Thoracoplasty

The procedure known as thoracoplasty has historically been applied to treat spinal deformities while also enhancing the posterior chest wall's aesthetics. Both posterior and anterior spinal surgery procedures might include thoracoplasty. The method has also been applied to correct rib hump deformity without spinal fusion and to correct residual chest wall distortion in a spine that has already undergone spinal fusion. In the majority of mild to moderate deformity patients, the use of thoracoplasty has been significantly reduced thanks to the success of pedicle screw fixation in combination with direct spinal derotation procedures. As surgeons became aware of their ability to fix deformities effectively, they decided that the additional surgical risk and potential pulmonary function effects of penetrating the chest wall were not necessary.

Interestingly, costotransversectomy methods with rib head excision became more popular as part of the method for pedicle subtraction osteotomies or column resection procedures in pediatric patients as surgeons shifted away from both thoracoplasty and anterior surgery due to concerns about decreases in pulmonary function seen with chest wall violation. When treating severe abnormalities in idiopathic patients, surgeons can obtain excellent three-dimensional correction by combining thoracoplasty procedures with traction and direct pedicle screw manipulation. A surgeon can use convex and concave thoracoplasties as useful tools to mobilize the spine during deformity correction procedures on an as-needed basis.

 

What is Thoracoplasty

The term thoracoplasty (TPL) refers to a range of procedures intended to decrease a hemithorax's volume. This is accomplished by removing many ribs, which causes the chest wall to collapse and the parietal to adhere to the visceral or mediastinal pleura. These techniques have been utilized to treat postpneumonectomy empyema, obliterate a septic pleural space covering an unexpandable lung, compress cavitary pulmonary tuberculosis, and minimize the pleural gap when the residual lung does not expand enough after pulmonary resection.

 

Thoracotomy vs Thoracoplasty

A thoracotomy is a surgical technique used to open the chest's pleural area. To get access to the thoracic organs, most frequently the heart, lungs, or esophagus, or to the thoracic aorta or the anterior spine, it is carried out by surgeons (in some cases, emergency doctors or paramedics). A thoracostomy is a little incision in the chest wall that keeps the drainage hole open. It is most frequently used to treat pneumothoraxes.

 

Thoracoplasty Indications

TPL was a surgery that was suitable for cavities in the top portion of the lung, typically the superior portion of the lower lobe and the apical and posterior portions of the upper lobe. Large cavities in the paravertebral gutter and those located medially in the apex of the lung are challenging for TPL to collapse. TPL frequently failed to seal cavities less than 5 cm in diameter, and it also frequently did not respond to cavities that were distended due to partial bronchial obstruction (tension cavities). Another condition that precludes TPL is tuberculous bronchiectasis. Although rarely done, bilateral TPL may be possible if just three to five ribs on each side are involved. 

Since the development of decortication for unexpanded lung, intrathoracic muscle flap transposition for the management of empyema and bronchopleural fistula, and antibiotic therapy and pulmonary resection for tuberculosis, the indications for TPL have significantly decreased. These approaches might, however, not work. For instance, if the lung is fibrotic and inexpandable, decortication will fail. TPL can offer a straightforward one-stage solution to a challenging issue. The decision between muscle flap surgeries and TPL must be taken into account when pulmonary resection for advanced lung cancer has been undertaken and complicated by bronchopleural fistula or empyema. A one-stage TPL may be more beneficial for a patient with a poor long-term outlook than multiple-stage muscle flap surgery and a prolonged hospital stay.

The parietal pleura must be thin and flexible for the conventional extrapleural TPL to be effective in obliterating the pleural gap. In the treatment of early bronchopleural fistula (BPF) and empyema, this is not a pertinent issue. No matter how well drained the chronic empyema is, space obliteration is impossible because the parietal pleura has grown too thick and rigid. As a result, the TPL evolved into the Grow, Kergin, and Andrews modifications.

 

Thoracoplasty Preparation

When a preoperative choice is made to use the technique, thoracoplasty is performed most effectively. The surgeon can assess the remaining chest wall contour after the abnormality has been repaired in the operating room before deciding whether to employ the method. With instrumentation in situ, the process is more challenging to perform, and the secondary gain of larger primary curve correction is lost. Additionally, it's crucial to go over the technique's use with the patient's family before surgery. The patient should go over the additional surgery required for the approach and any potential side effects. It's important to mention the probable temporary decrease in lung function. When patients are well-informed, the surgeon will frequently have a good understanding of what the patients expect from the surgical outcomes, which can help in decision-making. Unexpectedly, many patients will choose to move forward with thoracoplasty techniques if the surgeon feels they offer a significant improvement in chest wall contour. This is because the excellent radiographic results obtained with pedicle screw constructs do not always correspond with the patient’s satisfaction with their chest wall shape.

When treating abnormalities, the thoracoplasty should be planned to target the area with the most prominent ribs closest to the apex of the deformity. Small pieces of the apical 5 ribs can be removed, which significantly improves the shape of the chest wall. The tenth rib is typically the lowest rib removed. Due to their natural mobility and distance from the apex of most abnormalities, thoracoplasty done on the 11th or 12th ribs results in less improvement. Additionally, in teenagers who sit on hard-backed school chairs, the 10th rib may protrude and become an uncomfortable prominence if the thoracoplasty terminates at the 9th rib.

The surgeon needs to prepare a chest tube and inform the family of the possibility. Even if the resection is extrapleural, the local posterior hematoma can pass through the pleura and cause a large effusion that may necessitate the insertion of a chest tube a few days after surgery. The patient's family and the surgeon are both quite disappointed when the chest tube installation is delayed and this will delay patient discharge.

