A RIP Saw Tale And A Bloody, Blob Monster By Gary Grist RN CCP Emeritus
Many years ago the heart surgeon at the hospital where I was working had just gotten his first pneumatic reciprocating saw (aka rip saw). Prior to that, he used a Gigli saw to open most chests. Gigli saws are a lot of work, so the surgeon was thrilled to have the new saw. This particular case was a redo operation. Several years prior, the patient had a Vineberg procedure where the internal mammary arteries were implanted directly into the myocardium of the left ventricle in an attempt to alleviate chest pain from myocardial ischemia. After removing the sternal wires the surgeon unzipped the chest from bottom to top with the new reciprocating saw, similar to what is seen in this short YouTube video.
But, unlike the video, blood immediately welled up out of the open wound like lava from a volcano and began spilling on the floor. He ordered the suckers up to full speed and sucked the deluging blood into my pump. The anesthesiologist who was hidden behind the linen drapes peered over the ether screen to see what was happening. In the excitement of the situation he neglected to give the heparin. With his first assistant shoving large lap sponges into the breech, the surgeon rapidly established femoral cannulation and went on CPB. As I transfused the unheparinized shed blood (I did not realize it was not yet heparinized) that was captured in my cardiotomy/venous reservoir with the suckers, I witnessed an ominous sight. A huge clot had formed in the venous reservoir. As the reservoir level dropped, the huge clot perched on a reservoir baffle, emerged into view like a bloody, blob monster rising from a swamp. I quickly injected a full heparin dose into the venous reservoir system. I expected that venous blood coming into the pump would soon stop or that the clot would be sucked by the pump and pushed into the disk oxygenator, or be pushed further on into the rudimentary arterial filter we were using which could mean sudden death for the patient.
Fortunately none of those things occurred to the degree that CPB was interrupted. The patient survived the operation intact, but I had aged ten years! After things settled down the surgeon discovered that his new saw had severed both internal mammary arteries just above their implantation sites in the myocardium. Luckily none of the vital cardiac structures had been breached which probably explains why the patient survived.
Nowadays, everybody knows not to rip open a redo sternotomy with a reciprocating saw. I guess the surgeon did not know that back then. Powered sternal saws were new to the market and there weren’t very many patients who required a redo sternotomy. He had done redo sternotomies before with the Gigli saw. It required a lengthy sub-sternal dissection from sternal notch to xyphoid with Metzenbaum scissors that looked to be 2 feet long to me. Then, using a long tonsil clamp sub-sternally, one end of the Gigli wire saw blade was pulled under the sternum. The saw is composed of a wire blade with small chain-style steel teeth and attached at either end by two handles. The handles, attached to each end of the wire blade, are moved back and forth in a pulling motion to rasp through the sternum. This a lot of work for the surgeon, appears brutal in execution and there is a risk that the saw can damage sub-sternal structures. I could not find a good YouTube video of a sternotomy, let alone a redo sternotomy using a Gigli saw. But here is a good example of a Gigli saw being used in an orthopedic procedure. This is Civil War technology folks!
Unless they have spent time at an overseas mission where Gigli saws are still used, I doubt that most American perfusionists today have ever seen a Gigli saw used on a virgin sternotomy let alone a redo. Oscillating saws that are glorified cast saws and much safer than reciprocating saws are used nowadays to open a redo sternotomy.
When it came to the new, powered reciprocating sternal saw, I assumed the surgeon knew what he was doing….but what did I know,? I was only 19 years old. This was probably my first lesson in the old cliché; “Don’t assume anything, it makes an ass out of you and me!” From that time onward, I became a very “unassuming” perfusionist and nurse.