Transposition of the great omentum for infected sternotomy wounds in cardiac surgery. Report of 16 cases and review of published reports

Laparoscopic Harvest of an Omental Flap to Reconstruct an Infected Sternotomy Wound

Sternotomy dehiscence is associated with a high mortality rate. In most cases this complication may be treated by simple debridement and antibiotic therapy, but sometimes it is necessary to fill the sternal defect with viable tissue. The greater omentum seems to be the ideal tissue to be transposed because of its malleability, good vascularization, and high lymphatic tissue content. The transposition of the greater omentum usually requires a midline laparotomy for the preparation of the flap, with significant laparotomy-related morbidity. Laparoscopic access may represent an effective alternative for preparing and transposing the omental flap. The key points of the laparoscopic technique are (1) the coloepiploic detachment, (2) the section of the anastomotic arterial branches between the Barkow's arcade and the gastroepiploic arcade, (3) the mobilization of the greater omentum pedicled on the right gastroepiploic artery, and (4) its transposition into the mediastinum, taking care to avoid twisting the gastric greater curvature and the flap itself.

Laparoscopically harvested omental flap for chest wall and intrathoracic reconstruction

Minimally invasive surgery has gained popularity in the last decade and its applications to plastic surgery are expanding. Pedicled omental flaps are used for the reconstruction of chest wall defects following debridement of sternal infections and mediastinitis. The main advantages of using an omental flap are its large size and bulk to fill large 3-dimensional dead spaces, long pedicle, and rich vascular and lymphatic networks. Recently, laparoscopic techniques have been described for harvesting omental flaps. Over the last 5 years in our institution, 9 laparoscopic omental flap harvests were performed. Seven were used in the reconstruction of complicated chest wall defects, sternal infections, mediastinal abscesses, and mediastinitis following cardiac surgery. Two were used to repair intrathoracic viscera. Prior abdominal surgery was not a contraindication to the laparoscopic harvest. In 1 patient, the omental transfer was converted to a free flap due to the detachment of the pedicle, and in 1 patient the omental harvest was converted to open technique due to technical difficulty due to severe abdominal adhesions. None of the patients had major intraabdominal complications postoperatively. One patient had a small transdiaphragmatic hernia treated by laparoscopic techniques. The use of laparoscopy techniques facilitated the harvesting of the omentum, making it ideal in the treatment of complicated patients with multiple comorbidities. With these techniques, pedicled omental flaps will be a reasonable treatment option for chest wall reconstruction.

Pedicled myocutaneous and muscle flaps in the management of complicated cardiothoracic problems

The purpose of this study was to review our experience with the management of patients with complicated cardiothoracic problems by the use of pedicled myocutaneous or muscle flaps, and discuss the various methods of reconstruction. Over the last 11 years, we have treated 54 patients with complicated cardiothoracic problems by reconstruction with pedicled myocutaneous or muscle flaps. The underlying causes were chest wall tumours (n = 13), radionecrosis of the chest wall (n = 12), deep or chronic sternal infections (n = 25), and bronchopleural fistulas (n = 4). The most commonly used muscles for reconstruction were pectoralis major and the rectus abdominis. Our results compare favourably with those reported elsewhere. We conclude that although the use of pedicled myocutaneous or muscle flaps is not free of complications, it is an effective and reliable method for the management of patients with complicated cardiothoracic problems.

Two-Stage Reconstruction of Infected Deep Median Sternotomy Wound With an Intercostal Pedicled Oblique Rectus Abdominis Musculocutaneous Flap After Coronary Artery Bypass Grafting

Median sternotomy wounds infected after coronary artery bypass grafting with bilateral internal mammary arteries are generally poor in condition, cannot be debrided adequately, and are limited in flap selection for reconstruction. The authors treated 2 patients with two-stage reconstruction using a modified superior-based rectus abdominis musculocutaneous flap. First, simple debridement was performed with the goal of preserving the internal mammary artery grafts. Then, delayed reconstruction with the oblique rectus abdominis musculocutaneous flap supplied by the superior epigastric and seventh intercostal vessels was performed. Despite ligature of the bilateral internal mammary arteries at their full length, the large oblique skin paddle designed along the angiosome as far as the midaxillary line survived almost completely in both patients, resulting in cessation of pus discharge. The circulation to the superior epigastric and intercostal vessels might be reinforced because of the delay phenomenon. Two-stage reconstruction with a superior pedicled oblique rectus abdominis musculocutaneous flap presents a successful resolution of infected median sternotomy wounds after coronary artery bypass grafting with sacrifice of bilateral internal mammary arteries.

Laparoscopic mobilization of an omental flap for reconstruction of an infected sternotomy wound

The omentum is used for reconstruction of intra- and extra-abdominal wounds because of its high vascularity and immunological properties. It is used most often in patients in whom sternal wound infection develops after coronary artery bypass grafting. The major drawback of using the omentum is the necessity of performing a laparotomy to dissect and mobilize it to the thorax. The authors report their experience with an 81-year-old man, on whom they performed laparoscopic dissection and mobilization of the omentum, and transfer of the omentum based on its blood supply from the left gastroepiploic artery to reconstruct an infected sternal wound. The current literature is reviewed as well. The authors conclude that obtaining an omental flap via a laparoscopic approach is feasible and safe. It should be considered whenever an omental flap is needed outside the abdominal cavity. This approach mandates close collaboration between the plastic and the laparoscopic surgeons.

Radical sternectomy and primary musculocutaneous flap reconstruction to control sternal osteitis

OBJECTIVE

Sternal osteitis after median sternotomy is associated with considerable morbidity and mortality. The use of muscle and omentum flaps has been proved as valid adjunct to combat these severe infections. In this study we present our experience with a more radical approach.

METHODS

Sternectomy consisted of the resection of the entire sternum, including the costochondral arches and the sternoclavicular joints, and was followed by the repair of the defect with musculocutaneous flaps without any restabilization of the thoracic wall. Thirteen patients received a vertical rectus abdominis musculocutaneous flap, 14 patients received a pedicled latissimus dorsi musculocutaneous flap, and 12 patients received a free latissimus dorsi musculocutaneous flap (total of 40 flaps in 39 patients of 66 patients who required surgical revision for sternal osteitis of 6078 total patients with sternotomies).

RESULTS

Two patients died within 30 days after the operation (early mortality of 5.1%); however, they did not die of sternal infection, which was cured without any recurrence in all cases. Seventeen patients (44%) required secondary, mostly minor operations for local complications. Despite some paradoxic chest movements, the patient satisfaction rating was unanimously high at the long-term follow-up (0.4 to 8.5 years, median 2.3 years). The short- and long-term complication rates were similar in the three groups.

CONCLUSION

We conclude that radical sternectomy and immediate musculocutaneous flap repair provided definitive control of sternal infection in even the most severe cases, thus reducing infection-related mortality. The trade-off was a substantial rate of local complications; however, these did not cause any relevant morbidity.

Monobloc and midface distraction osteogenesis in pediatric patients with severe syndromal craniosynostosis

We present 2 children with severe syndromal craniosynostosis who were in need of urgent midface advancement surgery due to recurrent ocular dislocations (Pfeiffer's syndrome type II) or severe upper respiratory obstruction (Crouzon's syndrome). They were operated using distraction osteogenesis, with gradual midface or monobloc advancements. In the Pfeiffer patient, a maxillary distraction of 25 mm achieved effective cessation of ocular dislocations, whereas a 23-mm monobloc advancement in the Crouzon patient achieved cessation of nocturnal arterial desaturations. No major postoperative complications were recorded. Distraction osteogenesis has become a versatile and safe technique that allows for large skeletal advancements.