THORACOSCOPIC ASSISTED PARTIAL RIB RESECTION

Assisted partial rib resection. A 16-year-old male presents with a two-month history of left-sided chest pain. His physical exam is unremarkable. The chest X-ray shows an ill-defined 3 x 5 x 5 centimeter calcified lesion in the left lower lung zone. It is pedunculated and exophytic on CT scan arising from the internal aspect of the left 6th rib. Resection was advised due to the ongoing symptoms of pain and the diagnostic uncertainty. We began by positioning the patient with the left side elevated 30 degrees using a beanbag. A single 5 millimeter port was placed posteriorly in the fifth intercostal space. The lesion was easily identified. The remainder of the hemithorax was inspected and free of abnormality. The stock was inspected and confirmed to be pedunculated, originating from the inner aspect of the 6th rib. The chest wall was palpated to grossly determine the exterior margins of the lesion. We better define the margins by passing a 22 gauge needle through the chest wall to map out the smallest incision possible. We made a 5 centimeter incision with electric cautery. The chest wall was entered above and below the 6th rib, anterior and posterior to the stock of the lesion. The intercostal muscles and the neurovascular bundles were separated from above and below the 6th rib. The rib was cut anterior and posterior to the stock of the lesion. And then the rib segment and lesion were extracted from the chest. A small chest wall defect remained, which was closed in layers. The specimen consisted of a 3.5 centimeter rib segment and a 5x 3 x 5 centimeter lesion. The final pathology showed an atypical osteochondroma with normal underlying rib and negative margins. The duration of the operation was 67 minutes, and it was complicated by a small postoperative pneumothorax which was managed with oxygen therapy. The patient was discharged on the 3rd postoperative day. At 8 months follow-up, the patient was pain-free and back to his normal activities. We have successfully demonstrated how thorascopic assistance during chest wall excision is a useful technique for benign and malignant lesions to optimize cosmesis and margins. Well, I think we certainly all enjoyed your waving at us. Thank you very much. Great video. Any questions? Dan Duarte from Los Angeles. I had a similar case. Uh, what's interesting about these lesions, uh, is that oftentimes they are familial. Uh, you can have a syndrome of hereditary osteochondromatosis. So I'd be curious to know if this patient had any other lesions, and they should probably be followed as they can to have some malignant degeneration in the future. Also, uh, these lesions can be spiculated, uh, and oftentimes they'll present with a pneumothorax or hemothorax from direct injury to the adjacent lung. Yeah, he'd, he'd had, uh, on his first episode of chest pain, some, uh, a little bit of an effusion. We didn't see any blood when we were, um, when we were there, um, but it was a few months after that. He asked about metachronous lesions. So, he asked about metachronous lesions. Any other lesion? No, no other lesions were identified at all. OK, thanks. Second question is, uh, Chris Moyer from Rochester, since you brought up the hereditary aspect, uh, we've seen several of these patients as well. So I actually have an alternative method for you to consider, especially with patients with familial osteochondromatosis, because you can't go resecting multiple ribs. And because these osteochondromas have, they're pedunculated off the rib, you can do a sort of partial resection by just going through the cortex of the bone and getting it all thoracoscopically entirely with the scope. Uh, it's sometimes difficult to do it with our instruments, so you can borrow the ortho instruments to do so, and I've used the, the knee arthroscopy stuff where you just kind of carve off the osteochondroma from below and you save the rib, particularly with patients who have multiple ones. Just a little comment for, for later use. Great, thanks. We've got time for a third question. Oh, can I just make a Warwick Tea from Adelaide, but recently in Edinburgh, can I make a shameless plug for my poster 223, which addresses. Uh, this condition and the tho the thoracoscopic assisted orthopedic resection with rib sparing. Thanks very much. Thanks a lot.