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Delayed Closure of the Median Sternotomy Incision
HOW TO DO IT
Delayed Closure of the Median Sternotomv Incision Douglas A. Murphy, M.D. ABSTRACT Attempts to close a median stemotomy incision in the patient with profound cardiac or pulmonary dysfunction following a cardiac surgical procedure can result in severe hemodynamic deterioration. Delayed sternal closure in this setting may be a lifesaving technique. A method is described for delayed sternal closure that employs a temporary impermeable rubber patch sutured to the presternal fascia.
Profound hemodynamic deterioration may complicate attempts to close the median sternotomy incision after completion of a cardiac surgical procedure [l]. This problem occurs most commonly in the setting of acute myocardial or pulmonary injury. Attempts to reapproximate the sternal edges in this situation may result in hemodynamic changes resembling cardiac tamponade with a rise in right and left heart filling pressures and a fall in cardiac output. When myocardial or pulmonary injury does not respond promptly to therapeutic measures, it may be necessary to leave the sternal edges open and close only the skin edges. In extreme instances, it may even be necessary to leave the skin edges apart to maintain satisfactory hemodynamic function. Our past experience with this latter group of patients generally has been unsuccessful. Although such patients usually die of multisystem dysfunction, infection that presumably originates at the site of the open mediastinum has been common. A technique of delayed median sternotomy closure using a temporary impermeable rubber patch is described. This method has been employed successfully in 3 consecutive patients with severe cardiac compression at the time of attempted stemotomy closure.
Technique The technique is used in patients in whom the median sternotomy cannot be closed without unacceptable hemodynamic compromise. Two 36F chest tubes are positioned for drainage in the lower end of the mediastinum, and a small irrigation catheter is placed very high in the mediastinum, as shown in Figure 1. Pleural chest tubes are placed laterally if necessary. Small quantities of bone wax are used to stop bleeding from the sternal marrow. A large elliptical patch is fashioned from a sterile sheet of 60-gauge rubber (Richards Medical Co., Memphis, TN). This patch is then sutured to the presternal and abdominal fascia (Fig 2) with running 3-0polypropylene suture. From the Joseph 8. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, GA. Accepted for publication Aug 27, 1984. Address reprint requests to Dr.Murphy, Emory Clinic, 1365 Clifton Rd, NE, Atlanta, GA 30322.
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The outer surface of the patch and the adjoining subcutaneous tissue are covered with gauze soaked in povidone-iodine solution; this dressing is changed frequently in the postoperative period. As drainage from the chest tube decreases, mediastinal irrigation is begun with 0.25% neomycin or saline solution warmed to body temperature. Dressings and imgation are continued until cardiac function is sufficiently improved to permit sternal closure, usually three to five days after the initial procedure. Mechanical ventilation is continued during this period. The patient is then returned to the operating room, and the entire anterior chest is prepared with copious amounts of povidone-iodine solution. The rubber patch is carefully removed and discarded from the operative field along with all segments of polypropylene used to secure it. Any fragments of fibrin or blood clot are carefully removed, and cultures are taken from the exposed mediastinum. To remove the previously placed bone wax, the sternal edges are debrided for 2 mm back to bleeding marrow. The mediastinal contents are copiously irrigated with several liters of warm saline solution. The chest tube drains and mediastinal irrigation catheter are left in place. The sternal edges are reapproximated with interrupted stainless steel wire, and the fascia is closed with absorbable suture. The subcutaneous tissue and skin are left open to heal secondarily. Mediastinal irrigation is continued for 48 to 72 hours postoperatively, after which the mediastinal tubes are removed. Dressing changes to the subcutaneous tissues are continued until healing is complete.
