Yes, traditional coronary artery bypass surgery requires splitting your breastbone (sternum) down the middle to access the heart. This approach, called a median sternotomy, has been the standard method for decades and is still the most common way the procedure is performed. The bone is divided vertically from top to bottom, then spread apart with a retractor to give the surgical team a clear view of the heart and its arteries. Despite how dramatic that sounds, most patients tolerate it well, and the sternum heals over a period of roughly 6 to 12 weeks.
What Happens During a Traditional Sternotomy
The surgeon makes a vertical incision along the center of your chest, then uses a specialized saw to cut through the sternum lengthwise. A retractor holds the two halves apart, creating an opening wide enough to operate on the coronary arteries. In most traditional bypass procedures, a heart-lung machine takes over the work of pumping blood and delivering oxygen so the heart can be temporarily stopped. This gives the surgeon a still, bloodless field to graft new vessels around the blocked arteries.
There is also an “off-pump” version of the surgery where the heart keeps beating throughout the procedure. Even in that case, though, a full sternotomy is still performed in order to reach all areas of the heart. The difference is in how the heart is managed during the operation, not in how the chest is opened.
How the Chest Is Closed
Once the bypass grafts are complete, the two halves of the breastbone are brought back together and secured. The most common method uses stainless steel wires threaded around the bone in a figure-eight pattern, typically five or more wires depending on the length of the sternum. These wires stay in your body permanently. They’re small enough that most people never notice them, though they can occasionally show up on airport metal detectors or future imaging scans.
Newer closure systems use braided stainless steel cables instead of single-strand wires. In mechanical testing, these cables proved about ten times more durable and showed virtually no failure even after millions of stress cycles, while traditional wires had a measurable rate of breakage. Some centers also use rigid titanium plates for patients at higher risk of healing problems. Your surgical team chooses the closure method based on your bone quality and risk factors.
Minimally Invasive Alternatives
Not everyone needs a full sternotomy. Minimally invasive direct coronary artery bypass (MIDCAB) uses a small incision between the ribs on the left side of the chest, entering through the fourth intercostal space. The surgeon works through this opening to bypass the blocked artery, typically using an artery from inside the chest wall as the graft. This approach avoids cutting the breastbone entirely, which means faster bone-related recovery and less restriction on upper body movement afterward.
The trade-off is that MIDCAB works best for bypassing one or two vessels on the front of the heart. If you need three, four, or five grafts across multiple areas, a full sternotomy usually remains necessary to reach them all.
Robotic totally endoscopic coronary artery bypass (TECAB) takes the minimally invasive concept further, using robotic arms inserted through small port incisions. No bones are cut. The exclusion criteria are relatively narrow: emergency cases, severely weakened heart muscle, and patients whose left chest cavity is scarred from previous lung surgery. For everyone else, it’s at least a theoretical option, though availability depends heavily on the surgical center and the team’s experience with the technology.
Recovery and Sternal Precautions
If you have the traditional sternotomy, the bone needs time to knit back together, much like any other fracture. Most patients reach initial stability within 4 to 6 weeks, though full bone healing can take closer to 10 weeks. Chest pain or soreness commonly persists for 8 to 12 weeks after the procedure.
During those early weeks, you’ll be given specific restrictions to protect the healing sternum. The details vary by hospital. The Cleveland Clinic, for example, advises against lifting anything over 20 pounds for the first 6 to 8 weeks. Ohio State Medical Center sets that limit at 10 pounds for 6 weeks. Most programs also restrict pushing and pulling motions, reaching both arms overhead, and movements that pull the shoulder blades together forcefully. The goal is to prevent the two halves of the breastbone from shifting before they’ve fused.
In practical terms, this means you won’t be driving for several weeks, you’ll need help with groceries and household tasks, and you’ll use a small pillow pressed against your chest when coughing or sneezing. Getting in and out of bed involves rolling to your side rather than sitting straight up, which puts less stress on the sternum.
Pain Compared to Other Chest Approaches
Sternotomy is actually less painful than the alternative of going in through the side of the chest between the ribs (posterolateral thoracotomy), which involves cutting through muscle and spreading ribs apart. Research comparing sternotomy to video-assisted approaches found that pain scores, chest tube duration, and hospital stays were broadly similar between the two methods. Sternotomy patients did use slightly more pain medication around days five and six after surgery, and reported somewhat higher pain scores toward the end of the first week. But the overall differences were modest.
Most patients describe the sternotomy pain as a deep ache or pressure rather than sharp pain, especially once the first few days pass. The discomfort is generally well-managed with medication and improves steadily week by week.
Wound Infection Risk
The overall rate of infection at the sternotomy site is about 1.6%. Most of these are superficial infections that respond to treatment. Deep sternal wound infections, which reach the bone itself, are rarer but significantly more serious, with a mortality rate as high as 16.5% when they do occur. Risk factors include diabetes, obesity, and use of both internal chest arteries as grafts (which reduces blood supply to the breastbone). Your surgical team takes extensive precautions to minimize this risk, including antibiotic dosing before the incision and careful wound closure techniques.
Signs to watch for during recovery include increasing redness, warmth, or drainage at the incision site, fever, and any sensation of the breastbone clicking or shifting with movement. Catching a problem early makes a significant difference in outcomes.