Fifty Complex Chest Reconstructions with Laparoscopic …

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A New Era in Chest Wall Reconstruction: Omento-Pectoral Flaps, Laparoscopy, Jet Lavage and Vacuum Dressings

Jeffrey H. Donaldson, MD; John A. Attwood, MD; Roy A. Cobean, MD

BACKGROUND: Post-sternotomy wound complications have challenged surgeons for more than fifty years. They often yield large defects with inadequate blood supply, predisposed to local infection in the setting of underlying critical illness. Early debridement and muscle flap coverage reduced mortality from as high as 50% in the 1960’s to 10-20% by the 1980’s; more recent authors have extolled omental flaps for their immunologic and angiogenic properties.1-3 Advances in surgical technique and wound care technology now combine with this experience in a sophisticated, multi-modality approach to reconstruction.

METHODS/PROCEDURES: Between 1998 and 2004, 7640 sternotomies resulted in 182 sternal wound complications at one tertiary care hospital. Beginning in 2001, vacuum dressings were usually applied to the chest at the time of diagnosis. Seven plastic surgeons used combination omento-pectoral flaps to reconstruct 60 of these chest wall defects. Patients included 26 females and 34 males who ranged in age from 33 to 89 years.

Each operation began with aggressive wound debridement: jet lavage, curettage and radical sternectomy when osteomyelitis was suspected. Pectoral flaps were then raised while a general surgeon laparoscopically dissected and rotated a pedicled omental flap toward the thorax. An anterior diaphragmatic window to the abdomen was created and the omentum was pulled into the chest. Finally, the defect was closed in three layers, with omentum, pectoralis and skin.

Patients were followed post-operatively to determine the safety and efficacy of this approach. The surgical literature was reviewed for comparison with both similar and alternative methods.

RESULTS: Pre-operative diagnoses included mediastinitis (38), sternal infection (17), sternal instability (4) and aborted closure secondary to cardiogenic shock (1). Co-morbidities included coronary arteriosclerosis (50), hypertension (34), diabetes mellitus (30), chronic renal insufficiency/failure (12) and chronic obstructive pulmonary disease (5). Six patients had already failed one reconstruction with rectus abdominus (1), pectoralis (2) or a combination of both muscle flaps (3). Vacuum dressings provided bridge therapy between diagnosis and reconstruction in 84% of all cases (31/37) performed after its first use in this series in June, 2001.

Mean operative time was 141 minutes (range 78- 240 minutes). Forty omental flaps used a right gastroepiploic vascular pedicle, 18 used a full bilateral gastroepiploic arcade, and two flaps used a left gastroepiploic pedicle. All omenta were harvested with laparoscopic technique, without open conversion. Bilateral pectoralis flaps were advanced to the midline in 48 patients. Primary skin closure was achieved in 59 cases, while split-thickness skin grafting was used once.

There were seven in-hospital deaths attributed to underlying disease processes (mortality=12%). No deaths resulted from untreated mediastinal sepsis or complications of chest reconstruction. Donor site complications included a mesenteric injury treated with partial transverse colectomy, a gastric leak treated by primary repair on the thirteenth post-operative day, and seven late “paraomental” hernias of abdominal contents into the chest treated by laparoscopic mesh repair. Graft-related complications included suspected flap ischemia treated with amputation and pectoralis closure, forceful pedicle avulsion treated with omentectomy and rectus flap repair, and two partial flap necroses treated with debridement and healing by secondary intention. Wound complications included six local infections/abscesses treated with incision and drainage, four persistent leakages through drains or sinus tracts and one hematoma. During a mean follow-up period of six months, two patients underwent subsequent rectus flap reconstruction to treat recurrent infection.

Omental flaps harvested by open technique incur mortality rates as high as 16% and donor site complications in as many as 19% of patients.4,5 Large series using predominantly pectoralis, latissimus and/or rectus muscle flaps include mortality rates as high as 29% and other complications in as many as 19-25% of patients.6-8 When used as single therapy, closed antibiotic irrigation systems yielded a 79% failure rate when treating infected sternal dehiscence in one recent prospective study.9

CONCLUSIONS: The omento-pectoral flap, when combined with minimally-invasive harvesting, pulse irrigation, wide debridement and preparatory vacuum dressings, offers a valuable alternative for treatment of large chest wall defects. It is often favorable when compared to the morbidity and mortality incurred by other treatments. Plastic surgeons should consider this combination flap and multi-modality approach when evaluating complicated post-sternotomy wounds – whether for initial therapy or for salvage after other closures have failed.

REFERENCES:

1. Jurkiewicz, J.M., and Arnold, G.P. The Omentum: Account of its Use in the Reconstruction of a Chest Wall. Ann Surg. 185:548-554, 1977.

2. Zhang, Q.X., Magovern, C.J., Mack, C.A. et al. Vascular Endothelial Growth Factor is the Major angiogenic factor in the Omentum: Mechanism of the Omentum-Mediated Angiogenesis. J Surg Res. 647:147-154, 1997.

3. Bikfalvi, A., Alterio, J., Inyang, A.L., et al. Basic Fibroblast Growth Factor Expression in Human Omental Microvascular Endothelial Cells and the Effect of Phorbol Ester. J Cell Physiol. 144:151-158, 1990.

4. Yasuura, K., Okamoto, H., Morita, S., et al. Results of Omental Flap Transposition for Deep Sternal Wound Infection After Cardiovascular Surgery. Ann Surg. 227(3):455-459, 1998.

5. Hultman, C.S., Carlson, G.W., Losken, A., et al. Utility of the Omentum in the Reconstruction of Complex Extraperitoneal Wounds and Defects: Donor-Site Complications in 135 Patients from 1975 to 2000. Ann Surg. 235(6):782-795, 2002.

6. Arnold, P.G., and Pairolero, P.C. Chest-Wall Reconstruction: An Account of 500 Consecutive Patients. Plast Reconstr Surg. 98(5):804-810, 1996.

7. Jones, G., Jurkiewicz, M.J., Bostwick, J. et al. Management of the Infected Median Sternotomy wound with Muscle Flaps: The Emory 20-Year Experience. Ann Surg. 225(6):766-778, 1997.

8. Lopez-Monjardin, H., de-la-Pena-Salcedo, A., Mendoza-Munoz, M. et al. Omentum Flap versus Pectoralis Major Flap in Treatment of Mediastinitis. Plast Reconstr Surg. 101(6):1481-1485, 1998.

9. Rand, R.P., Cochran, R.P., Aziz, S. et al. Prospective Trial of Catheter Irrigation and Muscle Flaps for Sternal Wound Infection. Ann Thorac Surg. 65:1046-1049, 1998.

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