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PubMed2004

The infected median sternotomy wound: management with the rectus abdominis musculocutaneous flap.

Treatment of patients with infected median sternotomy wounds includes debridement and closure using vascularized tissue, most often the pectoralis major muscle. However, occasionally, surgeons use other flaps to close sternotomy wounds. The purpose of this study is to review 1 center's experience with infected median sternotomy wounds utilizing a less common technique, the rectus abdominis musculocutaneous flap.

Adolescent↗
PubMed2006

Definitive closure of the infected median sternotomy wound: a treatment algorithm utilizing vacuum-assisted closure followed by rigid plate fixation.

Mediastinitis and sternal wound dehiscence are devastating and life-threatening complications of median sternotomy incision. Ten consecutive patients between July 2001 and May 2005 were diagnosed with sternal wound infection and dehiscence following median sternotomy. Patients were managed by precise debridement and wound excision in the operating room and then dressed with vacuum-assisted closure device. Intravenous antibiotics were prescribed for wound and blood culture microbiological sensitivity. When wounds were bacteriologically controlled, patients returned to the operating room for definitive closure using rigid sternal plating. All patients were extubated postoperatively. No patients died. Average total hospital stay was 21 days. The pectoralis advancement flap was exclusively used for soft tissue reconstruction in 7 patients. There were 2 cases of chronic superficial sternal infection requiring plate removal; however, bony union of the sternum was achieved in all patients. This treatment algorithm provides a useful management strategy for patients with complicated median sternotomy.

Adult↗
PubMed1987

The inframammary incision for median sternotomy in pediatrics.

Median sternotomy offers the ideal exposure for most cardiac and mediastinal procedures. One infrequently mentioned morbidity of the traditional median sternotomy is the unsightly scar, especially in pediatric and adolescent patients who are extremely sensitive about their body appearance. We report our experience using a bilateral inframammary "butterfly" incision on 31 patients in association with a median sternotomy to provide excellent exposure and an improved cosmetic result.

Breast↗
PubMed1988

Sternotomy closure with Parham bands.

The closure of a median sternotomy incision requires secure bony approximation to prevent postoperative pain, sternal click, and/or nonunion of bone. The standard technique of sternotomy closure involves the use of stainless steel wires for reapproximation of the sternum. These wires occasionally break or pull through bone, resulting in instability of either a portion of the sternum or the entire sternum. Presented here is our technique for sternotomy closure that provides secure closure with reduced postoperative morbidity.

Bone Wires↗
PubMed1991

The risk factors of median sternotomy infection: a current review.

Sternal sepsis following median sternotomy is an infrequent yet devastating complication of cardiac surgery, leading to prolonged hospitalization, increased hospital expense, and a high associated morbidity and mortality. The development of sternotomy infection is multifactorial. Numerous prospective and retrospective studies have pointed to a multitude of clinical and perioperative variables as being causative, with as many other studies presenting evidence of the contrary. This has led to confusion about which clinical variables should be modified so as to minimize the individual patient's risk for developing this severe complication. Other less obvious factors also come into play. Malnutrition, whether overt or subclinical, is not uncommon in cardiac patients. Immune competency is affected by operative trauma, as well as a variety of perioperative factors including underlying nutritional status, transfusion, cardiopulmonary bypass, and anesthesia. This creates a complex milieu for the development of postoperative infection. In this review, the multiple risk factors of median sternotomy infection are studied and treatment options briefly discussed.

Cardiac Surgical Procedures↗
PubMedDate not supplied

Reoperative median sternotomy using a cast spreader.

Repeat median sternotomy carries a high mortality rate secondary to a higher incidence of injury to the underlying vital structures. The reported incidence of reentry accidents may be as high as 6% to 10%. We describe a new technique of redo sternotomy using a nitrogen-powered oscillating saw and a cast spreader. The new technique was used for 89 consecutive cases without any incidence of injury to the underlying structures. The use of a case spreader during repeat median sternotomy may enhance the safety of reentry.

Humans↗
PubMedDate not supplied

Postoperative chylothorax: differences between patients who received median sternotomy or lateral thoracotomy for congenital heart disease.