Case Report A 69-year-old man was admitted to Emory University Hospital with unstable angina associated with dyspnea. He had a history of heavy tobacco abuse and chronic obstructive lung disease. Cardiac catheterization revealed a 100 mm Hg peak systolic gradient across the aortic valve, left ventricular end-diastolic pressure of 28 mm Hg, and high-grade stenoses of the circumflex and right coronary arteries. At operation, a heavily calcified aortic valve was replaced with a 23-mm porcine prosthetic valve and saphenous vein bypass grafts were constructed to the distal circumflex and right coronary arteries. Total aortic cross-clamp time was 97 minutes. Myocardial function recovered promptly, and the patient was easily weaned from cardiopulmonary bypass. However, severe bronchospasm with air trapping developed that responded poorly to intensive bronchodilator therapy. Attempts to reapproximate the sternal edges resulted in marked elevation of right and left heart filling pressures and a fall in the cardiac index from 2.5 to 1.25 L,/min/m*. Because similar hemodynamic deterioration occurred with attempts to close only the skin edges, the wound was managed with the technique just described.
77 How to Do It: Murphy: Delayed Closure of Median Sternotomy Incision
Fig 2 . Delayed closure ofa median sternotomy incision. An irnpermeable rubber patch is sutured to the presternal fascia. Fig I . Placement of rnediastinal drainage tubes and irrigation catheter when delayed closure is planned.
Bronchospasm responded well to pharmacological therapy in the postoperative period, and on the third day after the initial procedure, the patient was returned to the operating room. After the rubber patch was removed, the mediastinum was found to be very clean; subsequent cultures were sterile. The sternum and fascia were closed, and the mediastinum was irrigated for three days. Subsequently, the patient required a tracheostomy and prolonged ventilatory support but was later discharged from the hospital in good condition. The median sternotomy healed well with no evidence of deep or superficial wound infection. This technique of wound management has been employed on 2 other patients at this institution in whom myocardial depression after operation prevented closure of the median sternotomy wound. A 58-year-old woman with severe myocardial dysfunction after emergency revascularization for failed angioplasty required wound closure with the rubber patch technique, with subsequent sternal closure five days later. A 67-year-old man with severe myocardial injury after reoperation for coronary artery disease also required closure with this technique, with subsequent sternal closure five days later. The median sternotomy wounds healed without infection or other complications in both patients.
tive cardiac failure. The use of a rubber patch, however, has several advantages in the adult patient with this syndrome. A rubber patch can be rapidly tailored from readily available and inexpensive rubber tourniquet material used in orthopedic surgery. A rubber patch is easy to suture, which enables rapid placement in critically ill patients as well as rapid removal for immediate access to the mediastinum in the event of cardiac arrest or massive bleeding. The greatest advantage of this technique, however, lies in the airtight closure of the wound resulting from the securely sutured rubber patch. It has not been possible to obtain such an impermeable closure with other coverings such as plastic operative drapes, which usually become detached within several hours after operation. The tight closure afforded by a rubber patch prevents contamination of the mediastinum from external sources and allows for internal irrigation of the wound, two factors that may be important in preventing mediastinal sepsis in these patients. In sum, the rubber patch technique offers a rapid and effective means of temporary closure of the median sternotomy incision in the patient with critical cardiac dysfunction following heart surgery. Supported in part by a grant from The Wasie Foundation.
Comment
References
Delayed closure of the sternum may be a lifesaving technique in the patient with severe but reversible cardiac or pulmonary injury after heart surgery [2, 31. Delayed closure using a patch sutured to the presternal fascia allows for minimal compression of the heart while maintaining an effective barrier to wound contamination from external sources until definitive wound closure can be accomplished. Gangahar and colleagues (41 reported the use of a woven Dacron patch for temporary closure of a median sternotomy wound in a neonate with severe postopera-
1. Riahi M, Tomatis LA, Schlosser RJ, et al: Cardiac compression due to closure of the median sternotomy in open heart surgery. Chest 67113, 1975 2. Ott DA, Cooley DA, Norman J: Delayed sternal closure: a
useful technique to prevent tamponade or compression of the heart. Cardiovasc Dis (Bull Tex Heart Inst) 5:15,1978 3. Gielchinsky I, Parsonnet V, Krishnan B, et al: Delayed sternal closure following open-heart operation. Ann Thorac Surg 32273, 1981 4. Gangahar DM, McGough EC,Synhorst D Secondary sternal closure: a method of preventing cardiac compression. Ann Thorac Surg 31:281, 1980
Delayed Closure of the Median Sternotomv Incision Douglas A. Murphy, M.D. ABSTRACT Attempts to close a median stemotomy incision in the patient with profound cardiac or pulmonary dysfunction following a cardiac surgical procedure can result in severe hemodynamic deterioration. Delayed sternal closure in this setting may be a lifesaving technique. A method is described for delayed sternal closure that employs a temporary impermeable rubber patch sutured to the presternal fascia.
