Using the costal muscle flap with latissimus dorsi muscle to repair full-thickness anterior chest wall defects

Musculoosseous flaps with latissimus dorsi muscle are used for reconstruction of full-thickness anterior chest wall defects. The 11th and 12th ribs and the posterior parietal pleura are elevated with the latissimus dorsi muscle. The blood supply of the compound flap comes from the thoracodorsal pedicle and from perforating segmental vessels. The posterior thoracic wall island is transferred to the anterior chest wall defect to restore a skeletal plane and the transposed latissimus dorsi obliterates all the dead spaces that cannot be collapsed. The latissimus dorsi compound flap with the 11th and 12th ribs appears to be a "safe" procedure to reconstruct full-thickness anterior chest wall defects.     

甲壳素长纤维增强聚己内酯的制备及重建犬胸壁缺损的实验研究

目的观察可降解性甲壳素长纤维增强聚己内酯(PCL)人工肋条用于犬胸壁缺损重建的作用。方法采用熔融共混、模压法制备甲壳素长纤维增强PCL人工肋条。建立10只10cm×8cm的胸壁缺损犬动物模型,对其中8只犬采用甲壳素长纤维增强PCL人工肋条(实验组)、2只犬采用Marlex网(对照组)进行缺损修复,观察人工胸壁的植入状况及胸壁组织的再生过程,术后1,4和6个月时进行X线摄片、CT扫描检查。结果所有犬无手术死亡和围手术期死亡。实验组2只出现轻度的反常呼吸,2周后反常呼吸消失;无胸壁塌陷、感染,无严重并发症。肋骨断端接触处新生骨增生明显,与人工肋条紧密接触,界面良好,固定牢靠。对照组术后有明显的胸壁塌陷和反常呼吸,网材有皱折发生。结论可降解性甲壳素长纤维增强PCL人工肋条能够对胸壁提供有效的支撑作用。     

Chest wall stabilization with synthetic reabsorbable material.

Experimental results and preliminary clinical experience with synthetic reabsorbable materials in chest wall reconstruction are reported. Six beagle dogs underwent chest wall resection involving three or four consecutive ribs. Reparative procedure was performed by construction of a polydioxanone-band grid, anchored to the adjacent undamaged ribs. A mild wound infection developed in 1 animal but resolved without rejection of the prosthesis. The experimental material has shown favorable properties, both mechanical and biological. Subsequently, 11 patients, with different indications, underwent reconstructive procedures of the chest wall with reabsorbable prostheses. No complications have occurred. Long-term stability was excellent in all patients, with a mean follow-up longer than 6 months. The advantages of reabsorbable compounds are pointed out along with the possible applications for chest wall reconstruction after chest wall resection.     

Osteosarcoma of the rib: A challenge of diagnosis and surgical intervention: A case report

Introduction and importanceChest wall tumour could grow from various tissues composing the chest wall. Diagnosis and treatment of patients with chest wall tumour pose several challenges.Case presentationWe present a case of 55 year old woman with chief complaint of a painfull mass on her chest wall. Patient was diagnosed with osteosarcoma of the ribs. Patient underwent surgery and was hospitalized for seven days before discharged.Clinical discussionOsteosarcoma of the ribs is a rare case with wide resection as the main treatment. In this case, chest wall reconstruction was needed to prevent impaired chest wall mechanical function in respiration.ConclusionDiagnosis and treatment of osteosarcoma of the ribs pose challenges. The main treatment of the osteosarcoma of the ribs is wide resection, followed by reconstruction of chest wall when needed. Reconstruction could be performed with autologous tissue, gore-tex, and mesh. The adjuvant chemotherapy was considered to give for better outcome.     

Chest wall reconstruction using polyester mesh]

Using polyester, we prepared a new material for chest wall reconstruction. The polyester mesh has the same rigidity and elasticity as Marlex tracheal mesh. From January 1987 through July 1991, we performed chest wall reconstruction using the polyester mesh in 8 patients with lung cancer, 9 with empyema after open drainage, 2 with metastatic chest wall tumors, 1 with a primary osteogenic giant cell tumor originating from the rib and 1 with radiation dermatitis and costal chondritis. Three or more ribs were resected in 17 patients. The defects of the chest wall were reconstructed with the polyester mesh covered with a GORE-TEX soft tissue patch to achieve air tightness. Fifteen cases have passed at least one year with no sign of infection. In conclusion, the polyester mesh prevents flail chest and seems to be a satisfactory material for chest wall reconstruction.     

