Superficial Wound

Dehiscence after
Median Sternotomy
{ Surgical treatment versus secondary
wound healing
  Superficial wound dehiscnece after midline sternotomy is
considered a minor complication in cardiac surgery, although
it is quite frequent and requires prolonged medical treatment

 Non healed aseptic wounds might experience superimposed

infection

 Superficial wound dehiscence can be managed by topical

treatment, with delayed secondary healing, using irrigation of
disinfectant agents and gauze packing

 Alternatively, surgical treatment consist of extensive

debridement and primary skin closure

Background
  2400 consecutive patients underwent median sternotomy for
open heart surgery

 Surgery was performed after skin disinfection with povidone

iodine and 2g of ceftizoxime as prophylaxis antibiotic

 The sternum was reapproximated using stainless steel wires,

fascia and subcutaneous layers were closed with two
continues #0 polyglycolic acid (Dexon) suture lines and the
skin with an intradermic absorbable #4-0 poliglycolic acid
(Dexon) suture line

Material and Methods

  207 patients had sternal wound complications
 3 patients had mediastinitis
 66 patients had aseptic deep sternal wound dehiscence with
mobile sternal edges
 138 patients had superficial wound dehiscence

 Superficial Wound Dehiscence defined as dehiscence

involving the skin, subcutaneous, and fascia layers with stable
sternum edges, farther divided into septic and aseptic.

 After exclusion of sternal and mediastinal involvement,

patients entered the protocol of skin wound care on an
ambulatory basis

Material and Methods

  The first consecutive 96 patients (group 1) were treated by
local debridement of fibrin deposition and medication with
solution of chloramine steeped gauze. Medication repeated in
the outpatient clinic three times a week until complete healing

 The last 42 patients (group 2) were treated by extensive

surgical debridement of skin and subcutaneous tissue and
direct closure of the superficial layers

Material and Methods

  Depending on the severity of the patient, they were treated in
the outpatient clinic, using local anesthesia or temporarily
readmitted to the surgical ward, operated on general
anesthesia, and discharged home after 24 hours

 The surgical debridement included necrotic and

devascularised tissue. In some patients , when wound
dehiscence was particularly large and tension on suture lines
was expected, the subcutaneous tissue was widely mobillised

 Use of electrocautherization was avoided to prevent tissue

damage

Material and Methods

  The two groups were compared with regard to known
preoperative risk factors for surgical wound dehiscence and
infection by means of x2 table or two-tail t test for unpaired
data for dichotomic or continues variables respectively

 A p value less than 0.05 was considered statistically sinificant

Material and Methods

  Patients with wound dehiscence returned to Author’s unit
after a mean period of 29.3 days (range of 4 to 115 days) after
operation

 At that time, due to inflammatory process, the subcutaneous

tissue would lose its elasticity and the suture line under
tension will cut through.

Comment
  The mean length of treatment was 29.7 days (range 2 to 144
days) for group 1 (Secondary Wound Healing)

 The mean length of treatment was 12.2 days (range 2 to 37

days) for group 2 (surgical treatment)

 All patients experienced a complete wound healing

 In group 2, two procedures failed. Both patients had positive

culture for Staphylococcus aureus. These patients crossed over
to topical treatment until complete secondary healing (but
were included in the orginal group for the healing time)

Results
Results
Results
  Median Sternotomy is currently used in most cardiac
surgical procedures

 In the author’s institution, superficial wound dehiscence

accounted for 6% of all patients undergoing open heart
surgery winth median sternotomy access

 The relatively high rate of this complication can be

attributed for several risk factors

 DM, obesity, COPD, low cardiac output, advance age and

chronic renal failure are all known to increase the risk of
incision dehiscence

Comment
  Surgical techniques also play in a major role in wound
dehiscence

 Harvesting of the internal mammary arteries has been

revealed to reduce blood supply to the chest wall

Comment
Comment
  Recently, a vaccum assisted closure (VAC) system or also
called Negative Pressure Wound Treatmen (NPWT) used
to treat wound dehiscence related to cardiac surgery

 VAC used for both deep and superficial wound dehiscence.

 Tang and associates (2000) reported a mean duration of 27

days (8 to 66 days) of treatment with changing wound
dressing every 48 hours

 Although all patients experiencing complete healing, this

procedure appears costly and time consuming

Comment
Comment
  Faster healing means reduced cost and reduced ambulatory care,
because patients needs repeated medications would return to the
hospital for treatment

 In the conservative group, outpatient clinic visit reach a mean of

29,7 visits per patient

 The extension of wound dehiscence and the amount of bacterial

colonies was high in most patients of both groups (31%)

 3 patients required revision of the all length of the sternal wound

and presented extensive to confluent bacteria colonies colonies
and 4 patients required revision of one-third to two-thirds of the
wound, also presented extensive to confluent bacterial colonies

Comment
  Aggressive surgical debridement and primary closure if
superficial wound dehiscence after median sternotomy
seems to be safe and effective

 A positive culture of open wounds is not a contraindication

for surgical debridement and may reduce the spreading of
infection

 There are still rooms for development and research to

compare the previous two with the use of NPWT

 Further research with more samples and distinctive criteria

is needed to give the best result

conclusion
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