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Citation: Glizevskaja J, Abbas M, Nwaejike N (2021) Seroma after sternal wound debridement: Case report. J Surg Surgical Res 7(1): 047-048.
DOI: https://dx.doi.org/10.17352/2455-2968.000135
https://dx.doi.org/10.17352/jssr DOI:
2455-2968
ISSN:
CLINICAL GROUP
Case Report
Seroma after sternal wound
debridement: Case report
Julia Glizevskaja*, Mohammed Abbas and Nnamdi Nwaejike
Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester University NHS Foundation
Trust, Manchester, United Kingdom
Received: 23 November, 2020
Accepted: 08 April, 2021
Published: 10 April, 2021
*Corresponding authors: Dr. Julia Glizevskaja, Depart-
ment of Cardiothoracic Surgery, Wythenshawe Hos-
pital, Southmoor Road, Manchester M23 9LT, United
Kingdom, Email:
Keywords: Seroma; Imaging; Wound complications;
Sternal wound
https://www.peertechzpublications.com
Abstract
Seroma formation is a common complication of any surgery producing a signifi cant dead space or causing disruption of the lymphatic drainage. Although this
is uncommonly reported in cardiac surgery. Such collections can cause localized pain, wound dehiscence, infection and can reoccur frequently, requiring multiple
interventions. We present case of large sternal wound seroma after wound debridement with Computed tomography imaging for the patient, that initially underwent
Coronary artery bypass grafting.
Abbreviations
CABG: Coronary Artery Bypass Grafting; CT: Computed
Tomography
Introduction
Operations involving extensive soft tissue surgery and
disrupting lymphatic drainage may result in a postoperative
seroma. Although this is uncommonly reported in sternal
wounds after cardiac surgery. Such collections can cause
localized pain, wound dehiscence, infection and can reoccur
frequently, requiring multiple interventions. We present case
of sternal wound seroma after wound debridement.
Case presentation
57 years old male developed chronic sternal wound sinus
following CABG and required multiple courses of antibiotics.
His risk factors of wound infection included bilateral
mammary arteries harvest, long term smoker, use of systemic
immunosuppressant and topical steroid creams for severe
dermatitis. He fi rstly underwent one culpable sternal wire
removal 6 months following CABG. Limited strategy was used
to minimise wound infection risk in patient with severe skin
conditions. Following another 6 months he developed further
sinus lower to the previous one, therefore decision made to
proceed with all sternal wires removal. He underwent elective
sternal wound debridement, excising previous sternotomy scar
and removing all remaining sternal wires. Intraoperatively
he was found to have bone involving, and precise wound
debridement was performed including debridement of
unhealthy bone segment, living around 3x1x0.5cm sternal
defect without penetration to mediastinum or disturbing sternal
stability. To approximate wound edges, bilateral skin fl aps
with underlying subcutaneous tissues were prepared. Wound
closed layered, living Redon Redivac drain (PFM Redon system,
Mepro, Koln Germany) in both pockets. Postoperatively patient
made good recovery, he remained in hospital while drains were
in situ, draining 300 ml of hemo-serous fl uids over fi rst 24
hours. After drainage gradually reduced, drains were removed
on day 5 and patient was discharged home. Intra-operative
wound swab came back negative.
He presented to our department 2 weeks later with large
fl uctuating non painful swelling over sternotomy wound. There
were no signs of infection, sternal wound has healed well, his
infl ammatory markers were within normal limits. At admission
he underwent a CT scan, which demonstrated large 3.4x10.8x
18.8cm collection subcutaneously anterior to the sternum; the
fl uid collection did not contain locules of gas (Figure 1). There
was no connection of seroma with mediastinum and there was
no pericardial effusion. We proceed with drainage of collection
under local anaesthesia using vacuum-assisted drainage, as
described by Fitzgerald and Charles [1,2] and evacuated 150ml
of serous fl uids with immediate improvement. Patient was
discharged home same day. He was seen in our follow-up clinic
in 2 weeks time, unfortunately at that point seroma has re-
accumulated. After discussion with the patient, conservative
048
https://www.peertechzpublications.com/journals/journal-of-surgery-and-surgical-research
Citation: Glizevskaja J, Abbas M, Nwaejike N (2021) Seroma after sternal wound debridement: Case report. J Surg Surgical Res 7(1): 047-048.
DOI: https://dx.doi.org/10.17352/2455-2968.000135
“watch-and-wait” approach was selected. By the mean time
we referred him to his dermatologist for relapse of dermatitis.
