Postoperative sternal osteomyelitis is a rare but serious problem after cardiac surgery as the subsequent sepsis targeting the heart, suture lines, and prosthetic conduits or valves can be life-threatening [1, 4, 5]. Recent advances in cardiac surgery have enabled the surgical treatment of an increasing number of elderly and immuno-suppressed patients with multiple risk factors. However, despite efforts to control hospital infections and delivery of antibiotic treatment, the incidence of mediastinitis has remained constant over the years. Therefore, efforts to avoid high morbidity and mortality in these patients, has been required.
In 1963, antibiotic irrigation, debridement, and sternal re-closure were introduced [4]. After that, in 1976, Lee and colleagues [5] described complete excision of the sternum with wide debridement of costal cartilages, transposition of the omentum to the mediastinum with primary closure, while Jurkiewicz and colleagues [6] used muscle flaps. In 1995, Banic and colleagues [7] reported the use of free latissimus dorsi flap in cases of extensive sternectomy. In current practice, the most commonly utilized muscles for sternal reconstruction are the pectoralis major, rectus abdominus, latissimus dorsi and greater omentum.
Pairolero and Arnold [8] reported that, they primarily chose to obliterate the mediastinal space using omentum when previous interventions with different muscles have been unsuccessful. Omental flaps have several advantages. After complete or partial excision of sternum, the omental flap fills the mediastinal space and obliterates the dead space. The flap contains large number of immunologically active cells likely to be responsible for its anti-infective properties. As the omentum has extensive vascularization, and neovascularization potential, the increased blood supply leads to a higher concentration of antibiotics at the infection site. By absorbing wound secretions, the omental flap eliminates substrates for bacterial growth. Harvesting can be performed rapidly without the need for specialist knowledge, thus it can be undertaken by every surgeon [9].
The greatest disadvantage of utilizing the omentum in postoperative sternal osteomyelitis treatment is the need for a laparotomy. Laparotomy adds substantial surgical trauma in patients who are already very sick. On the contrary, the risk of potential peritoneal contamination seems to be negligible. Laparotomy may lead to postoperative pain that may interfere with the patient's ventilatory dynamic and may cause mucus retention, with possible respiratory infections. Furthermore, because of the postoperative ileus, it is more difficult to set the glucose values back to normal in diabetic patients [10].
Although omentoplasty is effective in mediastinitis treatment, it is a relative contraindication for future cardiac interventions through median sternotomy. The omental tissue has an excellent blood supply that limits the spread of infection. However, it also has adhesive properties that promote strong pericardial adherences and new vascular anastomosis with adjacent vessels that make a future sternotomy a real surgical challenge that no cardiac surgeon would like to face. Right or left thoracotomy may be a good alternative for these patients if coronary artery bypass grafting or valve surgery is to be performed, but not for other complex surgical procedures in which median sternotomy is mandatory [11].
