A radiologist's guide to median sternotomy.

Median sternotomy is widely recognised as the primary incision technique in cardiac surgery. This surgical procedure involves dividing the sternum to gain access to the heart and lungs, making it invaluable in correcting congenital heart defects. Furthermore, it is frequently employed in adult patients, particularly during coronary artery bypass graft (CABG) procedures. In this imaging review, we present a comprehensive overview of the pre-procedural assessment and various post-sternotomy complications encountered within our clinical experience at a tertiary cardiothoracic centre. The focus of this review is to outline the imaging features associated with mediastinal adhesions and establish the minimal safe distance between the sternum and common mediastinal structures when considering re-sternotomy. By providing visual examples, we aim to facilitate a better understanding of these key concepts. Moreover, we delve into a detailed discussion of a spectrum of postoperative complications that may arise following median sternotomy including those related to metalwork (sternal wire fracture), bone (sternal dehiscence, non-union and osteomyelitis), and soft tissue (abscess, haematoma).

The Results of Rigid Titanium Plate Reinforcement and Only Conventional Wire Methods in Sternal Fixation in Morbidly Obese Patients.

INTRODUCTION: In this study, it was aimed to compare the clinical results and complications of rigid titanium plate reinforcement and only conventional wire methods for sternum fixation in morbidly obese patients who underwent sternotomy for open-heart surgery. METHODS: The study was planned as a retrospective case-control study. Morbidly obese patients who underwent open-heart surgery with median sternotomy between 2011 and 2021 were analyzed retrospectively. RESULTS: There was no statistically significant difference between the two groups in terms of characteristics of the patients (P≥0.05). Sternal dehiscence, sternum revision, wound drainage, and mediastinitis were significantly less common in the titanium plate group (P≤0.05). There was no statistically significant difference between the groups in terms of 30-day mortality (P≥0.05). CONCLUSION: Rigid titanium plate reinforcement application produced more positive clinical results than only conventional wire application. In addition, it was determined that although the rigid titanium plate application prolonged the operation time, it did not make a significant difference in terms of mortality and morbidity compared to the conventional wire applied group.

Case Report of Complex Chest Wall Repair for Sternal Dehiscence After Bilateral Lung Transplantation.

BACKGROUND: We report a case of a complex chest wall reconstruction because of sternal dehiscence, requiring different surgical procedures for its complete resolution. CASE REPORT: A 54-year-old man patient with Langerhans cell histiocytosis and chronic obstructive pulmonary disease underwent bilateral sequential lung transplantation through a clamshell incision, using nitinol thermo-reactive clips for sternal closure. One year later, he consulted because of chest pain, fever, and purulent secretions. Physical examination and chest X-ray revealed a right pulmonary hernia due to post-clamshell wound dehiscence. Chest wall repair was performed, placing an expanded-polytetrafluoroethylene synthetic mesh, and the sternum was realigned and fixated with titanium plates and screws. However, in the immediate postoperative period, there was a large amount of serous drainage through the surgical wound, needing negative pressure therapy. Unfortunately, the wound became necrotic with exposure to the osteosynthesis material. In addition, a chest computed tomography scan showed fluid accumulation in the anterior chest wall. Therefore, two-stage revision surgery was indicated: first, the removal of the previous prosthesis and, the definite one, the use of a pedicled latissimus dorsi myocutaneous flap to provide effective coverage of the wound. CONCLUSION: Sternal dehiscence is not an uncommon complication after clamshell incision in patients undergoing bilateral sequential lung transplantation, and it is associated with significant morbidity. In the presence of chest wall instability, surgical repair is mandatory.

Surgical management of spontaneous bowel perforation and fascial dehiscence in a patient on bevacizumab and pembrolizumab in the setting of active Clostridium difficile infection.

Immunotherapy such as bevacizumab and pembrolizumab is used to treat an increasing number of malignancies. These medications have been associated with poor wound healing and several gastrointestinal complications, including intestinal perforations in rare cases. We present a unique case of a patient with metastatic cervical cancer on pembrolizumab and recent bevacizumab therapy, presenting with a colonic perforation requiring urgent exploratory laparotomy, in the setting of active Clostridium difficile infection. She required a second laparotomy shortly after due to fascial dehiscence, where a synthetic absorbable mesh was used for fascial approximation. We review the factors that led to these events and describe the surgical technique used for safe abdominal closure.

