Zentralbl Chir 2018; 143(02): 138-141
DOI: 10.1055/s-0043-111724
Videopaper
Georg Thieme Verlag KG Stuttgart · New York

Der gefäßgestielte Omentumlappen zur Behandlung tiefer sternaler Wundinfekte

Pedicled Omentum Flaps in the Management of Deep Sternal Wound Infections
Nick Spindler
1   Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig, Deutschland
,
Christian Etz
2   Herzzentrum Leipzig, Universitätsklinikum Leipzig, Deutschland
,
Martin Misfeld
2   Herzzentrum Leipzig, Universitätsklinikum Leipzig, Deutschland
,
Christoph Josten
1   Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig, Deutschland
,
Michael Borger
2   Herzzentrum Leipzig, Universitätsklinikum Leipzig, Deutschland
,
Friedrich Wilhelm Mohr
2   Herzzentrum Leipzig, Universitätsklinikum Leipzig, Deutschland
,
Stefan Langer
1   Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig, Deutschland
› Author Affiliations
Further Information

Publication History

Publication Date:
06 November 2017 (online)

Zusammenfassung

Zielsetzung Defektdeckung einer persistierenden, sternalen Wundheilungsstörung, die nach frustranem Deckungsversuch mittels eines gestielten Latissimus-dorsi-Lappens durch eine Omentumplastik zur Ausheilung gebracht wurde.

Indikation Tiefe sternale Wundheilungsstörungen sind seltene, aber schwerwiegende Komplikationen nach medianer Sternotomie. Wenn reguläre Deckungsverfahren fehlschlagen oder nicht zu entfernendes Fremdmaterial wie „Drivelines“ oder Gefäßprothesen mittels Muskellappen nicht zur Ausheilung gebracht werden können, bildet der Omentumlappen, aufgrund seiner immunologischen Kompetenz, eine sinnvolle Alternative.

Methode Nach Exploration des persistierenden, sternalen Defekts schießt sich das radikale tangentiale Débridement und die Spülung der Wunde mittels einer Jet-Lavage an. Das Gewebe des Omentums wird nach Medianlaparotomie und Präparation des Lappens durch einen im vorderen Diaphragma angelegten Tunnel in den Defekt verlagert und kann hier spannungsfrei zur Ummantelung der Prothese verwendet werden. Der im Vorfeld verwendete Latissimuslappen wird in diesem Fall für den oberflächlichen Weichteilverschluss wiederverwendet.

Schlussfolgerung Insbesondere bei infiziertem, nicht entfernbarem Restmaterial stellt der Omentumlappen aufgrund seiner immunologischen Kompetenz eine gute Behandlungsalternative zu Muskellappen dar.

Abstract

Aim Coverage of a deep sternal wound infection with a greater omentum flap. Due to a persistent infection caused by an infected aortic prosthesis, the primarily performed reconstruction with a latissimus dorsi flap had to be revised, and an alternative solution had to be found.

Indication A deep sternal wound infection is a rare but devastating complication following median sternotomy. If the commonly used muscle flap is not sufficient and artificial material is still present in the wound, for instant drivelines or a vascular prosthesis, the greater omentum flap is a useful option due to its immunologic capacity.

Method After an exploration of the persisting infected deep sternal wound, a radical debridement is performed followed by a jet lavage. The soft tissue from the greater omentum is prepared via median laparotomy and transferred through a tunnel created in the diaphragm. Then it is pulled into the wound cavity and can be used for tension-free sheathing of the aortic prosthesis. The previously used muscle flap can additionally be used for superficial soft tissue coverage.

Conclusion Due to its immunologic competence, the greater omentum flap is a good treatment alternative to the commonly used muscle flaps in defects with infected artificial material.

