En bloc resection of the chest wall. The chest cavity should be entered distal to the tumor as determined by chest CT or MRI. Through thoracotomy or sternotomy, the tumor is palpated within the chest; the lung, hilum, and mediastinum should be palpated for any pathology and to evaluate their resectability. Lymph node involvement and the extent of chest wall involvement must be defined prior to resection. In general, it is not possible to differentiate between chest wall invasion and adhesions reliably by looking at the CT scan. Removal of short rib segments facilitates mobilization of the chest wall segment and provides better visibility of the chest cavity. With resection beginning at the inferior or superior extent, the anterior and posterior margin is taken at each level with the pleura excised. The intercostal muscles are divided along with the pleura, and the posterior portions of the ribs are divided. Hemostasis for the intercostal bundle at each level should be achieved by coagulation or ligation

Disarticulation from the posterior rib to the transverse process. The patient must be placed at a 45° anterior oblique angle in a lateral position with an axillary roll under the downside to allow access to the dorsal costispinal junction. If disarticulation of the ribs from the transverse process is required to obtain negative margins, the paraspinous ligament must be mobilized from the spine and the cartilaginous junction between the neck of the ribs and transverse processes needs to be incised with either electrocautery or an osteotome. As the pleura from within the chest is incised, the osteotome is directed anteriorly toward the vertebral body and thus away from the spinal canal by lifting the head of the rib. The ribs should be disarticulated gently to avoid tearing the dural sheath and to prevent the resultant cerebrospinal fluid leakage. Intercostal bundles must be ligated at the level of the neural foramen. This needs to be done with care; a transfixion ligature may help prevent slippage with bleeding or opening of the epidural space. Only bipolar electrocautery should be used near the spinal foramen. Bleeding from epidural veins is controlled with bipolar electrocautery, and temporary compression with application of fibrin foam frequently is adequate. An accidental dural lesion should be sutured and covered by placing a small flap of paraspinal muscle. Once the chest wall bloc is mobilized, the attached underlying invaded lung parenchyma must be resected. In most cases involving the primary chest wall, this may be done via wedge resection or segmentectomy. In patients with secondary chest wall tumors by invasion of primary lung cancer, lobectomy with concomitant systemic mediastinal lymph node dissection is advised. (a) Disarticulation from the posterior rib to the transverse process. T5 5th thoracic vertebra. (b) Sternal resection for a chest wall tumor. SVC superior vena cava, CL clavicula, C11st, C2 2nd. rib