Discussion
Re-sternotomy is more challenging than primary sternotomy because of
adhesions8-10 and patients’ poor health status.
Increased reoperation risk through the reconstructed sternum is reported
due to the small amount of tissue initially placed over the
mediastinum8. Few reports described re-sternotomy
after an omental flap procedure5, although there have
been some similar reports6, 7. In our case, severe
adhesion between the omentum and mediastinal organs was expected because
preoperative CT showed limited space between the sternum and omentum due
to funnel chest. Re-sternotomy was completed safely because partial
cardiopulmonary bypass was introduced by decompression of the cardiac
volume and the omentum functioned as a cushioning material between the
sternum and mediastinal organs.
Although no reports have described this effect, the omentum tissue can
serve as a safety net for the mediastinal organs to prevent from injury.
Adachi et al. reported re-sternotomy after omental flap in which
dissection was safely performed5. Among 15 pediatric
cardiac patients who underwent treatment for mediastinitis, 3 (2 with
rectus flaps and 1 with pectoralis flap) underwent
re-sternotomy6. The surgeries were uneventful because
the rectus abdominus muscle was mobilized and
removed6. According to Varennes et al, re-sternotomy
after muscle flap repair could likely be accomplished without risk and
heart transplantation could be carried out7. On the
other hand, repeat median sternotomy after an omental flap procedure is
more hazardous because of severe adhesions between the omentum and
mediastinal structures11. Further studies regarding
this feature of the omental flap are warranted.
Diversity of ultrasonic devices available may cause more efficient
surgical procedures and improved patient outcomes12.
The ultrasonic scalpel is excellent in exfoliating adipose tissue. In
our patient, an ultrasonic scalpel was useful for dissecting between the
omentum and mediastinal organs, especially above the ascending aorta.
Adachi et al. also reported the effectiveness of an ultrasonic scalpel
for dissection during this procedure5. Because
Adachi’s patient received ascending aortic and aortic valve replacement
and mitral valve repair, the omental tissue was mobilized to the left
side of the anterior mediastinum5, whereas in our
patient, it was mobilized to the right side due to planned bypass
grafting to the obtuse marginal branch.
Although it might be difficult to detect targeted coronary arteries
after surgical treatment for mediastinitis because of severe
adhesion9, 10, the coronary arteries were detected
easily in our patient. According to Roselli et al, most injuries
including heart chambers, great vessels and native coronary artery
occurred on opening and during prebypass dissection10.
In the present case, inflammation due to mediastinitis might have been
limited to the area around the sternum and might not have extended into
the pericardial cavity.