At the further follow-up in 3 months time seroma has
completely resolved, at the same time following adjustment in
dermatological treatment his skin condition has signifi cantly
improved.
Discussion
A seroma is a serum collection that develops as a response
to trauma/injury such as surgery. Seroma formation is a known
complication of various types of surgeries. So far described
published cases of seroma in cardiac surgery were cases of
groin seromas as complication of peripheral cannulations.
The presence of seroma in a wound might delay the wound
healing and becomes medium for bacterial growth. Factors
predisposing to sternal wound complications (including
seroma) are diabetes, obesity, long operation duration, redo
sternotomy, mechanical ventilation longer than 72 hours and
smoking [3,4].
Few studies reported superfi cial sternal wound infection
rate between 0.5-6.4%, while deep sternal wound infection
between 0.22-1.6% [5,6]. Trans-sternal seromas post
thymectomies are uncommon complications as incidence rate
described by Kas et al. about 0.9% [7]. On the other hand, up to
35% of patients who undergo mastectomy develop seroma [8].
During our literature review (through PubMed), we could not
fi nd specifi c incident rate or risk factors for seroma in cardiac
surgery.
Conclusion
We presented a rare case of large sternal seroma after
sternal wound debridement with instructive images from
CT scan. Multiple management strategies of seromas are
known, including conservative management and observation,
multiple drainages and aspirations, wound re-exploration,
sclerotherapy. We have chosen initially percutaneously aspirate
seroma, however following re-accumulation it was left for
watch-and-wait tactic, which eventually lead to complete
resolving of seroma at 3 months follow-up.
In this man’s case we have observed, that addressing severe
skin pre-condition has facilitated clearance of large seroma
with conservative approach. We believe that combination of
exacerbation of dermatitis and extensive exfoliation of the
subcutaneous tissues were main factors of seroma formation
in our case.
Acknowledgement
The authors received no fi nancial support for the authorship
or publication of this article.
References
1. Fitzgerald JEF, Hayes AJ, Strauss DC (2011). Vacuum-assisted sterile
drainage of large post-operative seromas: the Royal Marsden technique. Ann
R Coll Surg Engl 93: 646–647. Link: https://bit.ly/3uBQDcn
2. Charles JB, Samer S, Pari-Naz M (2010). A closed vacuum drainage system
for the management of postoperative seromas. Ann R Coll Surg Engl 92: 354–
355. Link: https://bit.ly/3mu3tqs
3. Wouters R, Wellens F, Vanermen H, De Geest R, Degrieck I, et al. (1994).
Sternitis and mediastinitis after coronary artery bypass grafting. Analysis of
risk factors. Tex Heart Inst J 21: 183-188. Link: https://bit.ly/3mFJeX7
4. Milano CA, Kesler K, Archibald N, Sexton DJ, Jones RH (1995) Mediastinitis
after coronary artery bypass graft surgery. Risk factors and long-term survival.
Circulation 92: 2245-2251. Link: https://bit.ly/3dDlwq0
5. Ridderstolpe L, Gill H, Granfeldt H, Ahlfeldt H, Rutberg H (2001) Superfi cial and
deep sternal wound complications: incidence, risk factors and mortality. Eur J
Cardiothorac Surg 20: 1168-1175. Link: https://bit.ly/3dOmvUq
6. Salehi Omran A, Karimi A, Ahmadi SH, Davoodi S, Marzban M, et al. (2007)
Superfi cial and deep sternal wound infection after more than 9000 coronary
artery bypass graft (CABG): incidence, risk factors and mortality. BMC Infect
Dis 7: 112. Link: https://bit.ly/3cYwiYN
7. Kas J, Kiss D, Simon V, Svastics E, Major L, et al. (2001) Decade-long
experience with surgical therapy of myasthenia gravis: early complications
of 324 transsternal thymectomies. Ann Thorac Surg 72: 1691-1697. Link:
https://bit.ly/3s1rxSw
8. Hashemi E, Kaviani A, Najafi M, Ebrahimi M, Hooshmand H, et al. (2004).
Seroma formation after surgery for breast cancer. World J Surg Onc 2: 44.
Link: https://bit.ly/39OtMTd
Figure 1: Computed tomography demonstrated large 3.4 x 10.8 x 18.8 cm collection
subcutaneously anterior to the sternum. (A) Axial view. (B) Sagittal view.
Copyright: © 2021 Glizevskaja J, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
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