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Tricks - Thoracoscopic-Assisted Partial Rib Resection - Jack Langer
With Dr. Jack Langer
Part of
Chest Pain 6 items
Chapter 1 of 2 · Case-Based Learning
Case presentation
Case Presentation: Thoracoscopic-Assisted Rib Resection for Chest Wall Lesion
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
A 16-year-old male presented with a two-month history of left-sided chest pain.
Chest X-ray showed an ill-defined 3×5×5 centimeter calcified lesion in the left lower lung zone.
CT scan showed the lesion was pedunculated and exophytic, arising from the internal aspect of the left 6th rib.
Resection was advised due to ongoing symptoms of pain and diagnostic uncertainty.
Patient was positioned with left side elevated 30 degrees using a beanbag.
A single 5 millimeter port was placed posteriorly in the fifth intercostal space.
A 22 gauge needle was passed through the chest wall to map out the smallest incision possible and better define the margins.
A 5 centimeter incision was made with electric cautery.
The intercostal muscles and neurovascular bundles were separated from above and below the 6th rib.
The rib was cut anterior and posterior to the stock of the lesion, and the rib segment and lesion were extracted.
The operation duration was 67 minutes.
The specimen consisted of a 3.5 centimeter rib segment and a 5×3×5 centimeter lesion.
The operation was complicated by a small postoperative pneumothorax which was managed with oxygen therapy.
Final pathology showed an atypical osteochondroma with normal underlying rib and negative margins.
The patient was discharged on the 3rd postoperative day.
At 8 months follow-up, the patient was pain-free and back to normal activities.
For chest wall defects up to three ribs, a Surgisis patch can be used without struts.
For very large chest wall defects, struts or methylmethacrylate are required.
Osteochondromas can be shaved off rather than requiring rib resection; one was removed by biting it off with a rongeur.
For large chest wall gaps from multi-rib resections, patches can leave significant cosmetic deformity with respiratory variation.
An autologous rib can be harvested from above or below the resection site and used to replace the resected rib, providing better chest wall contour without respiratory gaping.
Autologous rib grafts used for chest wall reconstruction are free grafts (without preserved blood supply) and remain visible on X-ray months after surgery.
In patients with multiple hereditary exostosis, symptomatic lesions can be shaved off rather than requiring rib resection, particularly in younger children where malignancy is unlikely.