Thoracoplasty: Anterior, Posterior

Carrie A. Diulus and Isador H. Lieberman

Description

Thoracoplasty is a technique involving rib resection to alleviate the cosmetic rib deformity associated with scoliosis.

Expectations

Cosmetic improvement of truncal appearance.

Indications

Rib deformity is commonly encountered with advanced curves in patients with adolescent idiopathic scoliosis or congenital scoliosis with or without a previous posterior fusion. It may be a sequela of crankshafting after a previous posterior fusion. Patients typically present with cosmetic concerns and coronal sitting imbalance. Indications include the following:

Progressive or cosmetically unacceptable rib humps
To balance shoulder heights
To correct coronal sitting imbalance secondary to rib hump
As a source of bone graft for both anterior and posterior fusion procedures

Contraindications

Patients without a cosmetically noticeable rib deformity
Patients who cannot tolerate the pulmonary compromise of a thoracoplasty due to poor compliance of the chest cage, resection of numerous ribs, division of accessory respiratory muscles, or detachment of the diaphragm

Special Considerations

To prevent reoccurrence, delay thoracoplasty until the patient is physiologically mature.

Special Instructions, Position, and Anesthesia

There are three techniques to perform a rib resection thoracoplasty: (1) open internal transthoracic, (2) open posterior single or double incision, and (3) endoscopic internal transthoracic. Each has its merits, and the technique used depends on the clinical circumstances. Each case should be judged on its individual merits and ultimate expectations.

Open Anterior Transthoracic Internal

Selective double-lumen endotracheal intubation

Lateral position

Drape arm free to facilitate intraoperative evaluation of scapular position (Fig. 56.1)
Drape from midline posteriorly to sternum anteriorly

Fig. 56.1 Operative positioning.

Open Posterior with Single Midline, or Midline and Posterior Axillary Line Incisions

Prone position
Drape field from one anterior axillary line to the opposite anterior axillary line

Endoscopic Transthoracic Internal

Selective double-lumen endotracheal intubation
Lateral position
Drape arm free to facilitate intraoperative evaluation of the scapular position (Fig. 56.1)
Drape from midline posteriorly to sternum anteriorly

Tips, Pearls, and Lessons Learned

Trim rib flush with transverse process at each level to avoid scapular impingement with motion
Thoracotomy instruments should be quickly available during endoscopic procedure for emergency open exposure