BACKGROUND: Chylothorax after surgery for congenital heart disease is rare. We wanted to compare the different presentations of chylothorax in patients who received median sternotomy or lateral thoracotomy. PATIENTS AND METHODS: We retrospectively studied pediatric patients with congenital heart disease who received palliative or corrective surgeries and developed postoperative chylothorax between January 1992 and July 2003. Patients were divided into two groups by the type of surgery: median sternotomy and lateral thoracotomy. The average daily fluid amount (mL/kg/24 hours), latency period, duration of chylothorax, and requirement for surgery were compared. RESULTS: Seventeen patients (11 boys, 6 girls; mean age, 14.0 +/- 12.8-month-old) were enrolled. Diagnoses were tetralogy of Fallot (n = 8), right isomerism with complex heart defects (n = 3), patent ductus arteriosus (n = 2), transposition of the great artery (n = 1), ventricular septal defect (n = 1), and endocardial cushion defect (n = 2). There were 9 in the lateral thoracotomy group and 8 in the median sternotomy group. Only one patient required surgery because of the failure of conservative treatment. The lateral thoracotomy group had a significantly lower average body weight (6.9 +/- 2.9 kg vs. 11.0 +/- 3.8 kg) and longer average latency period before postoperative chylothorax (15.1 +/- 9.2 days vs. 7.2 +/- 4.7 days). CONCLUSION: The majority of pediatric patients who develop chylothorax after cardiac surgery can be successfully managed by medical treatment only. To avoid complications in pediatric patients after cardiac surgery, chylothorax should be suspected for patients with unexplainable, prolonged, and abundant pleural effusion.

Cardiac Surgical Procedures↗
PubMed1994

Type 1 procollagen as a marker of severity of scarring after sternotomy: effects of topical corticosteroids.

AIMS: To determine whether the abundance of newly formed collagen in healing surgical wounds correlated with scar severity, and whether topical application of steroid cream reduced new collagen formation in patients who have undergone median sternotomy. METHODS: Thirty three patients six weeks after sternotomy, and 12 controls were studied. Scars were photographed, and biopsy specimens from scars at sites treated or untreated with topical corticosteroids (clobetasol proprionate 0.5%) were examined using immunohistochemical staining for type 1 procollagen (PCP 1) and transforming growth factor beta (TGF-beta), and in situ hybridisation for type 1 procollagen messenger RNA (mRNA). RESULTS: The degree of hypertrophy of the scar and the abundance of PCP 1 immunostaining were ranked independently, blind, and a correlation between these two variables was observed (r = 0.604, p < 0.001). The PCP 1 immunostaining was accompanied by a great abundance of PCP 1 mRNA and only a slight increase in TGF-beta immunostaining, when compared with normal skin or mature scars. Following the application of topical corticosteroids, for either 48 hours or twice daily for seven days, there was no reduction in PCP 1 immunostaining nor the abundance of PCP 1 mRNA. CONCLUSIONS: These data suggest that the extent of new collagen formation as assessed by PCP 1 immunohistochemistry may be a useful marker of the exuberance of the scarring process following sternotomy, and that topical corticosteroids are ineffective in reducing this component of the fibrotic response.

Base Sequence↗
PubMed2004

Interlocking sternotomy: initial experience.

An interlocking sternotomy using a lazy-S-shaped incision was performed in 91 patients undergoing cardiac surgical procedures (group A). The results were compared with those of 77 patients (group B) who underwent a standard sternotomy by the same surgical team. In group A, the incidence of sternal instability was 2.27% (2/88) versus 8.21% (6/73). No dehiscence or mediastinitis was noted in group A, whereas 6.85% (5/73) in group B had this complication. Analysis of diabetics revealed no sternal complication in group A compared to 50% (3/6) in group B. The interlocking sternotomy significantly reduced the incidence of sternal instability and helped to prevent sternal dehiscence and mediastinitis. Use of this safe, simple, and reproducible technique is strongly recommended, especially in diabetics.

Adolescent↗
PubMedDate not supplied

An alternative, less invasive approach to median sternotomy for cardiac operations in adults: right infra-axillary minithoracotomy.

We compared the use of right infra-axillary minithoracotomy and conventional median sternotomy in direct open-heart surgery in 59 adults undergoing elective surgery for mitral valve stenosis, mitral valve disease, atrial septal defect repair, left atrial myxoma excision or mitral and tricuspid valve disease. Patients were randomized to the infra-axillary minithoracotomy group (Group A; n = 29) or the median sternotomy group (Group B; n = 30). Post-operative outcomes (post-operative bleeding; cross-clamp time; length of hospital and intensive care unit stays; and post-operative blood transfusion and analgesic requirements) were recorded and compared; they were found to be significantly lower in Group A than Group B. We concluded that right infra-axillary minithoracotomy is less invasive and can be used safely in adults as an alternative approach to conventional median sternotomy for some cardiac operations. Further multicentre studies in adults are now needed.

Adult↗
PubMed1989

Effect of sternotomy and coronary bypass surgery on postoperative pulmonary mechanics. Comparison of internal mammary and saphenous vein bypass grafts.

