Tricks - Thoracoscopic-Assisted Partial Rib Resection - Jack Langer

We present a case of a thoroscopic-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 5x5 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. Yeah. 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. No. 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. I sure will. 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 by 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. Fantastic. Um, let's open this up for comments. I'll tell you before we hit the audio that I have one of these cases coming up, and I was excited to see this video ahead of time. My question for you is, if it's involving more than one rib, do you reconstruct the ribs with little struts, or no? Um, I've, if, if it's too big of a thing, I just, I've usually put a patch in actually using, I've used Sergisis. Well, if it's, I mean, if it's huge, then you have to use struts or methylmethacrylate, but for, I've done up to three ribs with just a surgicis patch, just surgis, yeah, OK, OK. And it seems to heal in well. You get that scar tissue and, uh, it seems to work. Now, what's your thoughts? This is huge. Actually, you could put it up on your wall, look like antlers or something if, if you want. But, uh, do you, uh, I had one of these actually was a spike, the kid in sports had a spontaneous pneumothorax when getting tackled and popping his lung from it. But the osteochondromas, you can, I mean, you can leave them in theory, and you can also shave them. I actually took that off by sticking a rangejo in and biting it off. Do you need to take the rib or, um, what's your thoughts on that? Yeah, that's a, that's a good point. We weren't sure what the diagnosis was. We, I mean, that's what we thought it probably was, but I just wasn't completely happy that that's what it was. It was so big and, and, and it was symptomatic in this case. So, uh, that's why we took the piece of rib. Any comments? Uh, I would recommend, um, if you have a large gap in the chest wall, say, from a, uh, Ewing sarcoma or something like that, and you have more than a couple of rib spaces, sometimes the patches leave a significant cosmetic deformity where they almost, you know, they have a, um, respiratory variation. And what you can do is you can go either above or below your, um, resection, leave a rib intact, and then harvest the rib. Um, above or below and use that rib to replace the rib. And I've, I've used that technique in 3 or 4 cases, and, and that gives you a nice um contour of the chest without that respiratory gaping that you frequently see. Do you leave the blood supply to that rib, or do you just, uh, is it just a, I, what, what I have done is just a basically a free graft. Doesn't it die? It, it, you can see it on X-ray months after. So the answer would be, it's like using a You know, rib graft for other reconstructions that the plastic surgeons do or the orthopedics use, you know, when you give them the rib, they use it or you or use a fibula. Yeah. So, so, um, what about those metal, like those metal struts, right, that you can replace rib with? Uh, uh, I've never used it, but No, no one knows that. I know they use them for trauma. I've seen them advertised where you, when you have a rib, you can put like a little spacer metal thing that screws actually into the rib to close the gap. Any other, uh, comments out there about this technique? Uh, I think the only other place I've seen it is a patient with, uh, multiple hereditary exostosis, where one of them grew larger and was uncomfortable. Um, and then it's interesting you look in, and I just shave that one off as opposed to taking off the ribs since it was a younger child and unlikely to be malignant. But uh it's interesting in that situation, you see them all over the place and you wonder how much to do or not to do. I thought. We just published, um, we just published almost an identical technique for a mesenchymal hematoma in a newborn baby, where the diagnosis still also needs to be made. Um, I'm just curious, was this an osteochondroma then or what was the pathology, because it really didn't look like that. Yeah, it was an osteochondroma, but it was, it had atypical features, but it was benign. You know, I, I definitely like the, the, you know, there's no way to know where to make your incision, so I like you have to sort of mark out with the needle. I thought that was great. I'll definitely be using that in a few weeks. Um, all right, if, if there's no other, any other comments or questions about that? All right, let's go on to the next video. And this is um This is a video demonstrating the technique that I use for my laparoscopic hernias. Um, do we, do we have that video, Mark, or should we skip to the next one? Oh, OK. Um, so, um, the idea of, of adding a couple of elements of, uh, Uh, to the technique to make it a more durable repair, uh, by adding injury to the, uh, peritoneal surface. And actually, while we're waiting for this to load, there was a, a question that came up at, uh, the American College of Surgeons is could we apply this technique to diaphragmatic hernia repairs because some are saying that the tho thoracoscopic technique is a higher recurrence rate and could it be that there's not enough scar formed to keep the edges together. So, let's roll this video.