Chest Wall Resection

CHAPTER
20
Chest Wall Resection
Mark S. Allen
Step 1. Surgical Anatomy
 An understanding of the chest wall anatomy is important to plan and execute a resection of
the chest wall. The intercostal artery, vein, and nerve run just inferior to the edge of the rib.
 The bony structure of the chest covers the lungs and portions of the upper abdomen. The
diaphragm attaches to the ribs at various levels.

 Bony structure of the chest superimposed on the underlying organs is shown in Figure
20-1.
 The muscles of the chest wall are important to plan the incision and use for reconstruction.
Chest wall muscles that can be used for coverage include the latissimus dorsi, serratus ante-
rior, pectoralis major, and rectus abdominis.
 Latissimus dorsi muscle showing attachments and vascular supply is shown in Figure 20-2.
 Pectoralis major muscle showing attachments and vascular supply is shown in Figure 20-3.
Step 2. Preoperative Considerations
 After a history and physical, the major consideration concerns the location of the mass. What
is the size of the mass? Large tumors (i.e., >5 cm) should have an incisional biopsy rather
than an excisional biopsy. Where is the mass located? Is it near the diaphragm, vertebral
bodies, brachial plexus, or other vital structures?
210
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Chapter 20 • Chest Wall Resection 211
Thyroid cartilage
Cricoid cartilage
Thyroid gland
Trachea
Cervical (cupula, or dome, of)
parietal pleura Jugular (suprasternal) notch
Sternoclavicular joint Apex of lung
Clavicle Arch of aorta
1st rib and costal cartilage Cardiac notch of left lung
Right border of heart Left border of heart
Horizontal
fissure
of right
lung 1
(often
incomplete) 2
Right
nipple Left
3 nipple
Costomediastinal 4
recess of pleural
cavity 5
6
Oblique fissure
of right lung
7 Oblique fissure
Costodiaphragmatic of left lung
recess of pleural
cavity 8 Costodiaphragmatic
recess of pleural
9 cavity
10
Spleen
Inferior border of right lung Inferior border of left lung

Pleural reflection Left dome of diaphragm
Pleural reflection
Gallbladder
Stomach
Right dome of diaphragm Bare area of pericardium
Liver Xiphoid process
Figure 20-1
(From Netter FH. Atlas of Human Anatomy, 2nd ed. 1997, plate 184.
Netter Illustration Collection at www.netterimages.com. Copyright Elsevier
Inc. All rights reserved.)
Circumflex scapular a. & v.

Subscapularis m. Subscapular a. & v.
Serratus anterior m.
Teres major m.
(insertion)
Teres major m. Serratus branch

Thoracodorsal n.
Thoracodorsal a. & v.
Trapezius m. Latissimus dorsi m.
External oblique m.
Thoracolumbar fascia
Figure 20-2 Figure 20-3

(From Netter FH. Atlas of Human Anatomy, 2nd ed. 1997, (From Netter FH. Atlas of Human
plate 98. Netter Illustration Collection at www.netterimages. Anatomy, 2nd ed. 1997, plate 9.1.
com. Copyright Elsevier Inc. All rights reserved.) Netter Illustration Collection at
www.netterimages.com. Copyright
Elsevier Inc. All rights reserved.)
212 Section II • Thoracic Benign

Example showing a chest wall tumor located low on the chest and likely involving the
diaphragm is shown in Figure 20-4.
 Preoperative evaluation should include pulmonary function testing, which will be impaired
by resecting part of the chest wall.

 Preoperative chemotherapy or radiation therapy or both should be considered.
Step 3. Operative Steps
1. Incision
 Placement of the incision is very important. Usually an incision over the mass is acceptable,
but occasionally other factors are more important. All incisional biopsy sites should be
removed. Consideration for reconstruction should also be taken into account so that muscles
that might be needed for reconstruction are not devascularized by the incision.
 Obviously the mass should not be entered anytime during the resection. If the mass is not
palpable, it can be difficult to locate precisely on the chest wall; however, by correlating the
preoperative computed tomography (CT) scan, a general approximation can be made. The
chest cavity can be entered away from the mass, and then palpation of the mass from inside
the chest can guide excision of the chest wall. Some have used video-assisted thoracic surgery
(VATS) to visualize the mass directly and to guide placement of the incision for resection.
2. Resection
 Resection should be performed with 4-cm margins, if possible.

 When resecting ribs, removing a 1-cm piece on each end of the rib makes exposure easier
because the ends of the cut rib are not hitting each other.
 When the tumor is near the articulation with the vertebral body, the rib should be disarticu-
lated from the vertebral body. Exposure to perform this can be facilitated by removing the
transverse process of the vertebral body. Neurosurgical assistance should be available in most
instances.
 Chondrosarcoma that was near the articulation of the vertebral body is shown in Figure
20-5.
 Photo of the chest wall after the tumor has been resected showing the vertebral bodies is
seen in Figure 20-6.

