Repair of Inferior Sternal Cleft Using Bilateral Sternal Bar Turnover Flaps in a Patient with Pentalogy of Cantrell
Our patient is a 4-year-old Indonesian Chinese boy, diagnosed with pentalogy of Cantrell. At 10 months of age, he required early corrective cardiac surgery due to deteriorating cardiopulmonary function, and the repair of sternal, diaphragmatic, and abdominal wall defects was planned at the same time. He had partial herniation of the heart through a lower sternal defect (ectopia cordis), which was only covered by thin skin, allowing the cardiac pulse to be seen (). Although autologous tissue was preferred over alloplastic material, the patient's native tissue was not adequate for a reliable reconstruction at that time. A staged procedure was planned, and a resorbable PLLA-PGA plate was implanted as a temporary shield over his heart in the first stage []. This provided a stable soft tissue cover over his heart for 3 years. We carried out the second stage of rigid sternal reconstruction at 4 years of age, when the patient's thoracic skeleton had grown.\nOur technique for reconstruction of the inferior sternal defect is as follows: the patient is placed in a supine position. A sagittal incision is made over the previous midline scar. Skin and pectoralis major muscle flaps are raised using fine needle diathermy, exposing the sternal bar and proximal costal cartilages (). The superior rectus attachments are dissected from the lower border of the sternal bar and ribs. Further, the cartilaginous sternal bars are bisected using a scalpel, along their length, from lateral to medial, leaving the medial perichondrium intact (). This allows the anterior half of the bisected sternal bars to be turned over medially to cover the inferior sternal defect. The cartilaginous flaps are sutured together in the midline using polypropylene sutures, constituting a complete thoracic skeletal ring (). After suture apposition of the divaricated superior rectus muscles with polyglactin sutures, the rectus muscles are re-attached to the reconstructed lower sternum using polypropylene sutures. For sustained postoperative pain control, 0.025% bupivacaine is administered using elastomeric infusors via two epidural catheters. These are placed under the sternal bars, one on each side. The bupivacaine will infuse at 2 mL/hr over the next 48 hours. We place the drainage catheter over the sternal bars to avoid draining the infused bupivacaine solution. Further, bilateral pectoralis major flaps are advanced and sutured in the midline to cover the reconstructed sternum before skin closure.\nThe patient was admitted to a high dependency ward for 24 hours. The epidural infusion catheters were removed after 48 hours and the drainage catheter after 3 days. The patient remained relatively pain-free during the hospitalization and was discharged on postoperative day 5. The 10-month follow-up revealed that he was well and the reconstruction had remained rigid (). No complications were noted.