75: 1618-21.

Tector AJ, Cress DC, Downey FX, Schmahl TM. Use of internal Thoracic artery T-Grafts for complete arterial revascularization. Op techniques in cardiac and thoracic surgery 1996; 1:108-116.

Losanoff J, Collier A, Wagner-Mann C, Richman B, Huff H, Hsieh F, Diaz-Arias A, Jones J. Biomechanical Comparison of Median Sternotomy Closures. Ann Thorac Surg 2004; 77: 203–9.

Pinotti K, Cataneo D, Rodrigues O, Cataneo A. Closure of the sternum with anchoring of the steel wires: systematic review and meta-analysis.

J Thorac Cardiovasc Surg 2018; 155: 177-86.

Tugulan CI, Spindel SM, Bansal AD, Bates MJ, Parrino EP. Does Elective Sternal Plating in Morbidly Obese Patients Reduce Sternal Complication Rates? Ann Thorac Surg 2020; 110:1898-903

Goldratt E. The Goal, Introduction to the Theory of Constraints. 2017. The North River Press Publishing Corporation. Great Barrington, MA

Jeevanandam V, Smith CR, Rose EA, Malm JR, Hugo NE. Single-stage management of sternal wound infections. J Thorac Cardiovasc Surg 1990; 99: 256-62.

Levy A, Ascherman J. Sternal Wound Reconstruction made Simple. Plast Reconstr Surg Glob Open. 2019; 7: e2488.

Lewis F. Thoracic Trauma. 1982. Surg Clinics North America 62: 97-104.

MacIver R, Stuart R, Fredrickson J, Fullerton D, Horvath K. Topical Application of Bacitracin Ointment is Associated with Decreased Risk of Mediastinitis after Median Sternotomy. The Heart Surgery Forum 2006; 9 (5): E750 – 3.

Chan J, Diaconescu A, Horvath K. Routine use of topical bacitracin to prevent sternal wound infections after cardiac surgery. Ann Thorac Surg 2017; 104: 1496-500.

Dohman P, Markou T, Ingemansson R, Rotering H, Hartman J, van Valen R, Brunott M, Segers P. Use of Incisional Negative Pressure Wound Therapy on Closed Median Sternal Incisions after Cardiothoracic Surgery: Clinical Evidence and Consensus Recommendations. Med Sci Monit 2014; 20: 1814-25.

Hersh R, Kaza A, Long S, Fiser S, Drake D, Tribble C. A technique for the treatment of sternal infections using the Vacuum Assisted Closure device. Heart Surg Forum 2001; 4: 211-5.

Engelman D, Ali W, Williams J, Perrault L, Reddy S, Arora R, Roselli E, Khoynezhad A, Gerdish M, Levy J, Lobdell K, Fletcher N, Kirsch M, Nelson G, Engelman R, Gregory A, Boyle E. Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations. JAMA Surg 2019; 154: 755-66.

Adams J, Lotshaw A, Exum E, et al. An alternative approach to prescribing sternal precautions after median sternotomy, "Keep Your Move in the Tube". Proc (Bayl Univ Med Cent). 2016; 29: 97-100.

Ley J, El-Ansary, Mohd K, Adams J, Triano S, Gach R. Goodbye Sternal Precautions, Hello Move in the Tube. CTS NET (, 4-18-2019.

Stone P, Glied S, McNair P et al. CMS changes in reimbursement for HAIs. Med Care 2010; 48: 433-9.



How to Cite

Tribble, C., Merrill, W., Derryberry, S., & Parrino, G. (2021). The Median Sternotomy: The Unkindest Cut of All? Pearls, Pitfalls, Aphorisms, & Myths. The Heart Surgery Forum, 24(2), E267-E277.