Novel biodegradable lamina for lamina repair and reconstruction

Background contextPosterior laminectomy is an effective spinal surgical procedure. The adhesion of postoperative scar tissue to surgically exposed dura and, occasionally, to nerve roots can cause failed back surgery syndrome. The establishment of a barrier between scar tissue and dura that is made of hard material may prevent scar adhesions.PurposeTo evaluate the efficacy of a novel biodegradable multi-amino acid copolymer/nanohydroxyapatite composite artificial lamina.MethodsA cervical laminectomy animal model in goats was used, and the animals were randomly divided into three groups. In the test group, cervical 4 was removed by laminectomy and the artificial lamina was inserted (n=12). In the control group, the incision was closed directly without implantation (n=9). The goats in the normal group did not undergo any procedure or treatment. Copolymer efficiency was tested by using X-ray, computed tomography scanning, magnetic resonance imaging, scanning electronic microscope, and histologic and biomechanical measurements 4, 12, and 24 weeks postoperation.ResultsNo shifting of the artificial lamina or dural adhesion pressure was observed. New cervical natural bone formed in the defect and the bony spinal canal was rebuilt. In the control group, fibrous scar tissue filled the defect and exerted pressure on the dura. No paralysis was observed, and gait was normal in all test and control goats.ConclusionsArtificial lamina can prevent the epidural adhesions surrounding the defect and promote effectively bone tissue repair and new bone formation.     

Subscapularis muscle flap for reconstruction of posterior chest wall skeletal defect

IntroductionChest wall skeletal defects are usually closed using muscle flaps or prosthetic materials. Postoperative prosthetic infections are critical complications and often require plastic surgery support. We report a new surgical technique, involving a subscapular muscle flap, for covering posterior chest wall defect.Presentation of caseA 75-year-old man was admitted to our hospital. We performed a right upper lobectomy with posterior chest wall resection between the third and sixth ribs. The resulting chest wall defect was covered with a polytetrafluoroethylene mesh that became infected postoperatively. We removed the infected mesh and used the subscapularis muscle, the nearest muscle to the defect, to cover the chest wall defect. The scapular tip was lifted and the lower half of the muscle was dissected. The free end of the flap was sutured to the stumps of the anterior serratus and rhomboid major muscles. Computed tomography, 1 month later, revealed that the flap was engrafted to the chest wall.DiscussionNo previous study has reported the use of a subscapularis muscle flap for chest wall reconstruction. The lower third of the scapula was excised since blood supply to the scapula tip may be reduced after dissection of the subscapularis muscle, and to prevent the scapula tip from falling into the thoracic cavity.ConclusionThe use of a subscapularis muscle flap to repair chest wall defect is a simple and safe technique that can be conducted in the same surgical field as the initial reconstruction surgery and does not require plastic surgery support.     

An innovative method of pediatric chest wall reconstruction using Surgisis and swinging rib technique

PurposeHerein, we describe a new surgical approach for chest wall reconstruction using a native supporting rib and Surgisis.MethodsA retrospective review of 3 cases from 2 tertiary pediatric health care centers presenting with chest wall defects in the neonatal period was performed. Perioperative data were collected.ResultsTwo chest wall deformities were diagnosed at birth (Poland syndrome and cleft sternum). One patient was diagnosed prenatally with a mediastinal mass. The first infant had absent ribs 2 through 9. He underwent chest wall reconstruction at 4 weeks of life because of difficulty weaning from ventilation related to paradoxical breathing. The hamartoma of the second asymptomatic patient was removed at 6 weeks. The third patient's V-shaped sternal defect encompassed through the upper two thirds of the sternum and was repaired at 6 months of age with intraoperative transesophageal echocardiogram monitoring. In all cases, Surgisis (collagen matrix) was used as an onlay patch. In 2 cases, a swinging rib acted supportive. Neither patient had intraoperative complications.ConclusionSurgisis is useful in pediatric chest wall reconstruction, particularly in combination with swinging ribs. The capacity for adaptation to the child's growth of this approach is crucial. Short-term safety is shown, but long-term assessment is required.     

