Innominate Artery Cannulation Access in Pediatric Patients Undergoing Redo Sternotomy

Redo sternotomy in pediatric patients can be complicated due to the unsuitability of many arterial cannulation sites for the pediatric population. Innominate artery cannulation provides a safe and easily reproducible alternative and prevents many of the disadvantages seen in femoral and axillary artery cannulation. Its use in pediatric cardiac surgery has seen a rise [1]. Herein, we describe the technique for innominate artery cannulation in pediatric patients undergoing redo sternotomy and review our experience with the technique.

Comparison of clinical outcomes and postoperative recovery between two open heart surgeries:minimally invasive right subaxillary vertical thoracomy and traditional median sternotomy

Objective:To compare the clinical outcomes of minimally invasive right subaxillary vertical thoracotomy and traditional median sternotomy through right atrium in treatment of common congenital heart diseases.Methods:Clinical data of 59 cases of common congenital heart diseases treated with minimally invasive right axillary vertical thoracotomv from May,2011 to February,2013 and 77 cases of same diseases with traditional median sternotomy in the past three years were retrospectively analyzed,including atrial septal defect,membranous ventricular septal defect and partial endocardial cushion defect.The results were compared from the two groups,including the time for operation and cardiopulmonary bypass,amount of blood transfusion,postoperative drainage,ventilation time,hospital stay,and prognosis.Results:No severe complications happened in both groups,like deaths or secondery surgery caused by bleeding.No significant differences were in CPB time and postoperative ventilator time between groups(P>0.05),while for all of the operative time,the length of incision,postoperative drainage and hospital stay,minimally invasive right axillary vertical thoracotomy was superior to median sternotomy,with statistically significant differences(P<0.05).In six-month lollowup after operation,no complications of residual deformity and pericardial effusion were found in both groups bv doing echocardiography,but mild pectus carinatum was found in X patients in the traditional median sternotomy group(traditional groupi.whereas patients in another group were well recovered.Conclusions:Minimally invasive right subaxillary vertical thoracotomv for common congenital heart diseases is as safe as traditional median sternotomy,without the increasing incidence of postoperative complications.Additionally,compared with traditional median sternotomy,minimally invasive right subaxillary vertical thoracotomv is better in the aspects of hidden incision,appearance,and postoperative recovery.

Sternal Reconstruction of Deep Sternal Wound Infections Following Median Sternotomy by Single-stage Muscle Flaps Transposition

Objective To assess clinical effectiveness of using bilateral pectoralis major or plus rectus abdominis muscle flaps in treating deep sternal wound infection(DSWI) following median sternotomy. Methods Between January 2009 and December 2013, 19 patients with DSWI after median sternotomy for cardiac surgery were admitted to our hospital, including 14 males(73.7%) and 5 females(26.3%), aged 55±13(18-78) years. According to the Pairolero classification of infected median sternotomies, 3(15.8%) patients were type II, and the other 16(84.2%) were type III. Surgical procedure consisted of adequate debridement of infected sternum, costal cartilage, granulation, steel wires, suture residues and other foreign substances. Sternal reconstruction used the bilateral pectoralis major or plus rectus abdominis muscle flaps to obliterate dead space. The drainage tubes were placed and connected to a negative pressure generator for adequate drainage. Results There were no intraoperative deaths. In 15 patients(78.9%), bilateral pectoral muscle flaps were mobilized sufficiently to cover and stabilize the defect created by wound debridement. 4 patients(21.0%) needed bilateral pectoral muscle flaps plus rectus abdominis muscle flaps because their pectoralis major muscle flaps could not reach the lowest portion of the wound. 2 patients(10.5%) presented with subcutaneous infection, and 3 patients(15.8%) had hematoma. They recovered following local debridement and medication. 17 patients(89.5%) were examined at follow-up 12 months later, all healed and having stable sternum. No patients showed infection recurrence during the follow-up period over 12 months. Conclusion DSWI following median sternotomy may be effectively managed with adequate debridement of infected tissues and reconstruction with bilateral pectoralis major muscle or plus rectus abdominis muscle flap transposition.

