From the Columbia University Vagelos College of Physicians and Surgeons.
Division of Plastic Surgery, Department of Surgery.
Ann Plast Surg. 2023 Jun 1;90(6S Suppl 5):S521-S525. doi: 10.1097/SAP.0000000000003478. Epub 2023 Feb 4.
Sternal wound infection (SWI) and dehiscence after median sternotomy for cardiac surgery remain challenging clinical problems with high morbidity. Bilateral pectoralis major myocutaneous flaps are excellent for most sternal wounds but do not reach deeper mediastinal recesses. The omental flap may be a useful adjunct for addressing these deeper mediastinal infections.
Records of 598 sternal wound reconstructions performed by a single surgeon (J.A.A.) from 1996 to 2022 were reviewed. At the time of surgery, patients underwent sternal hardware removal, debridement, and closure with bilateral pectoralis major myocutaneous flaps. Pedicled omental flaps were also mobilized when additional vascularized tissue was required within the deeper mediastinum.
Complete data were available for 559 sternal wound reconstructions performed by the senior author during this period. Bilateral pectoralis and omental flaps were mobilized in 17 of 559 (3.04%) patients. Common indications for initial cardiac surgery included repair or replacement of diseased aortic roots (9/17; 52.94%), aortic valves (8/17; 47.06%), and mitral valves (6/17; 35.29). Mean American Society of Anesthesiologists score was 3.56. Preoperative morbidity included culture-positive wound infection (12/17; 70.59%), dehiscence (15/17; 88.24%), wound drainage (11/17; 64.71%), and inability to close the chest after the original sternotomy because of hemodynamic instability (6/17; 35.29%). Intraoperative deep mediastinal or bone cultures were positive in 8 of 17 (47.06%) patients. Postoperative complications included partial dehiscence (2/17; 11.76%), skin edge necrosis (1/17; 5.88%), seroma (1/17; 5.88%), abdominal hernia (1/17; 5.88%), and recurrent infection (2/17; 11.76%). Three patients (17.65%) died within 30 days of the reconstruction surgery.
Patients undergoing combined pectoralis major and omental flap closure frequently had a history of aortic root and valve disease, and other significant preoperative morbidities. However, postoperative complication rates after combined flap closure were relatively low. Combined pectoralis major and omental flap reconstruction thus appears to be an effective intervention in patients with sternal wounds extending into the deep mediastinum.
心脏手术后胸骨伤口感染（SWI）和裂开仍然是具有高发病率的挑战性临床问题。双侧胸大肌肌皮瓣对于大多数胸骨伤口是极好的，但无法到达更深的纵隔隐窝。网膜瓣对于处理这些更深的纵隔感染可能是有用的辅助手段。
回顾了 1996 年至 2022 年期间由一位外科医生（J.A.A.）进行的 598 例胸骨伤口重建的记录。在手术时，患者接受了胸骨内固定物取出、清创和双侧胸大肌肌皮瓣闭合。当需要在更深的纵隔内提供更多的血管化组织时，也会动员带蒂网膜瓣。
在这段时间内，高级作者完成了 559 例胸骨伤口重建，其中有完整数据。在 559 例患者中有 17 例（3.04%）动员了双侧胸大肌和网膜瓣。初次心脏手术的常见适应证包括修复或置换患病的主动脉根部（17 例中的 9 例；52.94%）、主动脉瓣（17 例中的 8 例；47.06%）和二尖瓣（17 例中的 6 例；35.29%）。平均美国麻醉医师协会评分（ASA）为 3.56。术前合并症包括培养阳性的伤口感染（17 例中的 12 例；70.59%）、裂开（17 例中的 15 例；88.24%）、伤口引流（17 例中的 11 例；64.71%）和由于血流动力学不稳定而无法在初次胸骨切开术后闭合胸部（17 例中的 6 例；35.29%）。17 例患者中有 8 例（47.06%）术中纵隔或骨培养阳性。术后并发症包括部分裂开（17 例中的 2 例；11.76%）、皮肤边缘坏死（17 例中的 1 例；5.88%）、血清肿（17 例中的 1 例；5.88%）、腹部疝（17 例中的 1 例；5.88%）和复发性感染（17 例中的 2 例；11.76%）。3 例患者（17.65%）在重建手术后 30 天内死亡。
接受胸大肌和网膜瓣联合闭合的患者常有主动脉根部和瓣膜疾病以及其他重大术前合并症病史。然而，联合瓣闭合后的术后并发症发生率相对较低。因此，胸大肌和网膜瓣联合重建似乎是治疗胸骨伤口延伸至纵隔深部的有效干预手段。