Coronary artery bypass grafting (CABG) is commonly performed via a median sternotomy with a reversed saphenous vein (SV) and/or an internal mammary artery (IMA) graft. Sternotomy and IMA harvesting may adversely affect postoperative respiratory function (PFTs) as disruption of the sternun may impair chest wall stability, and the decrease in intercostal muscle blood supply after removal of the IMA may reduce the force of respiration. We compared preoperative and six- to eight-week postoperative PFTs in patients undergoing CABG. The results were independent of age, sex, number of grafts, aortic cross clamp time, duration of bypass run, and postbypass fluid gradient. It was concluded that sternotomy caused a decrease in postoperative PFTs and that IMA harvesting may be accompanied by greater impairment in PFTs than when SV grafts alone were used.

Aged↗
PubMed2004

A steel band in addition to 8 wire cerclages reduces the risk of sternal dehiscence after median sternotomy.

BACKGROUND: Sternal dehiscence after full median sternotomy may result in wound-healing disorders, including osteomyelitis. The consequences are extended hospitalization, plastic surgery, stress for the patient, and increased costs. Stable closure of the median sternotomy plays a crucial role in the avoidance of sternal dehiscence and osteomyelitis. METHODS: All patients who underwent full sternotomy from January 1999 until December 2001 were investigated with respect to the incidence of sternal dehiscence. Since January 2000, patients supposed to be at risk for sternum dehiscence were more frequently treated with an Ethicon steel band at the third intercostal space in addition to standard osteosynthesis with 8 wire cerclages. RESULTS: Since the introduction of this method, the incidences of sternal dehiscence and sternal wound infections decreased from 2.9% and 0.9 %, respectively, in 1999 to 0.3% and 0.2%, respectively, in 2001. This decline resulted in shorter postoperative hospital stays, less stress for the patients, and substantial reductions in postsurgical costs. CONCLUSIONS: A steel band used in addition to standard osteosynthesis with 8 wire cerclages is a safe and effective procedure resulting in a statistically significant decrease in the frequency of sternal dehiscence.

Aged↗
PubMedDate not supplied

Closure of median sternotomy in dogs: suture versus wire.

Twenty normal, large-breed dogs underwent median sternotomy. Median sternotomies were closed with 20-gauge orthopedic wire in 10 dogs and no. 2 polybutester in 10 dogs. Closure with suture was faster than with wire (6.7 +/- 1.8 minutes versus 9.1 +/- 1.9 minutes, respectively). Significant differences were not observed in degree of postoperative pain or wound complication rates. Sternotomies closed with wire showed a trend to be more stable and had significantly less displacement on radiographic evaluation at 28 days. All sterna closed with wire examined histopathologically showed evidence of chondral or osteochondral bridging, while sterna closed with suture only showed fibrous union.

Animals↗
PubMed1998

[Lower mid-line skin incision and minimal sternotomy in pediatric open heart surgery--an alternative cosmetic approach].

Full median sternotomy has been the standard approach for open heart surgery. However, it leaves an unsightly surgical scar. We therefore designed a lower mid-line skin incision and minimal sternotomy approach as a cosmetic alternative. Since February 1993, 78 pediatric patients with congenital heart disease have undergone this open heart surgery procedure. Their ages ranged from 1 month to 13 years (median: 2 years and 7 months) and body weights ranged from 2.4 to 43 kg (median: 11.5 kg). Thirty-one patients had atrial septal defect, 34 perimembranous ventricular septal defect, 9 subpulmonary ventricular septal defect, and 4 other cardiac anomalies. All cannulations for cardiopulmonary bypass could be performed through this approach. No patients required conversion to standard median sternotomy and no peri- or postoperative complications related to this approach, such as injury to the great artery and vein, air embolism, or sternal deherence, were noted. This approach is technically easy and an excellent cosmetic approach in pediatric open heart surgery.

Adolescent↗
PubMed2000

[J-sternotomy approach for aortic valve reoperation].

Recent progress in cardiovascular surgery has promoted less non-invasive surgery. We reoperated in a forty-two year old female for aortic valve regurgitation using the J-sternotomy approach and experienced good results. The patient was operated on with AVR 12 years after her first cardiac operation. Chest computed tomography revealed an adhesion between the anterior chest wall and the right ventricle. We made a sternal incision from the sternal notch down to the fourth right intercostal space (J-sternotomy). Ascending aorta was cannulated in the conventional manner. A conventional Two-stage cannula was placed in the auricle of the right atrium. A venting tube was also cannulated through the right upper pulmonary vein. J-sternotomy and minimal adhesionectomy made for a good operative field to establish cardiopulmonary bypass and to perform aortic valve re-operation.

