1. Prep with arms abducted on arm boards to 90 degrees.
2. Preop IV antibiotics, contd for 24 hrs post op; double glove
3. Mark while awake in SDS the site of the interspace the bar will go thru on the right and left, at the site one interspace ABOVE the deepest part of the deformity
4. Widely drape and use iodoform drape to secure the towels
5. Measure for the bar in inches – from mid axillary line to mid axillary line – use the orange/brown Lorenz models for the bar
6. Make an oblique (mostly transverse) incision in R and L mid axillary lines, with pocket for the stabilizers
7. Bend the bar to the correct position – Too short is better than too long
8. Make a subxiphoid vertical midline incision – remove the xiphoid, and BLUNTLY dissect the retrosternal plane – a small Richardson retractor or appendix retractor helps lift up the sternum.
9. Use the curved long clamp to go over the muscle and fascia from lateral to pop thru against your finger beside the sternum. The passer is then substituted to bring the tape from lateral to the midline. Shove the passer all the way in – it dilates the space.
The same process is carried out on the other side and the taped pulled from the midline to the lateral incision. 2 umbilical tapes are used.
10. Tie one of the tapes to the bar, and pull it through over the guiding finger (asst can lift up the sternum with the Richardson).
11. Flip the bar over and adjust as needed.
12. Each stabilizer is secured with two #5 Tevdeks (each hole) and another of the same sutures is passed around the bar.
13. Use antibiotic irrigation, and suck out mediastinum and inflate lungs to 30 cm before closing xiphoid incision
14. CXR in RR – may not need to treat PTX if small
15. Bend one end of bar at removal