A Unique Apparatus to Treat Dehiscence Following Bilateral Cleft Lip Repair: A Case Report.

We report a case of a 6-month-old male that presented with wound dehiscence, in part due to mechanical tongue trauma, following bilateral cleft lip repair. A silastic sheeting dressing with retention sutures was uniquely fashioned to decrease wound tension and protect the surgical site from patient interference. This solution may potentially be used in similar circumstances.

Sternal Reconstruction Using 3D-Printed Titanium Custom-Made Prosthesis for Sternal Dehiscence After Cardiac Surgery.

Sternal dehiscence is an important complication that increases mortality and morbidity in cardiac surgery. Titanium plates have been used to reconstruct the chest wall for a long time. However, with the rise of 3D printing technology, a more sophisticated method, is making a breakthrough. Custom-made 3D-printed titanium prostheses are increasingly used in chest wall reconstruction because they allow almost perfect fitting to the patient's chest wall and lead to good functional and cosmetic results. This report presents a complex anterior chest wall reconstruction using a custom-made titanium 3D-printed implant in a patient with a sternal dehiscence after coronary artery bypass surgery. At first, reconstruction of the sternum was performed using conventional methods, which failed to give adequate results. Finally, a 3D-printed titanium custom-made prosthesis was used for the first time in our center. On the short- and mid-term follow up, good functional results were achieved. In conclusion, this method is suitable for sternal reconstruction after complications in the healing process of median sternotomy wounds in cardiac surgery, especially where other methods do not provide satisfactory results.

Brixia system of screws: a titanium modular system with wide applicability for reinforced sternal closure in cardiac and thoracic surgery.

The use of cannulated screws and titanium plates to reinforce the sternal closure or to treat sternal dehiscence after median sternotomy has already been suggested in several articles. The system proposed here has some important advantages over those already described. Moreover, thanks to its characteristics, this system can also be used to treat pathologies affecting the entire rib cage. The system consists of a first threaded cannulated screw that is inserted in the bone or chondral cartilage and accommodates a cap screw that is tightened into the first screw and fixes a plate according to the following scheme: a threaded cannulated screw/plate/cap screw (Brixia system of screws). This system allows the plates to be fixed on the anterior face of the ribs and/or sternum without the need to enlarge dissection of the tissue, thereby lowering the danger of haemorrhage and injury to the thoracic organs. For this reason, it is particularly suitable for treating post-sternotomy sternal dehiscence, but it can be used to reinforce the primary sternal closure (after median or transversal sternotomy) in high-risk patients with sternal dehiscence. Owing to the modular nature of the system, singular components can also be utilized independently.

Fascial dehiscence: predictable complication? Development and validation of a risk model: a retrospective cohort study.

PURPOSE: Fascial dehiscence is still an important cause of morbidity and mortality in the postoperative period of abdominal surgery. Different authors have sought to identify risk factors for this entity. Two risk scores have been developed, but they include postoperative variables, which hinder preventive decision-making during the early surgical period. Our aim is to identify preoperative and intraoperative risk factors for fascial dehiscence and to develop and validate a risk prediction score that allows taking preventive behaviors. METHODS: All adult patients, with no prior history of abdominal surgery, who underwent midline laparotomy by a general surgery division between January 2009 and December 2019 were included. Recognized preoperative risk factors for fascial dehiscence were evaluated in a univariate analysis and subsequently entered in a multivariate stepwise logistic regression model. A prognostic risk model was developed and posteriorly validated by bootstrapping. This study was conducted following the STROBE statement. RESULTS: A total of 594 patients were included. Fascial dehiscence was detected in 41 patients (6.9%). On multivariate analysis, eight factors were identified: chronic obstructive pulmonary disease (COPD), immunosuppression, smoking, prostatic hyperplasia, anticoagulation use, sepsis, and overweight. The resulting score ranges from 1 to 8. Scores above 3 are predictive of 18% risk of dehiscence with a sensitivity of 70% and specificity of 80% (ROC 0.88). CONCLUSIONS: We present a new preoperative prognostic score to identify patients with a high risk of fascial dehiscence. It can be a guide for decision-making that allows taking intraoperative preventive measures. External validation is still required.