Adult↗
PubMed2001

Reconstruction of the median sternotomy wound dehiscence using the latissimus dorsi myocutaneous flap.

BACKGROUND: Currently the internal thoracic artery (ITA) is the conduit of preference for coronary artery revascularization. Although this artery offers several advantages over the saphenous vein there is a higher incidence of postoperative sternal wound infection with its use. This incidence further increases with the use of bilateral internal thoracic arteries (BITA). The use of muscle or omental flaps to treat this complication has significantly reduced the morbidity and mortality. Typically the pectoralis major (PM) or the rectus abdominis (RA) muscles are the preferred method of reconstruction of the infected sternotomy wound. METHODS: In a retrospective study over a four-year period from February 1994 to October 1998, nine patients underwent reconstruction of an infected median sternotomy wound with a latissimus dorsi myocutaneous flap (LDMF). RESULTS: All of the patients in our study were successfully treated with a single LDMF with the exception of one who required a rectus abdominis flap to cover the lateral aspect of the recalcitrant poststernotomy infected wound. There was a single patient who had a wound dehiscence at the donor site. CONCLUSIONS: The LDMF is reliable and serves as an adjunct for treating sternotomy infections. The flap provides sufficient amount of pedicle length and muscle mass for coverage. Although there is a need to turn the patient into a lateral decubitus position once the debridement is performed the flap harvest and its mobilization is technically straightforward with a short operative time, 135 minutes on average with a range of 97 to 171 minutes. Furthermore, there exists an anatomical advantage in using the LDMF; harvest of the LDMF does not disrupt collateral blood supply to the sternum and parasternal tissues.

Arteries↗
PubMed2002

Coronary artery bypass grafting through complete sternotomy in conscious patients.

BACKGROUND: Complete sternotomy is the standard approach in cardiac surgery, and coronary artery bypass grafting (CABG) is the most common revascularization procedure to use this approach. A new technique has been developed that permits complete surgical revascularization with arterial grafts in awake patients. This technique, which we refer to as awake coronary artery bypass grafting, avoids general anesthesia, mechanical ventilation, and extracorporeal circulation, thereby creating the least invasive method for heart operations yet described. METHODS: A thoracic epidural catheter was placed at T2-T3 level one day before surgery. In 12 patients, single (n = 6), double (n = 5), or triple (n = 1) vessel coronary artery bypass grafting was performed without general anesthesia. In six patients, this procedure was performed after complete median sternotomy. RESULTS: Ten patients remained awake throughout the whole procedure. Two patients required secondary intubation due to incomplete analgesia in one case and pneumothorax in the other. Procedural time was 98.2 +/- 19.8 minutes. Intermediate care stay was 4.9 +/- 0.6 hours. There were no perioperative complications, and early angiographic results before discharge were excellent in all patients. CONCLUSIONS: The data presented show the feasibility and safety of complete surgical revascularization via median sternotomy using arterial grafts without general anesthesia. This approach shortens recovery time and increases patient comfort, suggesting that outpatient cardiac surgery may eventually be possible.

Aged↗
PubMed2002

[Myocardial revascularization via a median sternotomy without cardiopulmonary bypass in 250 patients--midterm results and study of graft patency].

OBJECTIVES: To evaluate mid-term results and one-year graft patency of less invasive coronary artery bypass grafting through a median sternotomy. METHODS: From January 1, 1998, to December 31, 1999, 250 patients had coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) through a median sternotomy. The patient base of 188 men and 62 women averaged 61.7 years, mean ejection fraction (EF) was 55.1%. An average of 2.7 (range 1 to 5) distal anastomoses per patient was achieved. Results are compared with a CPB subgroup of patients operated on through a median sternotomy in the same time (N = 1126). In a random subgroup of 100 patients (50 per group) an angiographic control of graft patency was done. RESULTS: A non-CPB group showed lesser occurrence of postoperative acute myocardial infarction (p = 0.038), atrial fibrillation (p = 0.029) and lower incidence of renal (p = 0.033) complications. We observed lower operative mortality (p = 0.019), as well as the occurrence of low cardiac output syndrome (p < 0.001) in the off pump group. The follow-up is 36 +/- 12 months and the number of patients with recurrent angina (5.4%), late AMI (0%) and late death (0.4%) is acceptable. We did not find an inordinate number of vein grafts occlusions (2.2%) and stenoses (7.8%) at anastomotic sites. None of the arterial grafts in both groups were occluded. CONCLUSIONS: We detected lower incidence of postoperative complications and decreased operative mortality in a non-CPB group. Angiographic assessment displayed an excellent run-off in both groups of patients. Off-pump coronary bypass grafting is associated with sufficient short-term graft patency and mid-term clinical outcomes.

Adult↗