Profound hemodynamic deterioration may complicate attempts to close the median sternotomy incision after completion of a cardiac surgical procedure [l]. This problem occurs most commonly in the setting of acute myocardial or pulmonary injury. Attempts to reapproximate the sternal edges in this situation may result in hemodynamic changes resembling cardiac tamponade with a rise in right and left heart filling pressures and a fall in cardiac output. When myocardial or pulmonary injury does not respond promptly to therapeutic measures, it may be necessary to leave the sternal edges open and close only the skin edges. In extreme instances, it may even be necessary to leave the skin edges apart to maintain satisfactory hemodynamic function. Our past experience with this latter group of patients generally has been unsuccessful. Although such patients usually die of multisystem dysfunction, infection that presumably originates at the site of the open mediastinum has been common. A technique of delayed median sternotomy closure using a temporary impermeable rubber patch is described. This method has been employed successfully in 3 consecutive patients with severe cardiac compression at the time of attempted stemotomy closure.
Technique The technique is used in patients in whom the median sternotomy cannot be closed without unacceptable hemodynamic compromise. Two 36F chest tubes are positioned for drainage in the lower end of the mediastinum, and a small irrigation catheter is placed very high in the mediastinum, as shown in Figure 1. Pleural chest tubes are placed laterally if necessary. Small quantities of bone wax are used to stop bleeding from the sternal marrow. A large elliptical patch is fashioned from a sterile sheet of 60-gauge rubber (Richards Medical Co., Memphis, TN). This patch is then sutured to the presternal and abdominal fascia (Fig 2) with running 3-0polypropylene suture. From the Joseph 8. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, GA. Accepted for publication Aug 27, 1984. Address reprint requests to Dr.Murphy, Emory Clinic, 1365 Clifton Rd, NE, Atlanta, GA 30322.
76
The outer surface of the patch and the adjoining subcutaneous tissue are covered with gauze soaked in povidone-iodine solution; this dressing is changed frequently in the postoperative period. As drainage from the chest tube decreases, mediastinal irrigation is begun with 0.25% neomycin or saline solution warmed to body temperature. Dressings and imgation are continued until cardiac function is sufficiently improved to permit sternal closure, usually three to five days after the initial procedure. Mechanical ventilation is continued during this period. The patient is then returned to the operating room, and the entire anterior chest is prepared with copious amounts of povidone-iodine solution. The rubber patch is carefully removed and discarded from the operative field along with all segments of polypropylene used to secure it. Any fragments of fibrin or blood clot are carefully removed, and cultures are taken from the exposed mediastinum. To remove the previously placed bone wax, the sternal edges are debrided for 2 mm back to bleeding marrow. The mediastinal contents are copiously irrigated with several liters of warm saline solution. The chest tube drains and mediastinal irrigation catheter are left in place. The sternal edges are reapproximated with interrupted stainless steel wire, and the fascia is closed with absorbable suture. The subcutaneous tissue and skin are left open to heal secondarily. Mediastinal irrigation is continued for 48 to 72 hours postoperatively, after which the mediastinal tubes are removed. Dressing changes to the subcutaneous tissues are continued until healing is complete.
