|2009 Annual Meeting Abstracts
400 Consecutive Infected Sternal Wound Reconstructions with Description of Split Omental Technique
Shayan A. Izaddoost, MD, PhD, Edward H. Withers, MD.
Baylor College of Medicine, Houston, TX, USA.
PURPOSE: The successful treatment of sternal wound infections requires close collaboration between the cardiovascular surgeon and plastic surgeon. Immediate detection of infection, meticulous debridement and ultimately, the introduction of vascularized tissue are essential for complete healing.
METHODS: 400 consecutive sternal wound reconstructions performed over 32 years by one surgeon (the senior author) at St. Luke’s Episcopal Hospital and The Methodist Hospital in Houston, Texas, were reviewed retrospectively. Initially a one-stage debridement with omental wound closure was employed. This led to a high mortality rate from sepsis (3 deaths in 12 patients [25%]). Subsequently, a multistage approach evolved with meticulous debridement initially, followed by vascularized flap coverage. Omental, pectoralis, and rectus flaps were used singularly and in various combinations.
Using the Pairolero and Arnold classification, sternal wounds are divided into three classes. Type I sternal wounds, occur within 1 week of surgery and demonstrate a high amount of drainage but no cellulitis or sternal involvement. These types of wounds were debrided, rewired or tightened and covered with a split omentum or pectoralis muscle. The split omentum allows for colsure of dead space behind and infront of the sternum. Type II wound infections occurring in the 2nd to 4th week post operatively and involving cellulitis and mediastinal purulent drainage. Type III infections are chronic sternal infections with drainage occurring months to years after surgery. They usually demonstrate osteomyelitis. Type II and III wounds were debrided with wire removal.
Early in the series (first 50 patients) wounds were closed using omental flaps only. Midway in the series most were covered with muscle flaps, using the pectoralis most often. Occasionally the rectus abdominus was used. We now favor a multiflap closure using a combination of muscle and omental flaps for most Type II and III wounds. The omental flap is used as filler and the muscle flaps for vascularity. These (3) flaps eliminate dead space and vascularize the wound. Recently, 10 patients with Type I wounds were treated acutely with a split omental flap. This covers the anterior and posterior sternum with one flap. No muscle is used.
Following the early septic deaths, three patients expired acutely during the latter parts of this series from hemorrhage (0.7%). Three patients required reoperation, one for a retained sternal wire and two for continued infection and dehiscence. Six patients demonstrated marginal skin necrosis (1.5%), two had seromas (0.5%), and two patients had hematomas requiring drainage (0.5%). Three patients complained of a symptomatic hernia and one was repaired (0.7%). In all, six patients were reoperated on out of 388 (1.5%).
Sternal wound infections should be recognized early and treated aggressively. There is a low morbidity and mortality associated with muscle and omental flap coverage. The split omental flap may reduce the need for muscle flaps. Most patients were discharged five to seven days postoperatively. Donor site morbidity is low and well tolerated. The hallmark of effective, safe treatment of sternal wounds is early detection, meticulous debridement and coverage with well-vascularized tissues.