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Ann Thorac Surg 2000;70:97-99
© 2000 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Ten-year experience with Mersilene-reinforced sternal wound closure

^a Department of Surgery, Cooper Hospital, University Medical Center, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Camden, New Jersey, USA

Address reprint requests to Dr Puc, Cooper Hospital, University Medical Center, 3 Cooper Plaza, Suite 411, Camden, NJ 08103

	Abstract

Top Abstract Introduction Surgical technique Patients and methods Comment References

 
Background. We were interested in reviewing our experience with Mersilene-reinforced sternal wound closure to evaluate its overall morbidity and its impact on patient management.

Methods. We reviewed our experience with 1,039 patients undergoing median sternotomy with Mersilene-reinforced sternal wound closure over the past 10 years. Major wound complications, which were categorized into two groups, required in-hospital management and operative intervention. Group 1 had a sternal dehiscence alone. Group II had a major sternal infection or mediastinitis.

Results. The incidence of wound morbidity was 2.4% (n = 25). There were 6 (0.58%) sternal dehiscences (Group I) and 19 (1.8%) sternal wound infections (Group II). Patients taken to the operating room for repair of their sternal dehiscence or sternal infection were noted to have two completely intact sternal halves.

Conclusions. While wound related morbidity with Mersilene tape closure is equivalent to the historical results of conventional wire closure, dehiscence occurs in a more controlled fashion with less bony destruction. The reduction in tissue damage associated with sternal wound dehiscence and sternal infection after Mersilene-reinforced sternal wound closure makes treatment of these potentially devastating complications easier and more efficient.

	Introduction

Top Abstract Introduction Surgical technique Patients and methods Comment References

 
The median sternotomy is the most commonly performed incision in cardiothoracic surgery. Sternal dehiscence with or without mediastinal or sternal infection occurs in approximately 0.4% to 5% of patients with a mortality ranging from 13% to 39.6% [1–10]. The type of closure technique along with risk factors such as low cardiac output postoperatively, prolonged mechanical ventilatory support, need for tracheostomy, postoperative blood loss, reoperation, rewiring, early reexploration, use of the internal mammary artery, and an improper incision have all been implicated in adversely affecting wound-related morbidity [4–8]. While stainless steel wire closure is standard, other techniques, such as nylon band closure and silk suture closure, have been employed to attempt a tighter and more secure reapproximation [11–13]. Results of these studies, however, have been poor. Reinforcement of stainless steel wire closure with braided Dacron suture has been reported to decrease the incidence of sternal infection and sternal dehiscence [3, 5, 7]. We present our experience with 1,039 patients who underwent sternotomy closure with braided Dacron suture (Mersilene tape; Ethicon, Inc, Somerville, NJ), which is the largest series to date.

	Surgical technique

Top Abstract Introduction Surgical technique Patients and methods Comment References

 
Mersilene tape of 5 mm thickness was used for closure of the median sternotomy. A No. 5 stainless steel wire was first placed in standard fashion at the top of the manubrium. This was followed by four 5-mm Mersilene tapes on a blunt needle, which were passed around the lateral edge of the sternum through the intercostal spaces: one around the manubrium and three around the body of the sternum. At the lower end of the sternum, a second No. 5 stainless steel wire was placed below the Mersilene tapes (Fig 1). The sternum was first pulled together by twisting down the steel wires and then secured with the Mersilene tapes. The knots from the Mersilene tape were placed at the edge of the sternum away from the middle of the incision. An assistant was needed to hold the first knot in the Mersilene tape while the surgeon completes tying the tape to secure a tight sternal closure. The subcutaneous tissue and the skin were closed with running absorbable suture. Prophylactic perioperative antibiotics were used routinely. A mediastinal chest tube and a left pleural chest tube were placed routinely and removed after the drainage was less than 100 cc for 12 hours.

View larger version (54K): [in this window] [in a new window]   Fig 1. Illustration showing placement of two stainless steel wires followed by the addition of four Mersilene tapes.