 If the tumor involves the diaphragm, this also can be resected as needed. Reconstruction of
the diaphragm is accomplished by either artificial material or repositioning the attachment

point of the diaphragm.
Figure 20-6
3. Reconstruction
 The primary methods for reconstruction of the chest wall include using a polytetrafluoroeth-
ylene (PTFE) patch (e.g., Gore-Tex) or polypropylene (Marlex) methylmethacrylate sand-
wich. The use of PTFE is somewhat easier because the patch can be used right out of the
package.
 A 2-mm-thick piece is used and sutured in place with nonabsorbable monofilament sutures
in an interrupted pattern. The patch should be taut. If a polypropylene sandwich is used,

the shape of the chest wall defect is reproduced on a back table, and methylmethacrylate is
placed on the Marlex with a centimeter free on the outer edges.
 Hardening of methylmethacrylate is an exothermic reaction; to avoid thermal injury, it should
be allowed to harden on the back table. Once hard, it is sutured into place using the exposed
edges of the Marlex mesh.
 CT scan demonstrates mass in the left chest wall. Needle biopsy proved this mass to be
an isolated metastatic Hürthle cell carcinoma (Fig. 20-7).

 Defect in the chest wall measures 10 × 10 cm after resection of a metastatic Hürthle cell
carcinoma (Fig. 20-8).

 Gore-Tex patch in place after chest wall resection; initial sutures have been placed (Fig.
20-9).
 Gore-Tex patch completed (Fig. 20-10).
 Coverage of the reconstruction is usually accomplished by muscle flaps. The latissimus dorsi
is the most commonly used muscle. Almost any other chest wall muscle can and has been
used.
 Example of a recurrence of breast cancer after chest wall irradiation. After excision the
latissimus dorsi muscle will be used to cover the chest wall reconstruction. Vascularized
muscle is necessary to cover resection and reconstruction after radiation therapy. This
photograph shows the defect in the bed of the left mastectomy site after radiation therapy
(Fig. 20-11).
Figure 20-7
 The area of recurrence has been resected, and the left latissimus dorsi muscle has been
elevated and detached from its insertion (Fig. 20-12).
 The muscle has now been passed under the skin bridge to cover the resected defect (Fig.
20-13).
 The muscle has been sutured into the bed of the reconstructed area to cover the recon-
struction of the bony chest wall. A skin graft will be placed over the vascularized muscle
(Fig. 20-14).
Step 4. Postoperative Care
 After the dressing is applied, an elastic wrap is placed around the chest, which is thought to
decrease the chance of a seroma.
 Pain management is important and usually consists of epidural and patient-controlled
analgesia.
Step 5. Pearls and Pitfalls
 Infected reconstructions usually present as increased pain, redness, or drainage from the
incision. An infected foreign body such as a Gore-Tex patch or Marlex-methylmethacrylate
sandwich usually needs to be removed. Fortunately, a thick membrane forms around the
material, so removal does not result in an open pneumothorax. With proper antibiotics,
removal of the artificial material, and careful wound care, the defect should heal. If there is
significant flail of the chest or an unsightly cosmetic result, the defect can be repaired once
the infection is healed.
 Follow-up should be a CT scan at least once a year to detect any recurrence. An advantage
of PTFE reconstruction is that it is easy to see on follow-up CT scans.
Suggested Readings
Abbas AE, Deschamps C, Cassivi SD, et al. Chest wall desmoid tumors: Results of surgical intervention. Ann Thorac Surg
2004;78:1219-1223.
Fong Y, Pairolero PC, Sim FH, et al. Chondrosarcoma of the chest wall. Clin Orthop Relat Res 2004;427:184-189.
Figure 20-14

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CHAPTER

Step 1. Surgical Anatomy

diaphragm attaches to the ribs at various levels.

Step 2. Preoperative Considerations

Inferior border of right lung Inferior border of left lung

Circumflex scapular a. & v.

Teres major m. Serratus branch

Figure 20-2 Figure 20-3

by resecting part of the chest wall.

Step 3. Operative Steps

 Resection should be performed with 4-cm margins, if possible.

seen in Figure 20-6.

the diaphragm is accomplished by either artificial material or repositioning the attachment

Figure 20-4 Figure 20-5

in an interrupted pattern. The patch should be taut. If a polypropylene sandwich is used,

an isolated metastatic Hürthle cell carcinoma (Fig. 20-7).

carcinoma (Fig. 20-8).

Figure 20-8 Figure 20-9

Figure 20-10 Figure 20-11

Step 4. Postoperative Care

Step 5. Pearls and Pitfalls

of PTFE reconstruction is that it is easy to see on follow-up CT scans.

Figure 20-12 Figure 20-13

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