Does Elective Sternal Plating Combined with Steel Wire Reduce Sternal Complication Rates in Patients with Obesity?

INTRODUCTION: In this study, sternal complication rates of sternal closures with steel wire or steel wire combined with titanium plate in patients with obesity that underwent cardiac surgery were investigated. METHODS: The data of 316 patients that underwent cardiac surgery between May 2018 and October 2021 were analyzed retrospectively; 124 patients withbody mass index (BMI) ≥ 30 kg/m2 were divided into group I, patients whose sternotomy was performed with steel wires, and group II, patients whose sternotomy was performed with steel wire combined with titanium plates. RESULTS: A total of 124 patients with BMI ≥ 30 kg/m2 were divided into group I (n=88 [70.9%]) and group II (n=36 [29.1%]). The rate of male patients was found to be significantly higher in group I, whereas the rate of female patients was significantly higher in group II (P<0.001). BMI values were found to be low in group I and high in group II (P<0.001). The distribution of complications was different in the BMI ≥ 35.00-39.99 kg/m2 and ≥ 40 kg/m2 groups (P=0.003). Development of complications was found to be higher in patients with BMI ≥ 40 kg/m2. Sternal dehiscence was observed in two patients in group I, while no dehiscence was observed in group II. CONCLUSION: The lower incidence of complications and the absence of non-infectious sternal complications and sternal dehiscence in patients with BMI ≥ 35 kg/m2 that underwent steel wire combined titanium plate sternal closure strengthened the idea that plate-supported sternal closure can prevent sternal complications in high-risk patients.

Early and late anastomotic leak after colorectal surgery: A systematic review of the literature / Dehiscencia de anastomosis temprana y tardía en cirugía colorrectal: revisión sistemática de la literatura

The aim of this study was to review and to assess the quality of the scientific articles regarding early and late anastomotic leak (AL) after colorectal surgery and their risk factors.An electronic systematic search for articles on Colorectal Surgery, AL and its timing was undertaken using the MEDLINE database via PubMed, Cochrane and Embase. The selected articles were thoroughly reviewed and assessed for methodological quality using a validated methodology quality score (MINCIR score). This review was registered in the PROSPERO registry under ID: CRD42022303012. 9 articles were finally reviewed in relation to the topic of early and late anastomotic leak.There is a lack of consensus regarding the exact cut-off in time to define early and late anastomotic leak, but it is clear that they are two differentiated entities. The first, occurring in relation to technical factors; whereas the latter, is related to impaired healing. (AU)

El objetivo de este estudio fue revisar y evaluar la calidad de los artículos científicos sobre la dehiscència anastomótica temprana y tardía después de cirugía colorrectal y sus factores de riesgo.Se realizó una búsqueda sistemática electrónica de artículos sobre Cirugía colorrectal, dehiscència de anastomoiis colorectal utilizando la base de datos MEDLINE a través de PubMed, Cochrane y Embase. La calidad metodológica de los artículos seleccionados se revisó minuciosamente y se evaluó mediante una puntuación de calidad metodológica validada (puntuación MINCIR). Este estudio fue registrado en PROSPERO con el ID: CRD42022303012. Despues de una seleccion basada en los criterios de búsqueda, finalmente se revisaron 9 artículos en relación al tema la revisión.Se pudo observar que existe una falta de consenso en cuanto al tiempo de corte exacto para definir la fuga anastomótica temprana y tardía, pero está claro que son dos entidades diferenciadas. La primera, ocurriendo en relación a factores técnicos; mientras que la segunda situación clinica se relaciona con una cicatrización alterada. (AU)

Early and late anastomotic leak after colorectal surgery: A systematic review of the literature / Dehiscencia de anastomosis temprana y tardía en cirugía colorrectal: revisión sistemática de la literatura