A rare case of chest wall reconstruction in a child

IntroductionEwing sarcoma/primitive neuroectodermal tumour (ES/PNET) is the most common malignant tumour of the chest wall in children and young adults. Chest wall defect left after complete resection of the involved ribs and chest wall defect requiring reconstruction, is surgically challenging for cosmetic as well as for functional purposes especially in growing children.ImportanceA rare but feasible and simple technique for a case of chest wall tumour reconstruction has been described here with its successful outcome with available composite muscular vascularised flap.     

Chondrosarcoma of the chest wall: a clinical analysis

Purpose. To discuss the management of different histological types of chondrosarcoma (CS) in the chest wall based on our clinical experience. Methods. The subjects of this study were 16 patients with CS of the chest wall surgically treated by resection at our institute between September 1981 and August 2000. There were 11 men and 5 women ranging in age from 23 to 74 years. The median follow-up period was 54 months. The tumor was located only in the ribs in ten patients, in the sternum and ribs in three, only in the sternum in two, and in the ribs and spine in one. The surgical margins were wide in 12 patients and marginal in four. Reconstruction using Marlex mesh combined with moldable metal plates was carried out to prevent flail chest in nine patients, resection alone was performed in five patients, and a muscular flap was used in two patients. Results. The survival rate was 86% after a median follow-up period of 54 months. One operative death (6.2%) occurred, and another required temporary tracheostomy. There were no infections in this series. Oncological outcome was clinically related to surgical margins and recurrence. The postoperative respiratory function test result was 10% less than the preoperative one. Conclusion. This series demonstrated that wide resection is the treatment of choice for chest wall CS and that Marlex mesh combined with metallic mouldable plates is a reliable technique for reconstruction. Received: April 3, 2001 / Accepted: November 20, 2001     

Preservation of pulmonary function by chest wall reconstruction

Thirteen mongrel dogs were resected 4 ribs with surrounding tissue. Eight dogs had the chest wall closed by skin alone, and in five animals, the chest wall reconstructed by a polyethylene mesh or marlex sandwich. In the latter PaO2 was significantly higher than that of animals not undergoing reconstruction 3 days after operation. Pulmonary function was appeared to be preserved by reconstruction. Clinically, 68 cases underwent chest wall resection and in 28 cases, defects were reconstructed. Although only portions of 1 or 2 ribs were resected in the non-reconstructed cases, VC, FEV1, and TLC significantly dropped post-operatively. In the reconstructed cases, VC significantly dropped postoperatively. Post-operative complications occurred in 3.6% of the reconstructed cases and in 9.8% of the non-reconstructed cases. Since only 1 rib resection led to reduced ventilatory function clinically, reconstruction for small chest wall defects appears advisable for maintaining pulmonary function.     

Total vertebrectomy (Th2) and dissection of the subclavian artery for a superior sulcus tumor invading the spine: A case report

IntroductionSurgery for primary lung cancer invading the spine remains challenging. Here, we present a case of superior sulcus tumor (SST) with vertebral invasion, successfully resected with total vertebrectomy (Th2) and dissection of involved apical chest wall and the subclavian artery (SCA).Presentation of caseA 62-year-old man was referred with the diagnosis of lung squamous cell carcinoma originating from left upper lobe (clinical stage IIIA/T4N0M0) involving the thoracic vertebrae (Th2) as well as the apical chest wall including three ribs (1st, 2nd and 3rd) and SCA. After induction concurrent chemo-radiotherapy, we achieved complete resection by three-step surgical procedures as follows: first, the anterior portion of involved chest wall including SCA was dissected through the trans-manubrial approach (TMA); next, the posterior portion of involved chest wall including ribs was dissected and left upper lobectomy with nodal dissection was performed through posterolateral thoracotomy; finally, total vertebrectomy (Th2) was performed through posterior mid-line approach.DiscussionThis tumor was existence of anterior and posterior position in pulmonary apex region. So that, it is very important for complete resecting this complicated tumor to work out operation’s strategy.ConclusionSurgery may be indicated for SST invading the spine, when complete resection is expected.     

Chest wall reconstruction using a combined musculocutaneous anterolateral�Canteromedial thigh flap

We present a massive 25 cm × 20 cm chest wall defect resulting from resection of recurrent cystosarcoma phyllodes of the breast along with six ribs exposing pleura. The chest wall was reconstructed with a Prolene mesh–methylmethacrylate cement sandwich while soft tissue reconstruction was carried out using a combined free anterolateral–anteromedial thigh musculocutaneous flap with two separate pedicles, anastomosed to the thoracodorsal and thoracoacromial vessels respectively. We explain our rationale for and the advantages of combining the musculocutaneous anterolateral thigh flap with the anteromedial-rectus femoris thigh flap.     

