Wundheilungsstörungen nach medianer Sternotomie : neue, stadiengerechte Klassifikation und Ergebnisse der Defektdeckung mit gefäßgestieltem, myocutanem Latissmus-dorsi-Lappen

Die mediane Sternotomie ist in der Kardio-Chirurgie der wichtigste Zugang zum Herzen. Postoperative Wundheilungsstörungen in diesem Bereich sind seltene, jedoch gefürchtete Komplikationen, die zu schwerwiegenden Konsequenzen führen können. Die zunächst einfache oberflächliche Wundheilungsstörung kann sich verkomplizieren und über eine Osteomyelitis des Sternums zu einer Mediastinitis mit eventuell letalen Konsequenzen führen. Aktuell geben unterschiedliche Autoren eine Inzidenz von 1 % – 8 % an. Die Mortalität der Sternumosteitis wird dabei zwischen 10 % und 30 % angegeben. Wird der Pathomechanismus der Erkrankung zu einem Algorithmus zusammengefasst, so kann sich über einen descendierenden Verlauf eine oberflächliche Wundheilungsstörung zu einer Sternumosteitis und schließlich zu einer Mediastinitis entwickeln. Natürlich kann sich die Infektion auch ascendierend ausbreiten. Über eine Infektion des Mediastinums oder des Sternums kann sich eine Infektion über die Weichteile bis an die Körperoberfläche ausdehnen. Der typische Patient, der eine Wundheilungsstörung erleidet ist in aller Regel polymorbide. Besonders bei diesem Patientenkollektiv sind eine kurze Behandlungsdauer und eine schnelle, postoperative Rehabilitation für das Ergebnis vorrangig. Ist der gewählte Therapieplan nicht aggressiv genug, so kommt es häufig zu chronischen Erkrankungen mit Fistelungen und einem konsekutiven Fortschreiten der Infektion in Weichteilen und Knochen. Neben medizinischen Gesichtspunkten kommen auch der wirtschaftliche Aspekte zu tragen. Wiederholte Operationen, lange Liegezeiten auf der Intensivstation und wiederholte sowie langwierige Rehabilitationsphasen sind nur wenige Beispiele der kostenintensiven Therapiebestandteile. Aufgrund der schwer beherrschbaren Infektsituation ist eine konsequent aggressive, definitive und zuverlässige Versorgung der infizierten Wunden von höchster Priorität. Dabei spielt es keine Rolle, ob es sich dabei um Wundheilungsstörungen im Bereich der Haut- und Unterhautweichteile, des Sternums oder des Mediastinums handelt. Zur Behandlung der Wundheilungsstörung nach medianer Sternotomie existieren verschiedene Behandlungsansätze und Therapieoptionen. Diese reichen von einfachen Debridements mit Sekundärvernähungen über Spül-Saug-Drainagen mit Antibiotika versetzen Lösungen bis hin zu Sternumteilresektionen, Vakuumverbänden und komplexen Lappenplastiken. ...Since 1957 median sternotomy provides surgeons with easy access to mediastinum, heart, and great vessels. Sternal wound complications after median sternotomy are rare but serious complications. An aggravation and extension of these diseases can lead to sepsis or lethal complications. Before, the postoperative infection rate was higher than 25%, present literature however shows an incidence of 1% - 8%. Similarly the mortality rate decreased from 80% to 5% - 30% today. If complications after median sternotomy are divided in an algorithm, a descending wound infection can be separated form an ascending one. A descending infection is a primary superficial wound infection that becomes more complicated by progressing into the deep structures. After an osteitis of the sternum, a sternal instability and furthermore a mediastinitis can result. On the contrary, the ascending process starts with an infection of the mediastinum or sternum that develops to a superficial outbreak as a fistula or a chronic wound. Due to these serious complications and the difficult treatment, first priority should be a consequent, aggressive and reliable therapy. Regardless, whether there is only a superficial wound complication or a fulminate mediastinitis. Patients that suffer from a wound healing complication are usually polymorbid. Especially for these patients a quick and fast therapy is necessary. If the treatment is not aggressive enough, fistulas and chronic infections may result. Apart from the health threat, economical aspects must be considered, too. Repeated operations, extended stays at the intensive care unit and long time periods for rehabilitation are only some examples for cost-intensive constituents. They come along with a prolonged hospital stay, increased hospital costs, and a high morbidity and mortality rate. In general, different treatment options for complications after median sternotomy have been proposed by various authors. They vary from an open treatment, a debridement with closed irrigation by an antibiotic solution, a vacuum therapy, and finally muscle flaps like the pectoralis flap or the latissimus dorsi flap. Because of the absence of a consistent and sufficient classification a comparison of the treatment options becomes impossible. ..