The aim of this study was to review and to assess the quality of the scientific articles regarding early and late anastomotic leak (AL) after colorectal surgery and their risk factors.An electronic systematic search for articles on Colorectal Surgery, AL and its timing was undertaken using the MEDLINE database via PubMed, Cochrane and Embase. The selected articles were thoroughly reviewed and assessed for methodological quality using a validated methodology quality score (MINCIR score). This review was registered in the PROSPERO registry under ID: CRD42022303012. 9 articles were finally reviewed in relation to the topic of early and late anastomotic leak.There is a lack of consensus regarding the exact cut-off in time to define early and late anastomotic leak, but it is clear that they are two differentiated entities. The first, occurring in relation to technical factors; whereas the latter, is related to impaired healing. (AU)

El objetivo de este estudio fue revisar y evaluar la calidad de los artículos científicos sobre la dehiscència anastomótica temprana y tardía después de cirugía colorrectal y sus factores de riesgo.Se realizó una búsqueda sistemática electrónica de artículos sobre Cirugía colorrectal, dehiscència de anastomoiis colorectal utilizando la base de datos MEDLINE a través de PubMed, Cochrane y Embase. La calidad metodológica de los artículos seleccionados se revisó minuciosamente y se evaluó mediante una puntuación de calidad metodológica validada (puntuación MINCIR). Este estudio fue registrado en PROSPERO con el ID: CRD42022303012. Despues de una seleccion basada en los criterios de búsqueda, finalmente se revisaron 9 artículos en relación al tema la revisión.Se pudo observar que existe una falta de consenso en cuanto al tiempo de corte exacto para definir la fuga anastomótica temprana y tardía, pero está claro que son dos entidades diferenciadas. La primera, ocurriendo en relación a factores técnicos; mientras que la segunda situación clinica se relaciona con una cicatrización alterada. (AU)

Abdominal fascia dehiscence: is there a connection to a special microbial spectrum?

INTRODUCTION: Acute fascia dehiscence (FD) is a threatening complication occurring in 0.4-3.5% of cases after abdominal surgery. Prolonged hospital stay, increased mortality and increased rate of incisional hernias could be following consequences. Several risk factors are controversially discussed. Even though surgical infection is a known, indisputable risk factor, it is still not proven if a special spectrum of pathogens is responsible. In this study, we investigated if a specific spectrum of microbial pathogens is associated with FD. METHODS: We performed a retrospective matched pair analysis of 53 consecutive patients with an FD after abdominal surgery in 2010-2016. Matching criteria were gender, age, primary procedure and surgeon. The primary endpoint was the frequency of pathogens detected intraoperatively, the secondary endpoint was the occurrence of risk factors in patients with (FD) and without (nFD) FD. RESULTS: Intraabdominal pathogens were detected more often in the FD group (p = 0.039), with a higher number of Gram-positive pathogens. Enterococci were the most common pathogen (p = 0.002), not covered in 73% (FD group) compared to 22% (nFD group) by the given antibiotic therapy. Multivariable analysis showed detection of Gram-positive pathogens, detection of enterococci in primary laparotomy beside chronic lung disease, surgical site infections and continuous steroid therapy as independent risk factors. CONCLUSION: Risk factors are factors that reduce wound healing or increase intra-abdominal pressure. Furthermore detection of Gram-positive pathogens especially enterococci was detected as an independent risk factor and its empirical coverage could be advantageous for high-risk patients.

[Pneumoperitoneum is not always caused by bowel perforation: a case report of vaginal cuff dehiscence].

Postcoital vaginal cuff dehiscence is a rare but well documented complication of hysterectomy. Common symptoms are vaginal bleeding and abdominopelvic pain with or without evisceration of the intraperitoneal contents through the separated vaginal cuff, which can lead to bowel injury, necrosis and sepsis. This potentially life-threatening condition usually occurs during the first postoperative act of intercourse or within the first few months of surgery. This case report presents the unusual case of vaginal cuff dehiscence in a 59-year-old woman 14 years after a total abdominal hysterectomy.

Change of the residual myometrial thickness during pregnancy in women who underwent laparoscopic niche resection compared with controls without niche surgery: a prospective comparative cohort study.