Comparison of straight median sternotomy and interlocking sternotomy with respect to biomechanical stability

AIM: To increase the stability of sternotomy and so decrease the complications because of instability. METHODS: Tests were performed on 20 fresh sheep sterna which were isolated from the sterno-costa joints of the ribs. Median straight and interlocking sternotomies were performed on 10 sterna each, set as groups 1 and 2, respectively. Both sternotomies were performed with an oscillating saw and closed at three points with a No. 5 straight stainless-stee wiring. Fatigue testing was performed in craniocaudal, anterio-posterior(AP) and lateral directions by a computerized materials-testing machine cycling between loads of 0 to 400 N per 5 s(0.2 Hz). The amount of displacement in AP, lateral and craniocaudal directions were measured and also the op-posing bone surface at the osteotomy areas were calculated at the two halves of sternum. RESULTS: The mean displacement in cranio-caudal direction was 9.66 ± 3.34 mm for median sternotomy and was 1.26 ± 0.97 mm for interlocking sternotomy, P < 0.001. The mean displacement in AP direction was 9.12 ± 2.74 mm for median sternotomy and was 1.20 ± 0.55 mm for interlocking sternotomy, P < 0.001. The mean displacement in lateral direction was 8.95 ± 3.86 mm for median sternotomy and was 7.24 ± 2.43 mm for interlocking sternotomy, P > 0.001. The mean surface area was 10.40 ± 0.49 cm2 for median sternotomy and was 16.8 ± 0.78 cm2 for interlocking sternotomy, P < 0.001. The displacement in AP and cranio-caudal directions is less in group 2 and it is statistically significant. Displacement in lateral direction in group 2 is less but it is statistically not significant. Surface area in group 2 is significantly wider than group 1.CONCLUSION: Our test results demonstrated improved primary stability and wider opposing bone surfaces in interlocking sternotomy compared to median sternotomy. This method may provide better healing and less complication rates in clinical setting, further studies are necessary for its clinical implications.

Vasoactive-Ventilation-Renal Score Predicts Cardiac Care Unit Length of Stay in Patients Undergoing Re-Entry Sternotomy: A Derivation Study

Background: The vasoactive-ventilation-renal (VVR) score includes pulmonary and renal dysfunctions not previously addressed by the vasoactive inotrope score (VIS) and may be a better predictor of cardiac care unit (CCU) length of stay (LOS) in patients undergoing re-entry sternotomy (defined as no earlier than 30 days after previous sternotomy) for congenital heart disease (CHD). Methods: Patients undergoing re-entry sternotomy for CHD from August 1, 2009 to June 30, 2016 were studied retrospectively. A total of 96 patients undergoing 133 re-entry procedures were identified. VVR scores were calculated on CCU admission post-procedure (at 0 hour), 24-hour, and 48-hour after admission to the CCU. The response variable was CCU LOS.? Recursive partition analysis identified variables predicting LOS. Results: 133 re-entry sternotomies in 96 patients made up the samples of the database;11 samples were removed due to incomplete data or placement on ECMO. Of the initial 25 features, 5 were removed for near zero variance and 3 categorical features were removed for non-information. Covariance analysis did not demonstrate any significant correlation amongst the remaining features. Initial recursive tree regression using ANOVA, cross validation and conditional predictive p-value (cp) = 0.01 produced 3 trees. The tree with lowest cross validation error was selected. The resulting 2 split trees with ventilator days less than 20 days and VVR score at 48 hours greater than 23 identified three CCU LOS groups with mean CCU LOS of 77.6, 55.1, and 9.5 days. Conclusions: Recursive partition analysis identified ventilator days greater than 20 days and the sub-population VVR at 48 hours as predictive of CCU LOS in patients undergoing re-entry sternotomy for CHD.

