Sunday, October 10, 2004

A New Era in Chest Wall Reconstruction: Omento-Pectoral Flaps, Laparoscopy, Jet Lavage and Vacuum Dressings

Jeffrey H. Donaldson, MD, John A Attwood, MD, and Roy A. Cobean, MD.

OBJECTIVE: To establish an improved approach to the reconstruction of large sternal defects.

METHODS/PROCEDURES: Post-sternotomy wound complications have challenged surgeons for the past half century. They often yield large defects with scant blood supply, predisposed to local infection in the setting of underlying critical illness. While authors have clearly documented the benefits of debridement and muscle flap coverage over recent decades, experience with newer and more sophisticated techniques has been limited. Between 1998 and 2004, 7640 sternotomies resulted in 182 sternal wound complications at one tertiary care hospital. Seven plastic surgeons used combination omento-pectoral flaps to reconstruct 60 of these chest wall defects. Patients included 26 females and 34 males who ranged in age from 33 to 89 years. Each operation began with aggressive wound debridement, including jet lavage, curettage and radical sternectomy when osteomyelitis was suspected. Pectoral flaps were then raised while a general surgeon laparoscopically dissected and rotated a pedicled omental flap toward the thorax. An anterior diaphragmatic window to the abdomen was created and the omentum was pulled into the chest. Finally, the defect was closed in three layers, with omentum, pectoralis and skin. Patients were followed post-operatively to determine the safety and efficacy of this approach. The surgical literature was reviewed for comparison with both similar and alternative methods.

RESULTS: Pre-operative diagnoses included mediastinitis (38), sternal infection (17), sternal instability (4) and aborted closure secondary to cardiogenic shock (1). Six patients had already failed one reconstruction with rectus abdominus and/or pectoralis muscle flaps. Vacuum dressings provided bridge therapy in more than half of all cases. Mean operative time was 141 minutes (range 78- 240 minutes). Forty omental flaps used a right gastroepiploic vascular pedicle, 18 used a full bilateral gastroepiploic arcade, and two flaps used a left gastroepiploic pedicle. All omenta were harvested with laparoscopic technique, without open conversion. Bilateral pectoralis flaps were advanced to the midline in 48 patients. Primary skin closure was achieved in 59 cases, while split-thickness skin grafting was used once. General surgical complications included flap trauma/ischemia requiring omentectomy and rectus flap repair (2), mesenteric injury requiring partial transverse colectomy (1) and gastric leak requiring primary repair (1). There were seven in-hospital deaths attributed to underlying disease processes. During a mean follow-up period of six months, seven patients developed ventral/diaphragmatic hernias where the omentum passed between abdomen and chest. Plastic surgical complications included minor local infections/abscesses requiring incision and drainage (6), persistent leakage through drains or sinus tracts (4), partial flap necrosis requiring debridement (2), and hematoma (1). Subsequent rectus flap reconstruction was required in two cases because of recurrent infection. These complication rates compare favorably to published series that used single muscle flaps, omental flaps via laparotomy and/or closed irrigation systems.

CONCLUSIONS: The omento-pectoral flap, when combined with minimally-invasive harvesting, pulse irrigation, wide debridement and preparatory vacuum dressings, may offer the best solution to large chest wall defects. Plastic surgeons should consider these methods when evaluating complicated post-sternotomy wounds whether for initial treatment or for salvage after other closures have failed.

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