BACKGROUND: Reduced residual myometrial thickness before and during pregnancy is associated with uterine rupture or dehiscence after vaginal birth after cesarean delivery. Laparoscopic niche resection performed in case of gynecologic symptoms has shown to increase residual myometrial thickness 6 months after surgery. OBJECTIVE: This study aimed to evaluate the change in residual myometrial thickness from baseline value before pregnancy to the third trimester of pregnancy in women with and without laparoscopic niche resection and evaluate niche presence, niche size during pregnancy vs before pregnancy, and obstetrical outcomes, including uterine rupture and dehiscence in both study groups. STUDY DESIGN: This was a prospective cohort study conducted in an academic medical center. Of note, 2 groups of pregnant women with a previously diagnosed niche were included: (1) women with a large symptomatic niche (residual myometrial thickness of <3 mm) followed by laparoscopic niche resection (LNR group) and (2) women with a niche without niche resection because of minimal symptoms or a residual myometrial thickness of ≥3 mm diagnosed before current pregnancy (expectant group). Participants underwent a transvaginal ultrasound at 12, 20, and 30 weeks of gestation. Changes in residual myometrial thickness and changes in niche measurements over time were analyzed with linear mixed models. RESULTS: A total of 100 women were included, 61 in the LNR group and 39 in the expectant group. The change in residual myometrial thickness from baseline value before niche resection to the third trimester of pregnancy was +2.0 mm in the LNR group vs -1.6 mm in the expectant group (P<.001). Residual myometrial thickness decreased from the first trimester of pregnancy onward in both groups. Although residual myometrial thickness was thinner at baseline in the LNR group, it was thicker in the LNR group than in the expectant group during all trimesters: 3.2 mm (P<.001) in the first trimester of pregnancy, 2.5 mm (P<.001) in the second trimester of pregnancy, and 1.8 mm (P=.001) in the third trimester of pregnancy. Uterine dehiscence was reported in 1 of 50 women (2%) in the LNR group and 7 of 36 women (19%) in the expectant group (P=.007) and was related to the depth of niche-to-residual myometrial thickness ratio before pregnancy (after niche resection) and residual myometrial thickness in the second trimester of pregnancy. No uterine rupture was reported. Most patients received a scheduled cesarean delivery in both groups. There was more blood loss during subsequent cesarean delivery in the LNR group than in the expectant group. CONCLUSION: Here, laparoscopic niche resection resulted in an increased residual myometrial thickness during a subsequent pregnancy. Moreover, a lower number of dehiscence was found in the LNR group than in the expectant group without niche surgery. Per-section blood loss was higher in the LNR group than in the expectant group. In general, laparoscopic niche resection is performed to improve gynecologic symptoms. Currently, there is no evidence to support a laparoscopic niche resection to improve obstetrical outcomes, but the trend toward more uterine dehiscence encourages further research.

Clinical Evaluation of Titanium-Alloy Bands for Sternal Closure after Median Sternotomy: Single-Center Experience.

Background: Median sternotomy is the most applied approach in open-heart surgery, while potential complications such as postoperative bleeding, sternal dehiscence, and deep sternal wound infection (DWSI) still remain a challenge to cardiac surgeons. Several new sternum-closure products instead of stainless wire have been brought into clinical application. The objective of this retrospective study is to evaluate the novel sternum-fixing product in terms of clinical outcomes. Methods: 689 consecutive cases undergoing cardiac surgery through median sternotomy between February 2015 and December 2018 in our center were enrolled in this study. All the cases were divided into two groups according to different sternum fixation methods: wire cerclage group and rigid fixator group. The demographic as well as clinical data including the mediastinal drainage of first, second, and third post-op 24 hours, the total mediastinal drainage of post-op 72 hours, ICU duration, length of hospital stay, and post-op mortality in 30 days were collected and compared between the two groups. Results: 278 cases were enrolled in the wire cerclage group and 411 cases in the rigid fixator group. There is no significant difference in the demographic data between the two groups, while the mediastinal drainage in the first and third 24 hours after surgery and the total mediastinal drainage in postoperative 72 hours of the rigid fixator group were significantly less than those of the wire cerclage group (P < 0.05). No significant difference was found in other clinical outcomes between the groups including ICU duration, LOS in hospital, and 30-day mortality. 14 cases (5.0%) in the wire cerclage group and 11 cases (2.7%) in the rigid fixator group had sternotomy-related complications including severe postoperative bleeding, sternal dehiscence, and DSWI. Conclusion: Compared with the conventional wire cerclage, the new rigid fixator is superior in median sternotomy closure in terms of postoperative mediastinal bleeding as well as incidence of sternotomy-related complications.