Lifesaving Emergency Sternotomy in Traumatic Cardiac Tamponade in a Teaching Hospital in Ghana: Survival of Two Rare Cases

Introduction: Patients presenting with cardiac injuries from gunshot wounds and blunt chest trauma have high mortality, without any observed survival benefit when presenting with cardiac tamponade. Cardiac tamponade is a life-threatening hemodynamically significant compression of the heart by a sudden or gradual accumulation of collections in the pericardial space that incites and overrides the body’s compensatory mechanism. Clinical Case: We present and discuss the successful management and survival of two patients with traumatic cardiac tamponade from gunshot wounds to the precordium who underwent successful lifesaving median sternotomy at a Teaching Hospital in Ghana with a new Cardiovascular and Thoracic Surgery Unit. Discussion: Usually the diagnosis of cardiac tamponade from traumatic haemopericardium is made by clinical findings which though may not always be present especially after blunt chest trauma. EFAST is a reliable tool for diagnosing and following cardiac tamponade. Median sternotomy is the standard procedure in these patients to access and repair cardiac injury either with or without cardiopulmonary bypass. Conclusion: Emergency median sternotomy in patients with cardiac tamponade from chest trauma especially after EFAST diagnosis can be lifesaving even in less resourced centres.

Minimally Invasive Aortic Valve Replacement with Partial Lower Sternotomy

Objectives: Due to recent spread of minimally invasive surgery, the demand for minimally invasive cardiac surgery (MICS) is increasing. We investigate the usefulness of minimally invasive aortic valve replacement (MICS-AVR) which was performed in our hospital. Methods: Of 63 consecutive patients undergone an isolated aortic valve replacement (AVR), 16 patients underwent MICS-AVR with partial lower sternotomy (M group) and 47 patients underwent AVR with median full sternotomy (C group). We compared the two groups in a retrospective study. Results: No significant difference was found in the surgical and perioperative-related factors between the two groups. However, the average of aortic cross-clamping time was longer, and intensive and high care unit stay was shorter in the M group. A tendency to decrease blood transfusion was observed in the M group. There was no hospital death in all patients. The mean follow-up period was 29 ± 15 months. There was no significant difference between the two groups in the survival rate, and the 5-year survival rates were 88.9% in the M group and 85.9% in the C group. Conclusion: It was suggested that the MICS-AVR could be safe and useful procedure in AVR.

Surgical Approaches to Retrosternal Goiter, When Sternotomy Is Mandatory? National Cancer Institute Experience (NCI), Cairo University, Egypt

Background: Retrosternal goiters (RG) are those lesions extending to occupy the thoracic cavity. They carry a surgical risk due to distorted anatomy, the minimal access, and the potential for great vessels or pleural injury. No other effective therapeutic alternative to surgery exists. Cervicotomy is still the surgical approach of choice, although a form of sternotomy may always be necessary for field extension and safe gland delivery. Materials and Methods: This is a single institution combined retrospective & prospective study including retrospective analysis of all cases presenting to the NCI, Cairo University with RG candidate for surgery between Jan. 2008 until the end of Dec. 2012, and a prospective study of all cases with the same presentation presenting to the NCI between Jan. 2013 until the end of Dec. 2015. Data was collected from archive of patients at the statistical department. Aims: To study the clinico-pathological characteristics, the presentation, work-up, surgical approaches and postoperative complications of RG. Results: 42 patients were included & were divided into benign (34 patients, 80.9%) and malignant groups (8 cases, 19.1%). All patients (100%) were adults ranging (19 to 73 years) with mean 53.1 years. There was a female predominance (36 female, 85.7%) versus (6 males, 14.3%). Median duration of symptomatology was 23 months ranging (6 - 53 months). 23 patients (54.7%) were symptomatic while 19 cases (45.3%) accidently discovered. Mean tumor size was 9.97 cm in the benign group and 11.1 cm in the malignant group. 31 patients (73.8%) were euthyroid, 9 (21.4%) were thyrotoxic and 2 (4.7%) were hypothyroid. All patients (100%) underwent total thyroidectomy. The commonest approach was cervicotomy (33 cases, 78.6%), while a type of sternotomy was done in 9 cases (21.4%). 2 cases (4.7%) received postoperative radiation therapy & 4 cases (9.5%) received postoperative radioactive iodine. No perioperative mortality occurred & the overall morbidity was 6 cases (14.2%) in the benign group and 2 cases (4.7%) in the malignant group (4.7%). The median follow up period was 17.5 months. The median overall survival (OS) was 39.4 months and the median disease free survival (DFS) was 9.8 months for the malignant group. Conclusion: Cervicotomy is a safe favorable approach to remove a RG. Intraoperative field extension up to a form of sternotomy may be necessary for gland delivery with increasing operating time, hospital stay and morbidity. Postoperative morbidity is mainly due to the respiratory, recurrent laryngeal nerve palsy and hypoparathyroidism which is mainly increased when sternotomy is performed.

