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Ann Thorac Surg 2002;74:634-635
© 2002 The Society of Thoracic Surgeons

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Correspondence

Sternal suturing technique and chest wound complication

^a Department of Cardiovascular Surgery, Kobari General Hospital, 29-1 Yokouchi, Noda City, Chiba 278-8501, Japan
^b Department of Cardiovascular Surgery, Shin-Tokyo Hospital, Chiba, Japan

e-mail: genex{at}nifty.com

To the Editor

We read with interest the article by Risnes and colleagues [1]. In their study, 300 patients were randomly assigned to either intracutaneous or transcutanous suture techniques for skin closure after various open heart operations, and they concluded that the sternal infection rate was lower with the transcutaneous suture technique (3.0%) than with the intracutaneous suture technique (8.0%).

Skin suturing technique is an important factor for sternal infection. The subcutaneous dead space is considered to play an important role in triggering superficial sternal infection. Risnes and associates described their double-layer sternal closure technique: after the sternum was closed with steel wire, the subcutaneous layer was approximated with 2-0 Vicrl and the skin was closed with either 3-0 Monocryl intracutaneous continuous sutures or 3-0 Ethilone percutaneous interrupted sutures. This intracutaneous skin closure technique may be adequate for thin patients but not for normal or obese patients. First, the suturing material (3-0 Monocryl) is too large for intracutaneous sutures. A large needle may damage the dermal layer, and thick sutures may block the microcirculation of the skin, which may result in increased frequency of superficial infection. Second, the double-layer closure (subcutaneous tissue closure and skin closure after sternal wiring) may not be good enough to reapproximate the chest wound. With the double-layer closure, dead space just above the sternum may remain. The combination of sternal wire and presternal dead space may trigger local inflammation and fluid accumulation, which may result in wound infection. With percutaneous closing, presternal dead space would be smaller than with intracutaneous closing, which may lead into more favorable results.

In our practice, all chest wounds are closed with a triple-layer closing technique after sternal wiring. The presternal fascia is first closed with 0-Vicril, subcutaneous tissue is closed with 2-0 Vicrl with continuous stitches, and then the skin is closed with continuous intracutaneous stitches using 5-0 PDS. No chest wounds are closed with interrupted percutaneous stitches with this triple-layer closure. Using this protocol, the presternal dead space and the damage to the dermal layer are minimized.

We performed 2,560 cases of coronary artery bypass grafting using the internal mammary artery (IMA) between January 1990 and October 2001, including 713 cases (27.9%) of bilateral IMA use, 185 (7.2%) of emergent surgery, 74 (2.9%) of redo cases, and 267 (10.4%) of poor left ventricular function patients (preoperative ejection fraction less than 40%). Our overall chest complication rate was 4.5% (116 cases); 85 cases (3.3%) were superficial wound separation, and 31 cases (1.2%) were deep sternal infection. No microorganisms were detected in the patients with superficial wound separation. Most of the superficial wound separations were due to fatty necrosis or electrocautery-related dermal burn.

We believe that intracutaneous continuous closure is cosmetically superior to percutaneous interrupted closure and that it is not inferior to percutaneous sutures in terms of postoperative wound infection. Minimizing the subcutaneous dead space is the operative key point to decrease chest complications after open heart surgery. We recommend the triple-layer closure for those who undergo intracutaneous skin closure.

References

1. Risnes I., Abdelnoor M., Baksaas S.T., Lundblad R., Svennevig J.L. Sternal wound infection in patients undergoing open heart surgery: randomized study comparing intracutaneous and transcutaneous suture techniques. Ann Thorac Surg 2001;72:1587-1591.[Abstract/Free Full Text]

This article has been cited by other articles:

				T. Bottio, G. Rizzoli, V. Vida, D. Casarotto, and G. Gerosa Double crisscross sternal wiring and chest wound infections: A prospective randomized study J. Thorac. Cardiovasc. Surg., November 1, 2003; 126(5): 1352 - 1356. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hirose, H. Articles by Takahashi, A. Search for Related Content PubMed PubMed Citation Articles by Hirose, H. Articles by Takahashi, A. Related Collections Extracorporeal circulation