Omental transfer in acute and chronic sternotomy wound breakdown

Median sternotomy is complicated by deep infection in 1-5% of cases. Internal mammary artery grafting (especially bilateral) may increase incidence and severity. Mediastinitis accompanied by sternal necrosis has a reported mortality up to 30%. The defect resulting from removal of dead bone requires reconstruction and skin cover. Twelve patients are presented in whom this defect was abolished by omental transposition. There were no deaths. Seven had chronically infected wounds (median time to operation 100 days) with very large defects following multiple debridements resulting in total sternectomy; these were treated by omental transposition and meshed split-skin grafting. Five were treated 'acutely' (median time to operation 28 days p less than 0.02) using smaller omental flaps and direct myocutaneous closure, despite total sternectomy being required in 4. One was bleeding from an infected aorto-saphenous anastomosis following povidone-iodine irrigation. Median total hospital stay in the acute group was 49 vs. 82 days in the chronic group (p less than 0.01) who also had 4 major complications (p NS). All wounds healed but further surgery was required to stabilise the chest wall in 1 of the 'Chronic' group. It is concluded that for severe sternal infection early radical removal of necrotic tissue, omental transposition, and direct closure reduces morbidity and hospital stay. In one patient bleeding from a septic aortic erosion we consider the procedure to have been life-saving.