Implications of Pediatric Chest Wall Surgery on the Risk of Developing of Scoliosis

Scoliosis, a three-dimensional deformity of the spine, is commonly encountered in orthopedic and multidisciplinary settings, with idiopathic scoliosis being the most diagnosed form. Complications arising from thoracic chest wall surgeries, including thoracotomy and sternotomy, often include scoliosis among other complications. However, reported prevalence rates of scoliosis following chest wall surgery vary widely. This study aims to compare the prevalence of scoliosis in children who have undergone chest wall surgery to the prevalence of idiopathic scoliosis in the general population, as well as to observe gender ratios and curve direction in post-surgery scoliosis cases. A systematic review was conducted using PubMed and Scopus databases to identify relevant studies. Inclusion criteria comprised studies reporting scoliosis prevalence post chest wall surgery with follow-up times post-surgery. The search yielded 30 articles, all retrospective institutional cohort studies published between 1975 and 2024. Despite heterogeneity in study characteristics, the analysis revealed a 19% prevalence of acquired scoliosis among 5722 children who underwent chest wall surgery, higher than the reported 1% - 4% prevalence in the idiopathic population. Only three studies showed prevalence rates similar to the idiopathic population, possibly due to short follow-up periods. Further research with longer follow-up into skeletal maturity is warranted to better understand the implications of pediatric chest wall surgery on scoliosis development.

Management of sternal osteomyelitis and mediastinal infection following median sternotomy

Background Median sternotomy is considered the most usually performed procedure in cardiac operations. This study aimed to assess clinical effectiveness of bilateral pectoralis major muscle flaps （BPMMF） for management of sternal osteomyelitis and mediastinal infection following median sternotomy.Methods Clinical data were collected and retrospectively analyzed from twelve patients who underwent the BPMMF transposition for management of sternal osteomyelitis and mediastinal infection following median sternotomy from January 2006 to June 2009. Procedure consisted of rigorous debridement of necrotic tissues, dead space obliteration using the BPMMF, and placement of drainage tubes connected to a negative pressures generator for adequate drainage.Results No patients died of drainage, and all 12 patients had viable BPMMF when discharged from hospital. At 1 week post discharge, 2 patients presented with sternal infection but recovered following local debridement and medication. No patients showed infection recurrence during the follow-up period over 10 months.Conclusions Sternal osteomyelitis and mediastinal infection following median sternotomy may be effectively managed through rigorous debridement of infected soft tissues, resection of the damaged stermal segment, transposition of the BPMMF to fill the damaged sternum resulting from debridement, and adequate postoperative drainage.