Case Report A 69-year-old man was admitted to Emory University Hospital with unstable angina associated with dyspnea. He had a history of heavy tobacco abuse and chronic obstructive lung disease. Cardiac catheterization revealed a 100 mm Hg peak systolic gradient across the aortic valve, left ventricular end-diastolic pressure of 28 mm Hg, and high-grade stenoses of the circumflex and right coronary arteries. At operation, a heavily calcified aortic valve was replaced with a 23-mm porcine prosthetic valve and saphenous vein bypass grafts were constructed to the distal circumflex and right coronary arteries. Total aortic cross-clamp time was 97 minutes. Myocardial function recovered promptly, and the patient was easily weaned from cardiopulmonary bypass. However, severe bronchospasm with air trapping developed that responded poorly to intensive bronchodilator therapy. Attempts to reapproximate the sternal edges resulted in marked elevation of right and left heart filling pressures and a fall in the cardiac index from 2.5 to 1.25 L,/min/m*. Because similar hemodynamic deterioration occurred with attempts to close only the skin edges, the wound was managed with the technique just described.
77 How to Do It: Murphy: Delayed Closure of Median Sternotomy Incision
Fig 2 . Delayed closure ofa median sternotomy incision. An irnpermeable rubber patch is sutured to the presternal fascia. Fig I . Placement of rnediastinal drainage tubes and irrigation catheter when delayed closure is planned.
Bronchospasm responded well to pharmacological therapy in the postoperative period, and on the third day after the initial procedure, the patient was returned to the operating room. After the rubber patch was removed, the mediastinum was found to be very clean; subsequent cultures were sterile. The sternum and fascia were closed, and the mediastinum was irrigated for three days. Subsequently, the patient required a tracheostomy and prolonged ventilatory support but was later discharged from the hospital in good condition. The median sternotomy healed well with no evidence of deep or superficial wound infection. This technique of wound management has been employed on 2 other patients at this institution in whom myocardial depression after operation prevented closure of the median sternotomy wound. A 58-year-old woman with severe myocardial dysfunction after emergency revascularization for failed angioplasty required wound closure with the rubber patch technique, with subsequent sternal closure five days later. A 67-year-old man with severe myocardial injury after reoperation for coronary artery disease also required closure with this technique, with subsequent sternal closure five days later. The median sternotomy wounds healed without infection or other complications in both patients.
tive cardiac failure. The use of a rubber patch, however, has several advantages in the adult patient with this syndrome. A rubber patch can be rapidly tailored from readily available and inexpensive rubber tourniquet material used in orthopedic surgery. A rubber patch is easy to suture, which enables rapid placement in critically ill patients as well as rapid removal for immediate access to the mediastinum in the event of cardiac arrest or massive bleeding. The greatest advantage of this technique, however, lies in the airtight closure of the wound resulting from the securely sutured rubber patch. It has not been possible to obtain such an impermeable closure with other coverings such as plastic operative drapes, which usually become detached within several hours after operation. The tight closure afforded by a rubber patch prevents contamination of the mediastinum from external sources and allows for internal irrigation of the wound, two factors that may be important in preventing mediastinal sepsis in these patients. In sum, the rubber patch technique offers a rapid and effective means of temporary closure of the median sternotomy incision in the patient with critical cardiac dysfunction following heart surgery. Supported in part by a grant from The Wasie Foundation.
Comment
References
Delayed closure of the sternum may be a lifesaving technique in the patient with severe but reversible cardiac or pulmonary injury after heart surgery [2, 31. Delayed closure using a patch sutured to the presternal fascia allows for minimal compression of the heart while maintaining an effective barrier to wound contamination from external sources until definitive wound closure can be accomplished. Gangahar and colleagues (41 reported the use of a woven Dacron patch for temporary closure of a median sternotomy wound in a neonate with severe postopera-
1. Riahi M, Tomatis LA, Schlosser RJ, et al: Cardiac compression due to closure of the median sternotomy in open heart surgery. Chest 67113, 1975 2. Ott DA, Cooley DA, Norman J: Delayed sternal closure: a
useful technique to prevent tamponade or compression of the heart. Cardiovasc Dis (Bull Tex Heart Inst) 5:15,1978 3. Gielchinsky I, Parsonnet V, Krishnan B, et al: Delayed sternal closure following open-heart operation. Ann Thorac Surg 32273, 1981 4. Gangahar DM, McGough EC,Synhorst D Secondary sternal closure: a method of preventing cardiac compression. Ann Thorac Surg 31:281, 1980