腹腔镜切口疝修补术中腹腔粘连的诊断、分型及分离技巧

背景与目的 切口疝是腹部手术的常见并发症之一，而患者在经历了腹部手术后常有不同程度的腹腔内粘连，分离粘连是切口疝修补过程中不可回避且有相对难度的工作。术前人工渐进性气腹是腹腔镜切口疝修补术中的重要环节，笔者前期发现，通过对比气腹前后的影像学资料，可评估切口疝患者腹腔内状态，有利于手术预判，提高手术精准度，减少手术风险。本文旨在进一步探讨人工气腹结合腹部CT在伴腹腔粘连切口疝患者的腹腔镜修补术中的应用价值，并总结腹腔粘连的类型和分离粘连的手术技巧。方法 回顾性收集分析2019年4月—2020年5月在中山大学附属第六医院胃肠、疝和腹壁外科行腹腔镜切口疝修补术患者的临床资料和手术录像。通过术前人工气腹前、后腹部CT对比，判断是否存在腹腔粘连。研究者通过手术录像复盘，观察腹腔粘连的分型，总结粘连分离的技巧，记录术中粘连分离时间和并发症，统计观察孔穿刺时副损伤情况，术后并发症与恢复情况。结果 共收集72例行腹腔镜切口疝修补术病例，其中15例术前未建立人工气腹，7例建立人工气腹后术前未复查腹部CT，15例气腹前或气腹后未行疝囊三维CT重建，均予以排除。最终纳入35例患者，均为II型腹壁缺损；复发疝5例；男16例，女19例；年龄（63.26±11.11）岁；体质量指数25.04（23.03~27.34）kg/m²；既往手术术后有腹腔内感染伴切口感染者4例，切口感染者7例；最多手术次数5次。通过人工气腹前、后腹部CT对比，诊断存在腹腔内容物与腹壁粘连者33例（94.29%），无粘连者2例（5.71%）。其中主要粘连物为肠管20例（60.61%），主要粘连物为网膜组织13例（39.39%）。根据粘连的形态可分为：点状粘连，线状粘连，片状粘连及混合型粘连。根据粘连的质地可分为：膜性粘连，瘢痕性粘连及复合型粘连。粘连分离采取层面变峰面，面转化线和点，钝锐结合分离膜性粘连，锐性分离瘢痕性粘连的程序化方法。全组均成功松解分离粘连，分离时间32（4.50~46.50）min。其中5例发生小肠壁浆肌层损伤，予3-0可吸收缝线行浆肌层缝合。在行观察孔穿刺时，均未发生腹腔内脏器损伤。术后1例出现肺部感染，术后恢复排气时间3（2~4）d。结论 术前人工气腹结合腹部CT有助于判断是否存在腹腔粘连及粘连部位，有利于观察孔布局的选择。根据其形态和性质采取程序化的方法有利于简化腹腔粘连的分离。     

Chest wall reconstruction using implantable cross-linked porcine dermal collagen matrix (Permacol)

Background/PurposeChest wall reconstruction in children is typically accomplished with either primary tissue repair or synthetic mesh prostheses. Primary tissue repair has been associated with high rates of scoliosis, whereas synthetic prostheses necessitate the placement of a permanent foreign body in growing children. This report describes the use of biologic mesh (Permacol; Covidien, Mansfield, MA) as an alternative to both tissue repair and synthetic prostheses in pediatric chest wall reconstruction.MethodsA retrospective chart review was performed identifying patients undergoing chest wall reconstruction with biologic mesh at our tertiary referral children's hospital between 2007 and 2011. Data collection included patient demographics, indication for chest wall resection, number of ribs resected, the administration of postoperative radiation, length of follow-up, postoperative complications, and the degree of spinal angulation (preoperatively and at most recent follow-up).ResultsFive patients (age, 9.0-21.7 years; mean, 15.4 years) underwent resection for primary chest wall malignancy followed by reconstruction with biologic mesh (Permacol) during the study period. There were no postoperative mesh-related complications, and none of the patients developed clinically significant scoliosis (follow-up, 1.1-2.6 years; mean 1.9 years).ConclusionBiologic mesh offers a safe and dependable alternative to both primary tissue repair and synthetic mesh in pediatric patients undergoing chest wall reconstruction.     