The effect of surgical skin tension reduction combined with early electronic line irradiation on keloid treatment after median sternotomy

Background Median sternotomy remains the preferred technique in open heart surgery. The middle part of the chest is a predilection site for keloids. Keloids are often accompanied by itching and pain, and seriously affect the beauty and quality of life. The main treatments of keloids include surgical resection, local injection of drugs, laser, cryotherapy, compression therapy, and topical application of silica gel. Unfortunately, there is no way to achieve superior results. Therefore, there is a need to find an effective way to treat keloid after median sternoto- my. Our study was designed to investigate the effect of reducing the tension of the skin and the early electronic line irradiation on the treatment of keloid after median sternotomy. Methods A retrospective analysis was per- formed in 54 patients with keloid after median sternotomy treated by reducing the tension of the skin and remov- ing the keloid, followed with electron beam irradiation treatment 24 hours after the operation. For each patient, 5 Gy electron beam irradiation was used every day after the operation for 4 days with the total dose of 20 Gy. The patients were followed up at 6 months and 12 months after surgery. Results Fifty-four cases of patients were followed up for at least 6 months. In 6 months follow-up, there were significant effects in 34 cases with a total effective rate of 98.1%. In 12 months follow-up, 33 cases were cured with the total effective rate was 96.3%. Conclusion The treatment of keloid after median sternotomy can be achieved by the combination of tension re- duction surgery and early electronic line irradiation.

Deep sternal wound infection after cardiac surgery: Evidences and controversies

Despite many advances in prevention and perioperative care, deep sternal wound infection(DSWI) remains a pressing concern in cardiac surgery, with a still relevant incidence and with a considerable impact on in-hospital mortality and also on mid- and long-term survival. The permanent high impact of this complication is partially related to the increasing proportion of patients at highrisk for infection, as well as to the many patient and surgical risk factors involved in the pathogenesis of DSWI. The prophylactic antibiotic therapy is one of the most important tools in the prevention of DSWI. However, the choice of antibiotic, the dose, the duration, the adequate levels in serum and tissue, and the timing of antimicrobial prophylaxis are still controversial. The treatment of DSWI ranges from surgical revision with primary closure to surgical revision with open dressings or closed irrigation, from reconstruction with soft tissue flaps to negative pressure wound therapy(NPWT). However, to date, there have been no accepted recommendations regarding the best management of DSWI. Emerging evidence in the literature has validated the efficacy and safety of NPWT either as a single-line therapy, or as a "bridge" prior to final surgical closure. In conclusion, the careful control of patient and surgical risk factors- when possible, the proper antimicrobial prophylaxis, and the choice of validated techniques of treatment could contribute to keep DSWIs at a minimal rate.

Effect of acupuncture on short-term pain after standard thoracotomy

Background:To observe the effect of perioperative acupuncture on postoperative pain in patients undergoing standard sternotomy.Methods:57 patients who received standard median sternotomy were randomly divided into acupuncture group(30 cases)and control group(27 cases).The control group was treated with routine operation and nursing,and the acupuncture group was treated with acupuncture for 10 days on the basis of perioperative period.The pain levels of the two groups before and after operation were compared.Results:The pain level of the acupuncture group was significantly lower than that of the control group on the 2nd,10th,and 30th days after operation(P<0.05),and the short-term pain levels in the two groups were statistically significant(P<0.05).Conclusion:The perioperative acupuncture treatment has a significant analgesic effect on short-term pain for patients undergoing anterior midline thoracotomy,and it is helpful for patients to recover quickly after surgery.

