87 - Muscle flap coverage of sternal wound infections

Summary

The median sternotomy is the incision of choice for most patients undergoing coronary artery bypass grafting and heart valve surgery, as it provides unparalleled exposure of the heart and great vessels. Although sternal wound infections occur with a reported incidence of 5%, the associated morbidity and mortality is dramatically higher. In the early 1970s, treatment of these patients consisted largely of debridement, placement of catheters for antibiotic irrigation, and either primary or delayed primary closure of the rewired sternum. If the wound couldn't be closed, they were packed open and allowed to heal secondarily. Such management was associated with a mortality rate of 20%–50%, leading reconstructive and cardiothoracic surgeons to seek alternative treatment options. Fortunately, most institutions have abandoned these techniques with the advent of muscle flap surgery.

Wide debridement of all devitalized bone and soft tissues, removal of all foreign material (i.e., sternal wires) followed by immediate closure using various muscle and/or omental flaps is now widely performed and considered the standard of care for sternal wound infections. Typically, the overlying soft tissues are reapproximated following muscle flap transposition. When an omental flap is used for coverage, it is covered with a skin graft. The pectoralis major, rectus abdominus, and latissimus dorsi muscles are the structures of choice for mediastinal coverage and deadspace obliteration, with the patient's anatomy, wound status, and previous surgeries serving as the reconstructive surgeon's guide to proper flap selection.