 
  • Literatur

  • 1 Mauermann WJ, Sampathkumar P, Thompson RL. Sternal wound infections. Best Pract Res Clin Anaesthesiol 2008; 22: 423-436
  • 2 Toumpoulis IK, Anagnostopoulos CE, Derose jr. JJ. et al. The impact of deep sternal wound infection on long-term survival after coronary artery bypass grafting. Chest 2005; 127: 464-471
  • 3 Loop FD, Lytle BW, Cosgrove DM. et al. J. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990; 49: 179-186
  • 4 Ennker IC, Kojcici B, Ennker J. et al. [Examination of the opportunity costs and turnover situation in patients with deep sternal infections]. Zentralbl Chir 2012; 137: 257-261
  • 5 Graf K, Ott E, Vonberg RP. et al. Economic aspects of deep sternal wound infections. Eur J Cardiothorac Surg 2010; 37: 893-896
  • 6 Borger MA, Rao V, Weisel RD. et al. Deep sternal wound infection: risk factors and outcomes. Ann Thorac Surg 1998; 65: 1050-1056
  • 7 Spindler N, Zeplin P, Strunz H. et al. Sternal wound defect: way of treatment in Leipzig. Plastische Chirurgie 2013; 2: 107-108
  • 8 Vyas RM, Prsic A, Orgill DP. Transdiaphragmatic omental harvest: a simple, efficient method for sternal wound coverage. Plast Reconstr Surg 2013; 131: 544-552
  • 9 Steinau HU, Hebebrand D, Vogt P. et al. [Reconstructive plastic surgery of thoracic wall defects]. Chirurg 1997; 68: 461-468
  • 10 Pairolero PC, Arnold PG. Management of infected median sternotomy wounds. Ann Thorac Surg 1986; 42: 1-2
  • 11 Li EN, Goldberg NH, Slezak S. et al. Split pectoralis major flaps for mediastinal wound coverage: a 12-year experience. Ann Plast Surg 2004; 53: 334-337
  • 12 Beier JP, Arkudas A, Lang W. et al. [Sternal osteomyelitis – Surgical treatment concepts]. Chirurg 2016; 87: 537-550
  • 13 Iacobucci JJ, Stevenson TR, Hall JD. et al. Sternal osteomyelitis: treatment with rectus abdominis muscle. Br J Plast Surg 1989; 42: 452-459
  • 14 Beier JP, Croner RS, Lang W. et al. [Avoidance of complications in oncological surgery of the pelvic region: combined oncosurgical and plastic reconstruction measures]. Chirurg 2015; 86: 242-250
  • 15 Spindler N, Lehmann S, Steinau HU. et al. [Complication management after interventions on thoracic organs: deep sternal wound infections]. Chirurg 2015; 86: 228-233
  • 16 Dejesus RA, Paletta JD, Dabb RW. Reconstruction of the median sternotomy wound dehiscence using the latissimus dorsi myocutaneous flap. J Cardiovasc Surg (Torino) 2001; 42: 359-364
  • 17 Spindler N, Langer S. [Plastic reconstruction with a vascular pedicle latissimus dorsi flap after sternal osteomyelitis]. Zentralbl Chir 2016; DOI: 10.1055/s-0042-102657.
  • 18 Vogt PM, Busch K, Peter FW. et al. [Plastic reconstruction of the irradiated thoracic wall]. Langenbecks Arch Chir Suppl Kongressbd 1998; 115: 507-511
  • 19 Banic A, Ris HB, Erni D. et al. Free latissimus dorsi flap for chest wall repair after complete resection of infected sternum. Ann Thorac Surg 1995; 60: 1028-1032
  • 20 Taeger CD, Horch RE, Arkudas A. et al. Combined free flaps with arteriovenous loops for reconstruction of extensive thoracic defects after sternal osteomyelitis. Microsurgery 2016; 36: 121-127
  • 21 Schwabegger A, Ninkovic M, Brenner E. et al. Seroma as a common donor site morbidity after harvesting the latissimus dorsi flap: observations on cause and prevention. Ann Plast Surg 1997; 38: 594-597
  • 22 Lee KT, Mun GH. Fibrin sealants and quilting suture for prevention of seroma formation following latissimus dorsi muscle harvest: a systematic review and meta-analysis. Aesthetic Plast Surg 2015; 39: 399-409
  • 23 Ghazi BH, Carlson GW, Losken A. Use of the greater omentum for reconstruction of infected sternotomy wounds: a prognostic indicator. Ann Plast Surg 2008; 60: 169-173
  • 24 Sajjadian A, Valerio IL, Acurturk O. et al. Omental transposition flap for salvage of ventricular assist devices. Plast Reconstr Surg 2006; 118: 919-926
  • 25 Mathisen DJ, Grillo HC, Vlahakes GJ. et al. The omentum in the management of complicated cardiothoracic problems. J Thorac Cardiovasc Surg 1988; 95: 677-684
  • 26 Hultman CS, Carlson GW, 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 2002; 235: 782-795
  • 27 Weinzweig N, Yetman R. Transposition of the greater omentum for recalcitrant median sternotomy wound infections. Ann Plast Surg 1995; 34: 471-477
  • 28 van Wingerden JJ, Lapid O, Boonstra PW. et al. Muscle flaps or omental flap in the management of deep sternal wound infection. Interact Cardiovasc Thorac Surg 2011; 13: 179-187
  • 29 Salameh JR, Chock DA, Gonzalez JJ. et al. Laparoscopic harvest of omental flaps for reconstruction of complex mediastinal wounds. JSLS 2003; 7: 317-322
  • 30 van Wingerden JJ, Coret ME, van Nieuwenhoven CA. et al. The laparoscopically harvested omental flap for deep sternal wound infection. Eur J Cardiothorac Surg 2010; 37: 87-92
  • 31 Krabatsch T, Hetzer R. Poststernotomy mediastinitis treated by transposition of the greater omentum. J Card Surg 1995; 10: 637-643
  • 32 Yasuura K, Okamoto H, Morita S. et al. Results of omental flap transposition for deep sternal wound infection after cardiovascular surgery. Ann Surg 1998; 227: 455-459