Sternal Wound Reconstruction Research Articles

Choice of flap for the management of deep sternal wound infection – an anatomical classification

Infection of a median sternotomy wound is a rare albeit potentially fatal complication because of the risk of mediastinitis and deep sternal wound infection. Current treatment of deep sternal wound infection comprises antibiotics, debridement and transposition of muscle or omental flaps to fill the anterior mediastinal dead space. A retrospective analysis of the deep sternal wound infections treated in our unit over a nine-year period was performed. Out of the 11 903 consecutive coronary artery bypass graft procedures performed, 27 patients were referred to plastic surgery for management of deep sternal wound infection with flaps. Wounds were classified based on their location on the sternum as type A (upper (1/2)), B (lower (1/2)) or C (whole of sternum). Five patients had type A wounds, 12 type B wounds and 10 type C wounds. The mean age was 68 years and the M:F ratio was 20:7. We describe guidelines for the choice of flap for sternal wound reconstruction, according to the anatomical site of the wound dehiscence.

Sternotomy Reconstruction with Omentum Followed by Large Diaphragmatic Hernia

Poststernotomy mediastinitis carries significant morbidity and mortality. Aggressive wound debridement combined with a pedicled omental flap, with or without a pedicled muscle flap, has gained acceptance in the management of difficult sternal wound infections. Two cases of poststernotomy mediastinitis and sternal wound reconstruction with a pedicled omental flap were complicated by a large anterior diaphragmatic hernia containing the large bowel.

Sternal wound reconstruction: 252 consecutive cases. The Lenox Hill experience.

The authors report on a personal experience of 252 consecutive secondary sternal wound closures resulting from a series of 11,601 median sternotomies at a single institution performed over a 14-year period. Protocols for treatment are described from the time of initial consultation with the plastic surgeon through the period of postoperative care. The patients and wounds were diverse and complex, with each factor requiring careful analysis before a treatment course was selected. Complete and thorough wound débridement with the elimination of dead space ensured by the placement of healthy tissue and the maintenance of active suction at the operative site were the common elements of success.

Laparoscopic Omental Harvest for Flap Coverage in Complex Mediastinitis

Mediastinitis is one of the most serious complications of cardiac surgery. The standard of care in mediastinitis includes thorough sequential debridement, flap coverage, and culture-directed antibiotics. The most frequently utilized muscles for flap reconstruction include the rectus abdominus and the pectoralis major. However, in some instances these flaps may be inadequate, unavailable, or fail, thus requiring an alternative choice or adjuvant. Most coronary graft procedures utilize the left internal mammary artery, frequently eliminating the left rectus muscles, while prior open cholecystectomy patients frequently lose availability of their right rectus muscle. In addition, radiation therapy or prior flap failure may exclude other muscle transfer procedures. The omentum offers excellent coverage due to mobility and superb arterial and lymphatic flow. Unfortunately, in the past, this has required a celiotomy in an already critically ill patient. We present a series of 5 patients where the omentum was mobilized laparoscopically and passed through an anterior diaphragmatic incision. This option spares a celiotomy, seals the wound, and hastens recovery in very ill patients. We also present a complete review of literature on the topic and provide an algorithm for complex sternal wound reconstruction.

Sternal wound infection after heart transplantation: incidence and results with aggressive surgical treatment

Background. Sternal wound infection remains a significant complication. We reviewed the incidence and the treatment of sternal wound infection after heart transplantation. Methods. Of 226 patients who had a heart transplantation, 20 (8.8%) underwent postoperative wound debridement for superficial or deep sternal wound infection. The incidence and the survival of patients with sternal wound infection were analyzed. Results. The incidence of sternal wound infection was similar among patients treated with four protocols of immunosuppressive drugs: cyclosporine and prednisone (0 of 22; 0%); cyclosporine, prednisone, and azathioprine (2 of 24; 8.3%); cyclosporine, prednisone, azathioprine, and antithymocyte globulin (15 of 139; 10.8%); and cyclosporine, prednisone, mycophenolate mofetil, and antithymocyte globulin (3 of 41; 7.3%) ( p = 0.4). Six-month and 5-year survival of patients with sternal wound infection averaged 85% ± 8% and 74% ± 10% compared with 92% ± 2% and 82% ± 3% in patients without wound infection ( p = 0.15). Patients with deep sternal wound infection, debridement, and reconstruction had a 5-year survival averaging 80% ± 10%. Conclusions. The incidence of sternal wound infection remains similar between patients treated with the triple drug therapy. Surgical debridement and reconstruction can result in long-term survival after heart transplantation.

