Delayed sternal closure. An improved method of dealing with complications after cardiopulmonary bypass.

Intraoperative closure of the median sternotomy after cardiac operations in patients with complications, including severe postoperative bleeding, impaired cardiac function caused by myocardial edema, and cardiac dilatation, may lead to a critical and possibly fatal deterioration of hemodynamic function. In an effort to prevent this complication, we delayed mediastinal closure in 15 patients, covering the wound temporarily with a sheet of rubber latex (Esmarch bandage). An oval patch of this material was sized and sutured to the skin edges with a continuous suture. This technique provided easy and fast access to the mediastinal structures in four of the 15 patients who required multiple surgical interventions in the early postoperative period. Delayed closure was indicated for severe bleeding in 10 patients, heart compression in four patients, and severe postbypass arrhythmias in one patient. Definitive closure of the chest was delayed until satisfactory hemostasis was achieved or the heart size returned to normal. Thirteen of the 15 patients were long-term survivors, none of them had wound infections, and their wounds healed well. Delayed closure of the median sternotomy was an effective and safe approach in these groups of critically ill patients.