Step 1
Surgical Anatomy
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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.
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The bony structure of the chest covers the lungs and portions of the upper abdomen. The diaphragm attaches to the ribs at various levels.
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Bony structure of the chest superimposed on the underlying organs is shown in Figure 20-1 .
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.)
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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 anterior, pectoralis major, and rectus abdominis.
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Latissimus dorsi muscle showing attachments and vascular supply is shown in Figure 20-2 .
Figure 20-2
(From Netter FH. Atlas of Human Anatomy, 2nd ed. 1997, plate 98. Netter Illustration Collection at www.netterimages.com . Copyright Elsevier Inc. All rights reserved.)
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Pectoralis major muscle showing attachments and vascular supply is shown in Figure 20-3 .
Figure 20-3
(From Netter FH. Atlas of Human Anatomy, 2nd ed. 1997, plate 9.1. Netter Illustration Collection at www.netterimages.com . Copyright Elsevier Inc. All rights reserved.)
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Step 2
Preoperative Considerations
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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?
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Example showing a chest wall tumor located low on the chest and likely involving the diaphragm is shown in Figure 20-4 .
Figure 20-4
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Preoperative evaluation should include pulmonary function testing, which will be impaired by resecting part of the chest wall.
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Preoperative chemotherapy or radiation therapy or both should be considered.
Step 3
Operative Steps
1
Incision
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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.
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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
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Resection should be performed with 4-cm margins, if possible.
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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.
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When the tumor is near the articulation with the vertebral body, the rib should be disarticulated 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.
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Chondrosarcoma that was near the articulation of the vertebral body is shown in Figure 20-5 .
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