Ann Thorac Surg 1997;63:858-859
© 1997 The Society of Thoracic Surgeons
How To Do It
Omental Transfer as a Method of Preventing Residual Persistent Subcutaneous Infection After Mediastinitis
Katsuhiko Yoshida, MD,
Hideki Ohshima, MD,
Fumihiko Murakami, MD,
Yasuhiro Tomida, MD,
Akio Matsuura, MD,
Michiaki Hibi, MD,
Mitsuo Kawamura, MD
Division of Cardiovascular Surgery, Cardiovascular Center, Owari Prefectural Hospital, Ichinomiya, Japan
Accepted for publication September 25, 1996.
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Abstract
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Currently, poststernotomy mediastinitis frequently is being treated by debridement and immediate closure with omental drainage. This method is useful, but subcutaneous infection occasionally occurs. Divided omental transfer to the presternal space may be helpful in preventing this complication.
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Introduction
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See also page 859.
Mediastinitis after cardiac operation is still a dreaded complication associated with substantial morbidity and mortality [1]. The mortality rate has been improved considerably by treatment consisting of wide debridement and omental transfer without postoperative irrigation or drainage [2, 3]. However, subcutaneous suppuration may occur in spite of wide removal of the infected connective tissue [4], especially in cases of methicillin-resistant Staphylococcus aureus infection.
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Technique
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The median sternotomy incision is extended inferiorly to a point just above the umbilicus. After the peritoneal cavity has been entered, the right gastroepiploic vessels are identified on the greater curvature of the stomach, and branches to the stomach are ligated and divided. Division is extended to the left gastroepiploic vessels, and the gastroepiploic arch is detached from the greater curvature of the stomach. The omentum is divided from the transverse colon, and an omental pedicle based on the right gastropeiploic vessels is created (Fig 1
). The omentum is divided into two pedicles, one with a large mass and the other with a small mass (Fig 2). In so doing, careful division is necessary so as not to interrupt the blood flow of the omental pedicles. The larger pedicle is transferred to the anterior mediastinum through the diaphragm. After debridement of the sternum and infected presternal connective tissue, the sternum is closed and the smaller pedicle is transposed to the subcutaneous cavity (Fig 3). One suture is used at the top of the wound to anchor the pedicle over the sternum and drape it. The skin is closed completely with knot sutures.
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Fig 1. . The omentum divided from the stomach and the transverse colon. ( AEA = accessory epiploic artery; LEA = left epiploic artery; LGEA = left gastroepiploic artery; MEA = middle epiploic artery; REA = right epiploic artery; RGEA = right gastroepiploic artery; arrow = division line.)
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Fig 2. . The omentum is divided into two pedicles. ( LEA = left epiploic artery; MEA = middle epiploic artery; REA = right epiploic artery.)
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Fig 3. . One omental pedicle is transferred to the anterior mediastinum and the other drapes the sternum.
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Comment
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The divided omental technique was reported by Yamaguchi and associates [5]. They used the smaller pedicle to fill the intersternal space, but we transposed it to the subcutaneous cavity. We have used this technique in 4 patients with poststernotomy mediastinitis (Table 1), 2 of whom had methicillin-resistant Staphylococcus aureus infection. The infection of the mediastinum and presternal tissue resolved completely in all 4 patients. In the 3 patients with methicillin-resistant Staphylococcus aureus mediastinitis that had been treated by omental transfer to the mediastinum alone, on the other hand, discharge of pus from the skin persisted for many months. We think this technique may be useful in the prevention of complicating subcutaneous infection. The technique described is easy to perform and may be effective in methicillin-resistant Staphylococcus aureus infection as well.
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Footnotes
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Address reprint requests to Dr Yoshida, Division of Cardiovascular Surgery, Cardiovascular Center, Owari Prefectural Hospital, 2135, Kariyasuka, Yamato-cho, Ichinomiya, Aichi Prefecture, 491, Japan.
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References
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- Nishida H, Grooters RK, Soltanzadeh H, Thieman KC, Schneider RF, Kim WP. Discriminate use of electrocautery on the median sternotomy incision. J Thorac Cardiovasc Surg 1991;101:488–94.[Abstract]
- Heath BJ, Bagnato VJ. Poststernotomy mediastinitis treated by omental transfer without postoperative irrigation or drainage. J Thorac Cardiovasc Surg 1987;94:355–60.[Abstract]
- Sueda T, Kanehiro K, Morita S, Matsuura Y. Mediastinitis with an infection of methichillin-resistant Staphylococcus aureus treated by an omental transfer following CABG using a right gastroepiploic arterial graft: report of a case. Surg Today 1994;24:638–40.[Medline]
- Ivert T, Lindblom D, Sahni J, Eldh J. Management of deep sternal wound infection after cardiac surgery—Hanuman syndrome. Scand J Thorac Cardiovasc Surg 1991;25:111–7.[Medline]
- Yamaguchi A, Ino T, Mizuhara A, Adachi H, Ide H, Kawahito K. Post-sternotomy mediastinitis treated by omental transposition. Nippon Kyobu Geka Gakkai Zasshi 1993;41:2081–5.[Medline]
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Abstract
Introduction