 

Thoracoplasty Procedure

A thorough subperiosteal dissection of the spine is carried out with the patient lying on his back. The most noticeable ribs involved are seen on the convex side of the malformation, typically four to five ribs. When proximal rib segments are eliminated, all distal ribs that contribute to the posterior prominence may become more clinically apparent. The plane overlying the erector spinae muscles and beneath the thoracolumbar fascia is developed using a mix of electrocautery and blunt dissection. When bridging nerves are present, caution should be exercised to protect them. A plane is created by blunt dissection between the longissimus muscle (medially) and the iliocostalis muscle (laterally). The dorsal apex of the rib prominence can be seen through this muscle plane.

To incise the periosteum, electrocautery is utilized 1 cm laterally and 2 to 3 cm medially to the dorsal apex of the prominence, in line with the rib. Using a dry sponge or an Alexander dissector, the periosteum is peeled in the cranial and caudal directions. This procedure is carried out around the ventral side of the rib. For this, a Doyen retractor can be utilized. The neurovascular bundle inferiorly and the ventral pleura need to be protected with extra care. To avoid unintentional injury to the intercostal neurovascular bundle, a rib cutter is gently moved from inferior to superior around the rib. First, the lateral rib cut is made. The medial cut is then made once the rib has been clamped.

Considering that the apex of the rib prominence is typically placed sufficiently lateral to this joint, there is no need to interfere with the costotransverse articulation. After vertebral derotation, the remnant rib segment medial to the thoracoplasty site seldom becomes apparent. At this stage, a thorough examination of the thoracoplasty site is recommended. The minor cancellous bone bleeding that frequently occurs from the cut ends of the rib may typically be ignored. Absorbable bone wax may be utilized when cancellous bone bleeding becomes extensive. Tamponade or bipolar cauterization should be used to control vascular bleeding. A chest tube is used to treat pleura violations. A chest tube is not, however, inserted routinely. The periosteal sleeve leaves the ends of the ribs exposed. The erector spinae muscles are then reapproximated to the thoracolumbar fascia, which is subsequently stitched with a running, self-locking, polydioxanone suture in size 0. You might also use polyglactin running no. 0 instead. In a bone mill, the rib segments are broken down and used as an autologous bone graft. Postoperatively, no orthosis of any kind is necessary. After around 3 months, radiographic signs of rib reconstitution and remodeling normally appear.

 

What Happens After Thoracoplasty?

You will spend roughly a week in the hospital following the thoracoplasty. At least a few days will pass with the chest tube in place. Your medical team will motivate you to take a brief, supported walks, cough, and use the incentive spirometer. You will be helped by your team in managing your pain. Your healthcare professional will inform you of the results of any thoracoplasty performed to diagnose a condition, as well as any potential next actions.

 

Thoracoplasty Recovery

Following the surgery, you can resume your regular eating routine. To prevent constipation, you might wish to take a fiber supplement every day. If your doctor doesn't advise you to limit your fluid intake, you should be able to drink as much as you like. Take your painkillers as prescribed. Do not hold your breath because doing so could cause pneumonia. Following a thoracoplasty, you will stay in the hospital for roughly a week. After this procedure, you might, however, miss roughly two months of work. You must adhere to the instructions given by your medical team regarding when you can resume sexual activity, heavy lifting, and athletic activity. You must keep up your attempts to improve breathing when you are at home, which will entail deep breathing, coughing, and utilizing the incentive spirometer. Additionally, your healthcare practitioner can recommend arm and shoulder exercises.

 

Thoracoplasty Complications

The effects of thoracoplasty on pulmonary function may go beyond those previously covered in this chapter and include several other well-explained potential issues. One of the most frequent postoperative consequences is a pleural violation. The incidence has always been estimated to be around 5%, but patient- and technique-related factors invariably affect this. It is not advised to attempt a repair if a large pleural rupture has been caused. An alternative would be to insert a chest tube via the pleural defect. A hemothorax or pneumothorax might result from improper care of a pleural violation.

The detection of pleural effusion during the healing process is not unusual. Sometimes, this can be a pleural violation that was missed during surgery. It is more usually brought on by widespread pleural irritation. Radiographic observation and clinical correlation are sufficient in the great majority of cases. A thoracentesis, however, might be required when the effusion gets bigger. Chest tube insertion is advised if a thoracentesis doesn't fix the issue.

Following thoracoplasty, intercostal neuralgia is a possibility. Although longer-lasting symptoms have been reported, it is typically temporary. This problem should be less common if the periosteum is preserved when exposing the rib and the intercostal neurovascular bundle is carefully protected.

 

Is Thoracoplasty Painful?

Undoubtedly, a thoracoplasty hurts. The discomfort may induce breathing problems, which may ultimately result in pneumonia or atelectasis. There are several methods your medical team might use to manage the discomfort. These may include methods like taking oral painkillers, getting painkillers through an IV, or inserting an epidural catheter, to mention a few. The discomfort may last for a long period. Post-thoracotomy pain syndrome is the term for this.

 

Conclusion

Thoracoplasty has been utilized in conjunction with scoliosis surgery for many years as a way to enhance postoperative aesthetics and as a source of autologous bone transplant. Scoliosis surgeons are now able to achieve substantially better three-dimensional deformity correction, which has improved cosmesis, thanks to improvements in spinal instrumentation (such as segmental pedicle screws) and deformity correction methods (such as direct vertebral body derotation). Nevertheless, by minimizing the remaining asymmetric posterior rib prominence, thoracoplasty provides significant clinical appearance improvement. Whether thoracoplasty affects pulmonary function in a clinically important way is still up for debate.