	Patients and methods

Top Abstract Introduction Surgical technique Patients and methods Comment References

The overall incidence of wound related morbidity was 2.4%. There were six (0.58%) sternal dehiscences (group I) and 19 (1.8%) sternal wound infections (group II) requiring inpatient treatment. The majority of patients with sternal wound infections required only local operative debridement with preservation of a significant portion of the sternum. Six patients from group II required extensive debridement for deep sternal wound infections with major reconstructive repair and long-term intravenous antibiotic therapy. The distribution of the major complications categorized by the type of operation is shown in Tables 1 and 2.

When a sternal dehiscence or sternal infection was taken to the operating room for repair, it was repeatedly noted that the sternum remained completely intact. Essentially, there was no bony destruction of the sternum by the Mersilene tape and the sternum was able to be tightly reapproximated without any loose fragments that could potentially create an unstable closure.

	Comment

Top Abstract Introduction Surgical technique Patients and methods Comment References

 
Our population had a major complication rate comparable with similar reports in the literature for standard steel wire closure, as well as Mersilene tape. However, these positive results are found in the face of theoretical objection to the use of braided suture, which tends to entrap bacteria and make eradication of an infection more difficult. These conclusions were reinforced by reports in the literature that quantified the amount of bacterial adherence and the amount of local tissue reaction for a number of sutures including braided Dacron [14–16]. Although the braided Dacron had a low bacterial adherence index as compared with the sutures tested, the report did not include stainless steel wire. On the other hand, braided Dacron was found to produce a greater inflammatory response then stainless steel, which may lead to persistence of a local infection. However, the clinical relevance is unfounded, because our study revealed comparable wound-related morbidity. Another report tested the biomechanical strength of stainless steel versus braided Dacron on cadaver sternums [17]. This study only used braided Dacron on the cadaver sternums without the use of steel wires at the top or bottom of the sternum, as we have done. As expected, the stainless wire provided a more stable immediate closure, but the long-term clinical ramifications are again undetermined and only speculative. All of these points would lead one to expect that Mersilene tape should increase wound complication rates. This conclusion has not been supported by our population and multiple similar reports in the literature [3, 5, 7]. A study by Breyer and associates reported almost identical complication rates between patients with braided Dacron closure versus patients with wire closure [7]. Two other studies by Sirivella and associates and Johnston and associates also had excellent results and found Mersilene tape to be extremely beneficial [3, 5].

An important finding with Mersilene tape was that it did not lead to bony destruction of the sternum when a dehiscence occurred. Sirivella and associates and Breyer and associates both showed that steel wire, in contrast to Mersilene tape, had a tendency to cut through the sternal bone [5, 7]. The patients in our population, who were found to have sternal dehiscence, had marked preservation of both sternal halves. Even though stainless steel wire initially gives a stronger repair, this increased tension can potentially tear through the sternum. Also, the narrower diameter of the wire makes it more likely to cut the sternum into multiple fragments. The treatment of potentially devastating complications is more expeditious and efficient if two intact halves of the sternum are preserved. The documented efficacy and low complication rate of Mersilene tape provides a viable alternative when closing a sternal incision with the potential for a major complication.

Overall, Mersilene tape has a practical utility in sternotomy closure. It has been shown to have similar complication rates to the standard stainless steel wire closure with an added benefit. It tends to maintain the integrity of the sternum without the potential for a piecemeal destruction of the sternum when dehiscence does occur. This appears to be its major benefit over steel wire that deserves attention and consideration.

	Acknowledgments

 
We give special thanks to Paul Rogers, medical illustrator.

	References

Top Abstract Introduction Surgical technique Patients and methods Comment References

 

1. Demmy T.L., Park S.B., Liebler G.A., et al. Recent experience with major sternal wound complications. Ann Thorac Surg 1990;49:458-462.[Abstract]
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13. LeVeen H.L., Piccone V.A. Nylon-band chest closure. Arch Surg 1968;96:36-39.[Medline]
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16. Varma S., Lumb W.V., Johnson L.W., et al. Further studies with polyglycolic acid (Dexon) and other sutures in infected experimental wounds. Am J Vet Res 1981;42:571-574.[Medline]
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