Abdominal recovery after laparotomy and omental transposition into a grossly contaminated median sternotomy wound.

Grossly contaminated median sternotomy wounds are frequently treated with transposed omental flaps. A laparotomy adjacent to such an infected wound carries the risk of peritonitis. It has been suggested that this risk may increase when the omentum, which has anti-infective properties, is removed from the abdominal cavity and is transposed to the chest. The authors evaluated abdominal recovery after laparotomy and omental transposition into an adjacent, grossly contaminated median sternotomy wound. The study group included 15 patients who had sternal wound reconstruction with an omental flap between 1990 and 1998. All patients underwent median sternotomy reconstruction according to a "two-compartment" operative sequence protocol, which included division of the surgical field into an upper (thoracic) contaminated zone and a lower (abdominal) clean zone. The control group was comprised of 15 patients who underwent elective laparotomy for splenectomy during the same time period. The effect of the surgical procedure on the abdomen was compared between the two groups. The timing of the reappearance of peristalsis and regular bowel function, and the incidence of bowel obstruction and postoperative peritonitis were similar in the two groups. The findings indicate that laparotomy and omental transposition in the presence of a grossly contaminated median sternotomy wound is a safe procedure, and is associated with a low rate of abdominal complications.

Painful Pectoralis Major Myospasm as a Result of Sternal Wound Reconstruction: Complete Resolution with Bilateral Pectoral Neurectomies

Painful Pectoralis Major Myospasm as a Result of Sternal Wound Reconstruction: Complete Resolution with Bilateral Pectoral Neurectomies

Management of the infected median sternotomy wound with muscle flaps. The Emory 20-year experience.

The purpose of the study is to define those patient variables that contribute to morbidity and mortality of median sternotomy wound infection and the results of treatment by debridement and closure by muscle flaps. Infection of the median sternotomy wound after open heart surgery is a devastating complication associated with significant mortality. Twenty years ago, these wounds were treated with either open packing or antibiotic irrigation, with a mortality approaching 50% in some series. In 1975, the authors began treating these wounds with radical sternal debridement followed by closure using muscle or omental flaps. The mortality of sternal wound infection has dropped to < 10%. The authors' total experience with 409 patients treated over 20 years is described in relation to flap choices, hospital days after sternal wound closure, and incidence rates of morbidity and mortality. One hundred eighty-six patients treated since January 1988 were studied to determine which patient variables had impact on rates of flap closure complications, recurrent sternal wound infection, or death. Variables included obesity, history of smoking, hypertension, diabetes, poststernotomy septicemia, internal mammary artery harvest, use of intra-aortic balloon pump, and perioperative myocardial infarction and were analyzed using chi square tests. Fisher's exact tests, and multivariable logistic regression analysis. The mortality rate over 20 years was 8.1% (33/49). Additional procedures for recurrent sternal wound infection were necessary in 5.1% of patients. Thirty-one patients (7.6%) required treatment for hematoma, and 11 patients (2.7%) required hernia repair. Among patients treated since 1988, variables strongly associated with mortality were septicemia (p < 0.00001), perioperative myocardial infarction (p = 0.006), and intra-aortic balloon pump (p = 0.0168). Factors associated with wound closure complications were intra-aortic balloon pump (p = 0.0287), hypertension (p = 0.0335), and history of smoking (p = 0.0741). Factors associated with recurrent infection were history of sternotomy (p = 0.008) and patients treated for sternal wound infection from 1988 to 1992 (p = 0.024). Mean hospital stay after sternal wound reconstruction declined from 18.6 days (1988-1992) to 12.4 days (1993-1996) (p = 0.005). To clarify management decisions of these difficult cases, a classification of sternal wound infection is presented. Using the principles of sternal wound debridement and early flap coverage, the authors have achieved a significant reduction in mortality after sternal wound infection and have reduced the mean hospital stay after sternal wound closure of these critically ill patients. Further reductions in mortality will depend on earlier detection of mediastinitis, before onset of septicemia, and ongoing improvements in the critical care of patients with multisystem organ failure.