经胸骨正中手术切口感染创面的修复

TREATMENT OF REFRACTORY STERNOTOMY WOUND

目的对比观察不同方法修复经胸骨正中手术切口感染创面的治疗效果。方法1997年12月～2006年12月,分别用胸大肌内侧头肌瓣、胸大肌瓣、上蒂腹直肌瓣及大网膜移位修复经胸骨手术切口感染创面13例。男8例,女5例;年龄28～72岁,平均52岁。合并糖尿病8例,肺炎及心力衰竭4例,脓胸3例,慢性肺功能不全4例,恶性肿瘤1例,严重肥胖6例。11例为较新鲜裂开创面,2例为慢性创面。创面范围10cm×5cm～22cm×10cm。结果3例分别于术后3d因血管吻合处破裂大出血、肺炎及癌转移死亡。其余10例伤口期愈合6例,随访6个月～5年,均无复发;2例切口皮肤拉拢缝合处部分皮肤坏死,经再次手术扩创植皮后愈合;2例创口引流处感染,经换药愈合。结论创面较小且位于手术切口上端者适合用胸大肌内侧头肌瓣修复;创面较大且位于切口上端者适合用全胸大肌瓣修复;创面较小且位于切口下端的适合用上蒂腹直肌瓣修复;创面较长可联合应用胸大肌瓣、上蒂腹直肌瓣修复创面;创面巨大合并重要脏器外露时,可用大网膜移位修复创面。残余创面可经植皮及换药愈合。

Objective To investigate the therapeutic effect of infected incision wounds after sternotorny by using different reconstructive methods. Methods From December 1997 to December 2006, 13 patients （8 males, 5 females age, 28-72 years averaged 52 years） with infected incision wounds after sternotomy underwent the reconstruction surgery respectively using the pectoralis major muscle flaps, the medial flaps of the pectoralis major muscle, the rectus abdominis muscle flaps or the greater omentum transpositions. Among the patients, 8 were complicated by diabetes mellitus, 4 by pneumonia and heart failure, 3 by empyema, 4 by chronic insufficiency of the pulmonary function, 1 by malignant tumor, and 6 by severe obesity. Freshly-split wounds were found in 11 patients and chronic wounds in the other 2 -patients. The size of the wounds was 10 cm× 5 cm-22 cm × 10 cm. Results Among the 13 patients, 10 survived after operation and the other 3 died of massive hemorrhage from the anastomostic rupture of the blood vessel, pneumonia, and cancer metastasis, respectively. Of the I0 patients, 6 had their wounds healed by first intention. The follow-up for 6 months to 5 years revealed that there was no recurrence in all the survived patients. Of the 10 patients, 2 developed partial necrosis of the skins at the sutured wounds, which was healed after the skin grafting operation 2 had an infection at the drainage area but had a healing after the dressing changes. Conclusion The smaller wounds in the upper part of the sternotomy incision should be repaired with the medial flaps of the pectoralis major muscle; the greater wounds in the upper part of the incision should be repaired and reconstructed with the rectus abdominis muscle flap the smaller wounds in the lower part of the incision should be repaired with the pectoralis major muscle flap, and if the wounds are longer, they should be repaired and reconstructed with the pectoralis major muscle flap and the rectus abdominis muscle flap; and if the wounds are huge enough with an exposure of the important internal organs, the greater omentum transposition should be used, and the residual wounds should be treated with dressing changes and even skin grafting.