Thoracoplasty with Closed Pleural Space
The patient is best positioned in a lateral position, leaning slightly forward. There was some enthusiasm for operation in the prone position previously. Work that my team did on our service at the Albert Einstein College of Medicine in New York City demonstrated that this position, even in healthy volunteers, leads to an average reduction of cardiac output and blood pressure of approximately 25%, and we abandoned it. Use of a double-lumen endotracheal tube will lessen the secretions reaching the dependent lung. However, if the patient is being operated on for pulmonary hemorrhage, I prefer a large-diameter single-lumen tube, which allows for better removal of blood clots. In either case, it is highly advisable to do a bronchoscopic lavage at the end of surgery.
The incision should extend from the spine of the scapula down around its tip and anterior to the anterior axillary line (Fig. 106-1). After division of the trapezius, rhomboids, latissimus dorsi, and serratus anterior muscles, the scapula is elevated. This can be facilitated by placing one blade of a rib retractor on the point of the scapula and one on the chest wall and opening it to its greatest extent. This gives very good exposure of the upper ribs and frees the assistant for more productive activity.
A. The incision for thoracoplasty should be carried high up posteriorly to access the posterior elements of the upper ribs. B. Placing one blade of a rib retractor on the rib cage below and the scapula above permits a stable and wide retraction of the shoulder girdle.
Once the rib cage is exposed, it is necessary to divide the attachments of the serratus posterior, posterior and middle scalenus, serratus anterior, and pectoralis minor muscles to those ribs to be resected (Fig. 106-2). This is required for good collapse to occur. The periosteum is incised on the external surface of the ribs and stripped from them. This must be carried posteriorly to the costovertebral joint for total removal. Division of the costotransverse ligament facilitates this and removal of the transverse process, which is equally important if a posterior gutter is not to be left with incomplete collapse of the lung (Fig. 106-3).
Depending on the area of rib cage to be collapsed, it is necessary to divide the muscles inserting on the ribs to be removed.
It is important to remove all the ribs and the attached transverse processes if the posterior gutter is to be obliterated.
At this point, a decision must be made about the ribs themselves. They may be resected, which often leads to late orthopedic and cosmetic changes.8 They may be left in place, or they can be rotated 180 degrees and fixed at the ends to act as a plombe. The insertion of various materials between the ribs and the collapsed chest wall to act as a plombe was the cause of many complications and has been abandoned. Once the collapse is complete, the wound is closed in anatomic layers. Sometimes with a six-rib thoracoplasty, the tip of the scapula impinges on the top of the seventh rib, forming a painful bursa. This led some surgeons to do a hemiscapulectomy. This is ill-advised because it leads to rotation of the scapula with added deformity of the shoulder and usually does not solve the problem. It is better to resect a portion of the underlying seventh rib (Fig. 106-4).
Impingement of the scapula tip on the seventh rib can cause a painful bursa to develop. It is better to remove a portion of the rib than to remove a portion of the scapula.
Thoracoplasty with Open Pleural Space
In cases where there has been pleural space infection with tuberculosis or mixed infection, there may have been a need for prior drainage. Pure tuberculous infection at times can be treated with aspiration and antituberculous drugs if caught early but has the potential for formation of a pleural peel within 3 to 4 weeks. In the past month, I had such a patient with no parenchymal changes. Early decortication and antituberculous drugs have given a surprisingly good result for him. Although I can find no reference for it, I remember when in the 1960s there was some enthusiasm for steroids in cases of tuberculous pleural and especially pericardial effusions coupled with aspiration and drug therapy.
When conservative measures have failed and early decortication is contraindicated by marginal cardiopulmonary reserve, open drainage is required. This can be accomplished with a small thoracotomy, removal of proteinaceous debris, and insertion of a large-bore mushroom catheter. For more definitive drainage, an Eloesser flap can be created.9 Using a U-shaped skin incision with the base uppermost and the tip of the flap over the lowest portion of the cavity, portions of the underlying ribs are excised, and the skin flap is turned in and sutured to the upper end of the pleural opening (Fig. 106-5). Total unroofing of the cavity as proposed by Schede10 has been abandoned. In these patients, closure of the space occurs by secondary intention from the periphery of the cavity. This process can be accelerated by a localized extraperiosteal thoracoplasty.
For prolonged drainage of a pleural cavity, an Eloesser flap can be fashioned by creating a downward-facing flap, resecting the underlying ribs, and sewing the flap to the parietal pleura.
Thoracoplasty with Muscle Flap
The most challenging and debilitating disease occurs when either a primary or postresection space is caused by bronchopleural fistula. It should be noted that postresectional fistulas are encountered most commonly in patients operated on for tuberculous complications before adequate medical treatment has been achieved, such as for active pulmonary hemorrhage. In some of these patients, a combination of drainage, thoracoplasty, and antituberculous drugs will achieve a closure of the fistula. If this does not occur, it will be most helpful to bring in a vascularized muscle flap to apply to the bronchus or the fistula or to completely fill the cavity11,12 (Fig. 106-6). It can be pointed out here that the vascularized chest wall of a thoracoplasty was the first such myoplasty. Here again, patience is a winning virtue because time must be allowed for maximum medical benefit. Muscle flaps should not be brought into areas of active tuberculous infection. The muscles available are the pectoralis major, serratus anterior, latissimus dorsi, rectus abdominis, and intercostals and should be based on an intact blood supply. These can be introduced directly into a drainage already established or through a small thoracotomy placed to achieve the most direct path through the chest wall to the fistula. They should be sutured around the parenchymal defect or leaking bronchus. Here again, the obliteration of space is a good basic principle and can be achieved by an appropriate thoracoplasty or by filling the space with muscle or both.
Muscles released from the chest wall that is undergoing thoracoplasty (A) can be kept well vascularized and brought into the thorax to (B) obliterate space or close a bronchopleural fistula.
Tailoring a Thoracoplasty
In some patients who are candidates for resection of tuberculous residua, the adhesions and scar present in and around the lung that will remain are such that a postoperative space problem is predictable. In this case, a preliminary or synchronous thoracoplasty can be performed as described previously to tailor the thoracic space so that the lung will fill it. Temporal separation of the two procedures has the advantage of less impact on the patient. It also allows for evaluation of the result achieved so that, if needed, an additional rib or two can be conveniently resected at the time of pulmonary resection.
While this discussion has been limited to consideration of thoracoplasty in tuberculosis, it must be noted that the same forces that are leading to an upsurge in typical and atypical tuberculosis are also favoring development of various fungal diseases. The problem of residual space in the thorax is most often associated with aspergillosis, but especially in immune-compromised patients, often fungal disease may invade. In these patients, antifungal medical therapy is not always successful, and surgical intervention is required. All the considerations of maximal medical benefit, careful preoperative assessment, and strong nutritional support obtain. This topic is too broad for discussion here.13
Although the present need for thoracoplasty is infrequent, it seems that all thoracic surgeons should be familiar with its uses, variations, and timing as we move into a period of increasing drug-resistant tuberculosis and a parallel increase in opportunistic infections.