Internal mammary artery perforator flap for reconstruction of the chest wall

Abstract

We used internal mammary artery perforator (IMAP) flaps from the opposite side for reconstruction of small-to-medium-sized defects in the chest wall. The IMAP flaps were used in two patients who had unhealed, localised ulcers of the chest wall with exposure of the ribs after radical mastectomy. The lesion was excised widely, and the flap, based on a perforator vessel in the second or third intercostal space of the opposite chest wall, was raised. The flap was rotated from 90° to 180° along the vascular axis to the chest wall defect. The donor site was closed primarily. Both flaps showed stable postoperative circulation and survived completely. Defects of the chest wall could be covered with healthy, well-vascularised tissue on one perforator without deep infection. The IMAP flap is a reliable and less invasive option to be considered for medial, localised, reconstruction of the chest wall.     

Comparative studies of different types of osteosynthesis on the human corpse preparation in bilateral antero-lateral flail chest

IntroductionBilateral flail chest injuries are challenging in treatment and comparatively often require an operative stabilization of the anterior chest wall to re-establish normal physiological conditions of the chest wall in shape and statics. Various procedures have been described which are technically sophisticated for the surgeon. Consequently there is an increasing interest in potentials of operative care and their effectiveness on the anterolateral chest wall.Materials and methods12 Human cadavers were prepared and the natural Sternum Position (NP) was marked. A digital probe was fixed to the sternum at the height of the 4th intercostal space in order to measure and compare the stability of the thorax. Readings were taken of the sternal displacement at 1–5 cm sagittal distance from NP in starting conditions and from every combination of materials. Serial osteotomies were performed on 2 locations on ribs 2–8 to induce bilateral flail chest.Afterwards the stabilization was achieved with different implants:

• –Transsternal metalstrut.
• –Several combinations of locking plate fixation.

ResultsThe osteotomies lead to a subsidence of the sternum occurred to almost 75 mm from NP which corresponds to a maximal unstable situation. The unstable chest wall showed substantially more stabilization through the use of locking plates. Our materialcombinations showed a stability of up to 60% of normal. The more ribs were treated osteosynthetically, the higher the stability of the chest wall.Discussion and conclusionsLocking plate fixation offers anatomically realignment of the ribs whereas metal strut support only lifts up the chest wall, but could not provide realignment of the dislocated ribs.     

犬气管吻合口愈合的形态学研究

为观察气管吻合口修复的形态学改变，将２４条犬气管分单纯横断、袖状切除和管型重建３组。术后４周各组吻合口上皮均基本修复。袖状切除组因吻合口张力大、局部缺血、乏氧导致瘢痕形成，出现不同程度的吻合口狭窄；管型重建组因吻合口张力小，基本不影响吻合口愈合，不易产生物合口狭窄。作者认为带肋间血管蒂胸壁复合软组织瓣管型是较理想的气管替代物。     

Surgical resection and reconstruction for a giant cell tumor of the anterior rib

Giant cell tumors (GCTs) are rare neoplasms, most commonly arising in the metaphysis/epiphysis of long bones. They consist of multinucleated giant cells with surrounding spindle-shaped mononuclear stromal cells. GCTs rarely appear in the ribs. We report a case of a GCT originating from the anterior arc of the fourth rib in a 31-year-old man who presented with a progressively growing thoracic mass in the left anterior chest wall. Thoracotomy involving en bloc resection of the chest wall and tumor and a reconstruction of the chest wall were performed.     

A new method of reconstruction for chest wall resection

Sixteen patients who involved in chest wall disease underwent major chest wall resection between April 1995 and January 1999. The underlying diseases were 6 recurrence of breast cancers, 4 direct invasion by primary lung cancer, 2 metastatic chest wall tumor, one direct invasion by metastatic lung tumor, one direct invasion by metastatic mediastinal tumor, one radio-induced-necrosis of the chest wall, and one chest wall infection. In 9 patients, the thoracic cage reconstruction was performed using double sheets of absorbable mesh (Dexon mesh), cross string sutures and autologous ribs grafts. None of the patients had major respiratory failure and chest wall unstability. No late complications including infections, pains, recurrence and others related to reconstruction materials have been observed.