Assessment of Pericardium Volume by the Stroke Volume Variation in Patients with Off-Pump Cardiac Surgery

Objective: SVV is derived from the cardiopulmonary interaction, which is used to predict the responsiveness of cardiac preload guiding fluid therapy in patients under general anesthesia in non-opened chest surgery. From a clinical point of view, it is important to know how well SVV reflects preload and fluid responsiveness during cardiac surgery. This study was undertaken to assess the accuracy and reliability of SVV derived from the FloTrac/Vigileo system in monitoring changes in blood volume in patients undergoing off-pump coronary artery bypass grafting (OPCABG) under general anesthesia. Methods: After approval from the ethics committee and obtaining the permission of the patients, twenty-nine patients, ASA II-III and NYHA II-III, aged 44-7 yr, undergoing elective off-pump coronary artery bypass grafting, were randomly divided into 2 groups: the control group (group C, n = 8) and volume expansion group (group V, n = 21). After patients entered the operating room, veins were put in line, ECG, HR, SpO2, and PETCO2 were continuously monitored. Left radial arterial and right internal jugular vein catheters were inserted under local anesthesia. The FloTracTM/VigileoTM system was connected and MAP, CO, CI, SVV, SV, SVI, SVR, SVRI, CVP were continuously monitored. BIS values were kept at 45%-55.6% hydroxyethyl starch 130/0.4 sodium chloride solution 7 ml/kg was intravenously infused after completion of sternotomy and pericardiotomy at a rate of 0.25 ml/kg–1/min–1 in group V. MAP, HR, CVP, systemic vascular resistance (SVR), SVV, and stroke volume index (SVI) were determined 10 min before (T1) and after the infusion of finished (T2), and the change rate (ΔHR, ΔMAP, ΔCVP, ΔSVR, ΔSVV, ΔSVI) was calculated. Sodium chloride injection 3 ml/kg was infused in group C. Results: CVP, SVI, CO and CI were increased after volume expansion, SVRI and SVV significantly decreased in group V(P < 0.01), while MAP and HR were not changed. Changes in HR(r = –0.737, P and SVR(r = –0.480, P were significantly correlated to changes in SVI, but there was no correlation between ΔCVP, ΔMAP, ΔSVV and ΔSVI.

Comparison of Parasternal Intercostal Block Using Ropivacaine or bupivacaine for Postoperative Analgesia in Patients Undergoing Cardiac Surgery

Objective: The objective of this study was to compare the efficacy of 0.5% ropivacaine and 0.25% bupivacaine for parasternal intercostal block for postoperative analgesia in children undergoing cardiac surgery. Design: A randomized, controlled, prospective, double blind study. Setting: A tertiary care teaching hospital. Participants: One Hundred children scheduled for cardiac surgery through a median sternotomy were divided into 3 groups of at least 33 children each, receiving either ropivacaine, bupivacaine or saline (control). Interventions: A bilateral parasternal block performed either with 0.5% ropivacaine or 0.25% bupiacaine or 0.9% saline with 5 doses of 0.5 mL on each side in the 2nd to 6th parasternal intercostal spaces 1 to 1.5 cm lateral to the sternal edge, before sternal wound closure. Measurements and Main Results: The time to extubation was significantly less in children administered the parasternal blocks with ropivacaine or bupivacaine compared to the saline (control) group. The pain scores were lower and comparable in the ropivacaine and bupivacaine groups compared to the saline group. The cumulative fentanyl dose requirement over a 24-hour period was higher in the saline group than the ropivacaine (p < 0.001) and bupivacaine group. No side effects were observed in any of the children. Conclusions: Parasternal blocks either with ropivacaine or bupivacaine appear to be a simple, safe, and useful technique for supplementation of postoperative analgesia in children undergoing cardiac surgery with a median sternotomy.

Management of Thoracic Impalement Injury in Ghana: A Five-Year Experience at the Komfo Anokye Teaching Hospital

Impalement injuries are rare and among the most spectacular and dramatic traumatic injuries especially of the chest. The survival of a patient with a thoracic impalement injury can be extremely rare. Herein we present and discuss our successes of the management of 7 rare cases of thoracic impalement injuries over a 5-year period from January 2014 to June 2019 at the Komfo Anokye Teaching Hospital, Kumasi in Ghana. We discuss the presentation, diagnosis, treatment and outcomes of the seven cases encountered.

