Median sternotomy.

Although median sternotomy was succinctly described in 1897, "Milton's procedure" was essentially unused until it was recommended in 1957. With the advent of coronary bypass operation in 1968, median sternotomy became one of the most commonly performed surgical procedures. Even with the increasing use of median sternotomy for cardiac operations, thoracic surgeons have been reluctant to apply this operative modality in their practice. This is understandable because most pulmonary problems present in a distinctly unilateral manner and the tendency of most thoracic surgeons is to avoid median sternotomy in favor of the more familiar lateral thoracotomy. However, with the increasing use of CT scans of the chest, more patients with bilateral pulmonary pathologic factors are being identified. Median sternotomy is ideally applicable to this patient group for preservation of pulmonary function and for diminishing patient discomfort. Certainly, median sternotomy is infinitely preferable to staged bilateral thoracotomy if the same therapeutic goals can be accomplished. Younger thoracic surgeons who are trained in cardiac operation are less reluctant to use median sternotomy in the treatment of noncardiac disorders. This factor may account for the recent reports of increased usage of median sternotomy. It is a very natural tendency to use that with which one is familiar. Nonetheless, median sternotomy, other than for cardiac operation, is currently underused. The situation may ultimately be corrected as the use of median sternotomy is more fully appreciated. This relatively atraumatic, nonmuscle dividing approach to the anterior mediastinum, heart, lungs, diaphragm, pleural cavities, aortic arch and great vessels and liver deserves to be seriously considered as an appropriate alternative to more familiar, but more traumatic, approaches.