The laparoscopically harvested omental flap for deep sternal wound infection

Abstract

To report our experience with the laparoscopically harvested omental flap in the treatment of deep sternal wound infection, and to present a modification and introduce two supportive techniques in the perioperative management. Between June 2005 and September 2007, six patients with grade IV (El Oakley-Wright classification) deep sternal wound infection following a median sternotomy for coronary artery bypass grafting underwent a reconstruction with a laparoscopically harvested omental flap. The median age of the cohort of six, consisting of one female and five males, was 67 years (range: 61-77 years). In five patients, an unilateral internal thoracic artery had been used. Considerable preoperative risk factors were present: one patient suffered from severe chronic obstructive pulmonary disease (COPD) Forced expiratory volume in 1s (FEV1)1L; two from moderate chronic obstructive airway disease, three from insulin-dependent diabetes mellitus and three were on glucocorticoid steroid therapy preoperatively. Abdominal surgery had previously been performed in four patients. In all cases, the mediastinal wound was prepared with vacuum-assisted (<or=125 mmHg) therapy following debridement and pulsed irrigation. White, small-pore foam was placed over the right ventricle when the risk of adhesion to the sternal remnants or secondary haemorrhage was a concern. In all cases, the position of the spread-out omental flap was maintained intrathoracically with autologous fibrin glue and in one case the split-skin graft covering the flap was also dealt with in this way. In the five other cases, the omental flap was covered by mobilising and advancing the local soft tissue and skin towards the midline. Portable sonography proved useful in monitoring the doubtful intrathoracic flap. The 30-day perioperative mortality rate was zero, with a 2-year overall survival of 100%. One patient received a temporary colostomy due to a partial transverse colon necrosis. Follow-up ranged from 20 to 53 months (median: 39 months) for the group as a whole. Death occurred in one case 2.8 years after reconstruction due to reasons other than cardiac or mediastinal conditions. The laparoscopically harvested omental flap can contribute to a successful outcome following deep sternal wound infection and deserves serious consideration in type IV mediastinitis in particular, regardless of the co-morbidity or previous abdominal surgery.