Primary Cardiac Rhabdomyosarcoma in a Child—A Case Report

Unlike benign primary cardiac tumors like rhabdomyomas and fibromas, primary malignant tumors are extremely rare in children with very few cases reports in the literature so far. Rhabdomyosarcoma is a rare primary malignant tumor in children with most reported cases occurring in the right heart. We report a 15-month-old child with a primary rhabdomyosarcoma arising from the left ventricle and presenting with cardiac tamponade and circulatory failure. He underwent a diagnostic sternotomy and palliative chemotherapy but succumb to the disease later.

The Use of Fibula Free Flap for Reconstruction of Anterior Chest Wall Full-Thickness Defects

Reconstructions of the sternum remain a formidable challenge for the operating team. Reconstruction of the sternumdefect, regardless of the reason, should ensure the stability of the anterior chest wall, the return of acceptable respiratory parameters and the control of wounds. Stability of the chest wall can be provided by autogenous tissues or prosthetic materials. In our experience, the fibula free osteocutaneous flaps are harvested for reconstruction of the bone defect in two patients after full-thickness defect of the sternum and anterior chest wall.

Acute Presentation of Massive Retrosternal Thyrotoxic Goitres

Approximately 5% of goitres extend below the thoracic inlet and can potentially become life threatening due to compression of the airway and major vessels. Approximately 7% of these goitres which require surgical resection will need an additional sternotomy to deliver the intra-thoracic component. Massive retrosternal toxic goitres presenting acutely are rare and are described infrequently in literature. We hereby present two cases of massive retrosternal thyrotoxic goitres presenting with acute respiratory failure, requiring non-invasive ventilation, as well as significant head and neck venous compression. Surgery on the thyrotoxic patient with a goitre, even if not significantly enlarged, is associated with a high peri-operative mortality due to cardiac instability and hemorrhage. We discuss the challenges of surgical intervention in these patients with particular emphasis on the timing of surgery to relieve compressive symptoms and the time needed to achieve a euthyroid state. We also emphasize the need for meticulous hemostasis, use of a cell-saver, transfusion protocols, adjuncts to hemostasis, as well as careful monitoring and continuous adjustments to the coagulation profile.

Treatment of cervico-mediastinal goiters

AIM: To compare our ten year results for thyroidectomy for cervico-mediastinal goiters with the best surgical treatment reported in the literature.METHODS: From January 2000 to December 2009, of 1530 patients who underwent thyroidectomy in our department, we selected 105 cases of cervico-mediastinal goiter. In the majority of cases, the cervical approach is the standard procedure and only occasionally sternotomy or thoracotomy is necessary. The indications for surgery are generally related to a progressive increase of the thyroid mass into the anterior mediastinum with compression and dislocation of the trachea or esophagus and the possibility of an unknown malignancy.RESULTS: In 98(93.3%) of our 105 patients, the standard surgical approach was anterior cervicotomy followed by total thyroidectomy. In three cases, total sternotomy was performed and in the remaining four patients, a partial split sternotomy was effective to remove the intrathoracic mass. Post-operative complications included transient recurrent laryngeal nerve palsyin 6 patients(5.7%) which only became permanent in 2 patients(1.9%). The transient hypoparathyroidism rate was 22% but 2 mo after surgery permanent hypoparathyroidism was confirmed in only 2% of our selected group. No patients required temporary tracheostomy following surgery related to a possible bilateral nerve palsy. Patients received a single prophylactic antibiotic dose preoperatively and wound infections were not significant. There was no mortality in our selected group and most patients showed a significant improvement of dyspnea and other correlated symptoms postoperatively.CONCLUSION: The majority of cervico mediastinal goiters can be completely removed through a cervical incision. In selected cases, generally malignancies with local infiltration of mediastinal soft tissues and adhesions to large vessels, split sternotomy may be a safer approach to not increase morbidity.