The role of the unilateral pectoralis major muscle flap in the treatment of deep sternal wound infection and dehiscence.

Deep sternal wound infection and dehiscence has been classified as complex wound, and its treatment is a challenge for the surgeon. There are many flap choices for its treatment, each one having advantages and drawbacks. The article by Wang et al. evidenced that the unilateral pectoralis major muscle flap is a simple and effective option for wound closure resulting from sternotomy dehiscence in infants and children. The report discussed herein highlights that the unilateral pectoralis major muscle flap has been a good and feasible option for the reconstruction of the sternal wound in adults, as previously described by our group and other authors. This technique presents low morbidity and acceptable esthetic and functional results, providing stability to the sternal region.

An Algorithmic Approach to the Surgical Management of Sternal Dehiscence: A Single-Center Experience.

BACKGROUND: Deep sternal wound complications following sternotomy represent a complex challenge. Management can involve debridement, flap reconstruction, and rigid sternal fixation (RSF). We present our 11-year experience in the surgical treatment of deep sternal wound dehiscence using a standardized treatment algorithm. METHODS: A retrospective review was conducted of all 134 cardiac patients who required operative debridement after median sternotomy at a single institution between October 2007 and March 2019. Demographics, perioperative covariates, and outcomes were recorded. Univariate and subgroup analyses were performed. RESULTS: One-hundred twelve patients (83.5%) with a deep sternal dehiscence underwent flap closure and 56 (50%) RSF. Of the patients who underwent flap closure, 87.5% received pectoralis advancement flaps. A 30-day mortality following reconstruction was 3.9%. Median length of stay after initial debridement was 8 days (interquartile range: 5-15). Of patients with flaps, 54 (48%) required multiple debridements prior to closure, and 30 (27%) underwent reoperation after flap closure. Patients who needed only a single debridement were significantly less likely to have a complication requiring reoperation (N = 10/58 vs. 20/54, 17 vs. 37%, p = 0.02), undergo a second flap (N = 6/58 vs. 17/54, 10 vs. 32%, p < 0.001), or, if plated, require removal of sternal plates (N = 6/34 vs. 11/22, 18 vs. 50%, p = 0.02). CONCLUSION: Although sternal dehiscence remains a complex challenge, an aggressive treatment algorithm, including debridement, flap closure, and consideration of RSF, can achieve good long-term outcomes. In low-risk patients, RSF does not appear to increase the likelihood of reoperation. We hypothesize that earlier surgical intervention, before the development of systemic symptoms, may be associated with improved outcomes.

Breaking the Binary: The Approach to Chest Masculinizing Gender-Affirming Surgery in Trangender Men.

BACKGROUND: The purpose of mastectomy for the transgender patient is to produce a masculine appearance of the chest. A number of algorithms have been proposed for selecting the surgical technique. A holistic and surgical approach to transgender men includes our experience-based classification system for selecting the correct surgical technique. OBJECTIVES: To present and discuss the Transgender Standard of Care and our personal experience. METHODS: Data were collected from the files of female-to-male transgender persons who underwent surgery during 2003-2019. Pictures of the patients were also analyzed. RESULTS: Until May 2021, 342 mastectomies were performed by the senior author on 171 patients. The 220 mastectomies performed on 110 patients until November 2019 were included in our cohort. Patient age was 13.5 to 50 years (mean 22.5 ± 6.1). The excision averaged 443 grams per breast (range 85-2550). A periareolar approach was performed in 14 (12.7%), omega-shaped resection (nipple-areola complex on scar) in 2 (1.8%), spindle-shaped mastectomy with a dermal nipple-areola complex flap approach in 38 (34.5%), and a complete mastectomy with a free nipple-areola complex graft in 56 (50.9%). Complications included two hypertrophic scars, six hematomas requiring revision surgery, three wound dehiscences, and three cases of partial nipple necrosis. CONCLUSIONS: A holistic approach to transgender healthcare is presented based on the World Professional Association for Transgender Health standard of care. Analysis of the data led to Wolf's classification for female-to-male transgender mastectomy based on skin excess and the distance between the original and the planned position of the nipple-areola complex.