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THORACOPLASTY. GENERAL THORACIC SURGERY CHAPTER 62. Thoracoplasty . Operative removal of the skeletal support of a portion of the chest. Subperiosteal removal of a varying number of ribs segment.
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THORACOPLASTY GENERAL THORACIC SURGERY CHAPTER 62
Thoracoplasty • Operative removal of the skeletal support of a portion of the chest. • Subperiosteal removal of a varying number of ribs segment. • Unsupported portion of chest wall to sink in toward the mediastinum and reduces the size of hemithorax. • At present, thoracoplasty is used in treatment of chronic thoracic empyema without remaining pulmonary tissue to obliterate the pleural space.
Operative technique • Conventional thoracoplasty— Standard procedure, Alexander. • One stage for chronic empyema. • Two stage for tuberculosis.
Conventional thoracoplasty • Patient in lateral decubitus position, parascapular incision. • Seven ribs are resected (1st to 7th ribs, subperiosteraly, • Division of costotransverse ligment.), allow the scapula and extracostal musculature to drop into the space help to maintain collapse. • Attention– Postoperatively be paid to ensure proper functioning the ipsilateral shoulder girdle.
Axillary thoracoplasty • Apical thoracoplasty. • Skin incision as the operation for thoracic outlet syndrome, removed first rib. • Varing portion of 2nd, 3rd, 4th ribs are removed subperiosteraly to obtain the desired degree of collapse to obliterate the residual apical space. • Less traumatic, better tolerated.
Thoracomyopleuroplasty • Thoracomediastinal plication. • Only the ribs overlying the empyema space are resected. • Empyema space was entered, debridement, cavity is obliterated by suturing the pleuromusculo-periosteal wall to the mediastinal or visceral pleura. • Wound close without drainage. • Procedure– Much smaller than standard thoracoplasty, well tolerated by poor-risk patient.
Plombage thoracoplasty • Foreign body（paraffin, polyethylene bag, fiberglass）was inserted in a space created between the ribs and thoracic fascia • Freed periosteal and intercostals musculature to maintain the optimal collapse. • Contraindicated in management of chronic empyema. • Now be discarded.
Schede thoracoplasty • 1890. • Radical unroofing the empyema space by resecting the overlying ribs, intercostals bundle, subjacent parietal pleural peel. • Extracostal muscle and skin partially closed over gauze packing at intervals. • Freshly granulating tissue set up an obliterative healing process and eventually close the space.
Physiologic changes after thoracoplasty • Related to the development of an area of paradoxic motion of chest wall. • Effort of breathing increase. • Pendelluft （air flow from one lung to the other during ventilatory cycle）occur. • Cough mechanism reduced in effectiveness– As a result of inability to generate a high positive pressure in pleural space– Because of the unsupport portion of chest wall.
Physiologic changes after thoracoplasty • Postoperative problems were directly proportional to the number and lenth of the segments of ribs resected. • Skeletal deformity, • Rotoscoliosis,
Physiologic changes after thoracoplasty • Lung function test— Loss 27% vital capacity, 21% maximal voluntary ventilation of contralateral lung, 50% loss in both vital capacity, 60% loss in FEV1, 40% loss in total lung capacity. • Sacrifice the intercostals nerve result in paresis of the ipsilateral abdominal wall.
Morbidity and Mortality • Morbidity— Related to the type of thoracoplsaty and disease process present. Injury to the nerve during removed first ribs, injury to thoracic duct, septic complication. • Mortality—related to the underlying chronic disease, 5.4%-13%. • Result—failure rate 33% before 1976, 12-17% now.
