Ann Thorac Surg 1998;66:2125-2126
© 1998 The Society of Thoracic Surgeons
How To Do It
Reduction of wound healing problems after median sternotomy by use of retention sutures
Peter Lamm, MDa,
Oliver L. Gödje, MDa,
Thomas Lange, MDa,
Bruno Reichart, MDa
a Department of Cardiac Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
Accepted for publication June 29, 1998.
Address reprint requests to Dr Gödje, Department of Cardiac Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, 81377 Munich, Germany
e-mail: (doc.olli{at}lrz.uni-muenchen.de)
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Abstract
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Obese people have a higher risk of sternal wound dehiscence resulting from traction of suprasternal tissue. In such patients we recommend the use of retention sutures with extracorporeal plates to improve tissue connection and to disburden fascia and skin sutures. This augmented closure is simple and effective and, since 1996, has prevented wound healing problems in more than 50 patients with a body mass index greater than 27.
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Introduction
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Obesity is a well known risk factor for wound healing problems after any kind of operation. In cardiac operations, obese people show a higher incidence of sternal dehiscence and wound infection [1,2]. Women who have large breasts are prone to this complication [2,3] as the weight of both breasts puts additional traction on sutures that adapt sternal and suprasternal tissue. Although the rate of sternal wound infections in our clinic of 2.3% was within the range described in the literature [2,3,4], treating these infections was costly in terms of both time and money. In our opinion, most cases of severe sternal infections are based on superficial, inflammatory wound healing problems. Therefore, in addition to our routine sternal closure procedure (six wires, suture of the fascia, intracutaneous skin suture, perioperative antibiotic prophylaxis with cefuroxime), we improved suprasternal tissue connection by using retention sutures to reduce the incidence of postoperative sternal infection or instability.
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Technique
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Retention sutures (Ethicon, Norderstedt, Germany) consist of two polyethylene plates with a silicone rubber pad, 3 cm x 6 cm in size. Plates are connected by a 7-metric suture that is armed on both ends with a semicircular steel needle (Fig 1). After closure of the sternum by standard techniques using six to eight stainless steel wires with or without the figure-8 technique, retention sutures were inserted parallel on both sides of the skin incision so that they capture the complete suprasternal tissue, including fascia, subcutaneous fat, and skin (Fig 2). Two plates at a time are placed on opposite sides of the wound, approximately 5 cm from the middle line. Plates can be cut to the desired size. Then tension is put on the retention sutures so that both sides of the wound are approximated, but suture of the suprasternal fascia closure is still possible. To maintain the tension, sutures are temporarily connected by a small clamp instead of a knot. Then the suprasternal fascia is closed using single or continuous resorbable sutures. Final tension is put on the retention sutures and knots are placed. Intracutaneous skin closure with a resorbable suture is performed last. For a 20-cm skin incision we usually apply two retention sutures (Fig 3). At the caudal end of the wound, this tissue may also include the rectal fascia. The retention sutures are removed between postoperative days 8 and 15, depending on the length of time of wound healing and skin compatibility.
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Fig 2. Recommended position of retention sutures. All layers of suprasternal tissue should be included.
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Results
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Since 1996 we have used this technique on a routine basis for wound closure in obese patients who have a body mass index greater than 27. A total of 57 patients (15 men and 42 women) were included. Mean age of the patients was 64.2 ± 7.3 years (range, 46–82 years), height was 162.6 ± 9.2 cm (range, 145–178 cm), weight was 92.4 ± 11.2 kg (range, 78–123 kg), and body mass index was 35 ± 4 (range, 27–39). The following risk factors for sternal infections or instability were present: diabetes in 53%, chronic obstructive pulmonary disease in 6%, left internal mammary artery harvesting in 79%, and double mammary artery harvesting in 4% of the patients. None of the patients developed a sternal instability, wound dehiscence, or infection. Nine patients showed a superficial erosion of the skin under or near the plates, caused by the pressure of the plates on the skin. These erosions were treated with dry wound dressing and diminished after a few days. No necrosis of the skin under the plates was seen. The cosmetic effect was identical to wounds without retention sutures, as the imprint of the plates and the entry of the 7-metric suture diminished after a few days.
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Comment
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Wound healing complications in cardiac surgical patients are dangerous and might inhibit recovery. Furthermore, they are time-consuming for the doctors and not cost-effective for the hospital because of the prolonged hospital stay [5]. Many of these complications are initially based on skin dehiscence. In obese patients, because of the weight of the fat tissue, skin dehiscence might occur more easily. This risk is increased if one or both internal mammary arteries are used as bypass grafts [5], because in these patients wound healing can be delayed due to reduced blood perfusion. Older patients with comorbidities such as diabetes, chronic obstructive pulmonary disease, and peripheral arterial occlusive disease have more wound healing complications after open heart operation [4]. With the necessity to operate on these patients, any possible risk for a resternotomy should be reduced. Conversely, this prevention must not lead to excessive costs. Positive experiences in general operations and especially in abdominal operations led us to to improve tissue connection by using retention sutures. As only nine superficial skin erosions occurred, no major complications can be attributed to this technique. Our method offers a cheap, easily applicable, and effective method to prevent such complications, and we anticipate that further use of the retention sutures could also reduce the risk of suppurative sternal dehiscence. [6]
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References
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Fasol R., Schindler M., Schumacher B., et al. The influence of obesity on perioperative morbidity: retrospective study of 502 aortocoronary bypass operations. Thorac Cardiovasc Surg 1992;40:126-129.[Medline]
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Bitkover C.Y., Gardlund B. Mediastinitis after cardiovascular operations: a case control study of risk factors. Ann Thorac Surg 1998;65:36-40.[Abstract/Free Full Text]
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Copeland M., Senkowski C., Ulcickas M., Mendelson M., Griepp R.B. Breast size as a risk factor for sternal wound complications following cardiac surgery. Arch Surg 1994;129:757-759.[Abstract]
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Ottino G., DePaulis R., Pansini S., et al. Major sternal wound infection after open heart surgery: multivariate analysis of risk factors in 2,579 consecutive operative procedures. Ann Thorac Surg 1987;44:173-179.[Abstract]
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Vander Salm T.J., Okike O.N., Pasque M.K., et al. Reduction of sternal infection by application of topical vancomycin. J Thorac Cardiovasc Surg 1989;98:618-622.[Abstract]
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Grossi E.A., Esposito R., Harris L.J., et al. Sternal wound infections and use of internal mammary artery grafts. J Thorac Cardiovasc Surg 1991;102:342-347.[Abstract]
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Abstract
Introduction