Complications and Solutions in Propeller Flap Surgery

open7siPropeller perforator flaps (PPFs) have long been proven as valid reconstructive tools for a wide range of soft tissue defects in different body regions. During the last decade, despite their numerous advantages, many authors have thoroughly analyzed outcomes of these flaps, sometimes discouraging their use mainly because of a high failure rate. Accurate patient selection, adequate preoperative planning, and an appropriate dissection technique seem to potentially improve outcomes. Our study provides a review of the relevant literature related to PPF complications and of our experience, describing reasons for failure, measures for preventing them, and approaches for a prompt evaluation and management of complications.embargoed_20210801Cajozzo, M; Jiga, LP; Jandali, Z; Muradov, M; Pignatti, M; Cordova, A; D'Arpa, SCajozzo, M; Jiga, LP; Jandali, Z; Muradov, M; Pignatti, M; Cordova, A; D'Arpa,

Role of the Cadaver Lab in Lymphatic Microsurgery Education:Validation of a New Training Model

Microsurgical transplantation of vascularized lymph nodes (VLNT) or lymphatic vessels (VLVT) alongside derivative lymphaticovenous procedures are promising approaches for treatment of lymphedema. However, clinically relevant training models for mastering these techniques are still lacking. Here we describe a new training model in human cadaver and validate its use as training tool for microsurgical lymphatic reconstruction

An improved dual approach to post bariatric contouring - Staged liposuction and modified medial thigh lift: A case series

Objective: Following massive weight loss (MWL) medial contouring of the thigh is frequently requested to improve appearance and function. Thigh lifting can be associated with significant complications. We present a case series of post bariatric patients undergoing thigh lift using staged the liposuction, a modified T incision and a buried de-epithelialised dermal flap. Materials and Methods: From January to December 2012, 21 consecutive patients underwent a modified medial thigh lift. A retrospective review of the case notes was performed to assess complications that occurred. Results: There were no major post-operative complications in terms of reoperation, hematoma, thromboembolism and no seromas. Seven patients, all of which were smokers had minor superficial wound healing complications. Aesthetic outcomes were satisfactory for all patients at a minimum follow-up of 6 months. Conclusions: The modified ′T′ incision with staged liposuction is described. We have found the technique to be useful for a variety of different thighs. It is a reproducible method for contouring the medial thigh in MWL patients. In this series, our overall complications were low, and no seromas occurred

Role of the Cadaver Lab in Lymphatic Microsurgery Education: Validation of a New Training Model

Microsurgical transplantation of vascularized lymph nodes (VLNT) or lymphatic vessels (VLVT) alongside derivative lymphaticovenous procedures are promising approaches for treatment of lymphedema. However, clinically relevant training models for mastering these techniques are still lacking. Here we describe a new training model in human cadaver and validate its use as training tool for microsurgical lymphatic reconstruction. 10 surgeons with previous exposure to microsurgery were trained in a controlled environment. Lymphatic vessel mapping and dissection in 4 relevant body regions, harvesting of five different VLNTs and one VLVT were performed in 5 fresh-frozen cadavers. The number of lymphatic vessels and lymph nodes for each VLNT were recorded. Finally, the efficacy of this model as training tool was validated using the Dundee Ready Education Environment Measure (DREEM). The average cumulative DREEM score over each category was 30,75 (max = 40) while individual scoring for each relevant category revealed highly positive ratings from the perspective of teaching (39,3), training 40,5 (max = 48) and self perception of the training 30,5 (max = 32) from all participants. The groin revealed the highest number of lymphatic vessels (3.2 ± 0.29) as all other regions on the upper extremity, while the gastroepiploic VLNT had the highest number of lymph nodes (4.2 ± 0.37). This human cadaver model represents a new, reproducible “all-in-one” tool for effective training in lymphatic microsurgery. Its unique diligence in accurately reproducing human lymphatic anatomy, should make this model worth considering for each microsurgeon willing to approach lymphatic reconstruction