Ann Thorac Surg 2005;80:755-756
© 2005 The Society of Thoracic Surgeons
How to do it
Thoracoscopic Rib Resection Using a Gigli Saw
Tomoyuki Nakagiri, MD,
Akinori Akashi, MD,
Norihisa Shigemura, MD
*
Department of Thoracic Surgery, Takarazuka Municipal Hospital, Takarazuka, Hyogo, Japan
Accepted for publication February 18, 2004.
* Address reprint requests to Dr Nakagiri, Department of Thoracic Surgery, Takarazuka Municipal Hospital, 4-5-1, Kohama, Takarazuka-city, Hyogo, 665-0827, Japan; (Email: gilly64{at}okn.gr.jp).
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Abstract
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When a conventional approach is used to perform a rib resection, a skin incision longer than the rib to be resected must be made. As a result, a conventional rib resection leaves a rather large and esthetically unfavorable scar. After considering pain management, esthetics, and quality of life, we devised a new technique for thoracoscopic rib resection that uses a Gigli saw. This new technique was performed on an overweight woman with a solitary metastatic bone tumor of the right eighth rib, whose case is described herein. The patient’s postoperative course was satisfactory. Since this technique does not require a long skin incision, pain management and aesthetic results are improved compared with conventional techniques.
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Introduction
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From the perspective of pain management, surgery is occasionally indicated for metastatic rib tumors [1]. Although such operations improve quality of life (QOL) for patients, the long skin incision required for conventional rib resection techniques can result in significant postoperative morbidity and impact negatively on QOL. We devised a new thoracoscopic technique that yielded favorable results. This new technique is presented herein.
The patient was an overweight 59-year-old woman (height, 150 cm; weight, 65 kg) who was admitted because of right-sided back pain. Her past medical history included stage IV (pT2 pN1 M1[HEP]) colon cancer, for which she had undergone ileocecal resection under conventional open surgery. A catheter was inserted and left in the hepatic artery, and hepatic arterial infusion chemotherapy with cisplatin and 5-fluorourasil was subsequently performed. Colon fiberscopy did not reveal any tumor recurrence at the primary site, and computed tomography (CT) of the brain did not reveal any metastasis. Liver metastatic lesions were reduced, but still present. However, chest CT and bone scintigraphy identified a solitary metastatic lesion measuring 6 x 3 cm in the right eighth rib. The interval from the primary colon operation to observation of this lesion was 21 months. Radiotherapy was suggested, but the patient expressed a desire for surgical removal of the lesion as a palliative procedure.
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Technique
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To allow unilateral ventilation, intubation was performed with a double lumen endobronchial tube, and the patient was placed in the left lateral position under general anesthesia. The right chest, shoulder, and axilla were shaved. Placement of ports depends on the patient and the tumor location. In this patient, location of the tumor in the right eighth rib dictated the use of a camera port in the fifth intercostal space along the anterior axillary line (10-mm port), and working ports in the fourth and sixth intercostal spaces along the anterior axillary line (5-mm ports).
The parietal pleura under the eighth rib was opened 2 cm from the tumor margin. An electrical scalpel was used to detach the intercostal muscles in this region from the eighth rib. The intercostal artery and vein were then coagulated and cut with the electrical scalpel. Detachment of the area around the rib was confirmed by using forceps, as shown in Figure 1. A Gigli saw was then used to sever the eighth rib. To position the Gigli saw, one end was held with forceps and the saw was inserted into the thoracic cavity through a port. The saw was then positioned at the target area from the lower margin of the eighth rib. Clamp forceps were used to hold the Gigli saw from the upper margin of the rib, pull it into the target area, and hold it in position while the rib was severed (Fig 2). The other end of the eighth rib was detached in the same manner.
While forceps were used to hold and pull on the resection stump, the intercostal muscles were detached from the lower margin of the seventh rib and upper margin of the ninth rib with an electrical scalpel, thus freeing a 10-cm segment of the eighth rib. A bag was inserted through the ancillary port, and the resected rib segment was placed in the bag to allow its removal from the body. The port wounds were sutured in layers, and skin incisions were closed with buried sutures.
The operation time was 90 minutes, with minimal blood loss. The patient displayed an uneventful postoperative course, with no occurrence of flail chest. Intercostal water-seal drainage was removed the following day. The patient was discharged 2 days postoperatively, with no subsequent analgesia required.
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Comment
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Thoracoscopy has a long history, first being used in Sweden by Jacobaeus in 1910 [2]. In recent years, the applications of thoracoscopy have expanded substantially [3], as the technique has been shown to cause less pain, reduce duration of hospitalization, and offer esthetically advantageous results compared with open surgery [4].
The present thoracoscopic rib resection technique can be performed through ports, even for tumors located under the scapula or breast. As a result, the potential applications are wide. Although the number of reports detailing thoracoscopy-assisted rib resection have increased in recent years [5], few have described techniques that use only a thoracoscope, and even in these few reports, specialized equipment such as a drill has been required [6]. In contrast, the present technique uses a commonly available Gigli, allowing wide application of the procedure. For the present patient, thoracoscopic rib resection was performed out of consideration for QOL, to remove a metastatic bone tumor. The technique can also be used to excise benign tumors.
Recent advances in technique and technologies have expanded the indications and roles of thoracoscopy. The present thoracoscopic rib resection technique offers the potential for further expanding the role of thoracoscopy.
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References
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- Richardson J, Sabanathan S. Pain management in video assisted thoracic surgery: evaluation of localized partial rib resection. A new technique J Cardiovasc Surg 1995;36:505-509.[Medline]
- Jacobaeus HC. Possibility of the use of cystoscopy for the investigation of the serous cavities Munch Med Wochenschr 1910;57:3090-3092.
- Maziak DE. Video-assisted thoracic surgery Ann Thorac Surg 1995;59:780-781.[Free Full Text]
- Landreneau RJ, Hazelrigg SR, Mack MJ, et al. Postoperative pain-related morbidityvideo-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 1993;56(6):1285-1289.[Medline]
- Urschel HC. The transaxillary approach for treatment of thoracic outlet syndromes Semin Thorac Cardiovasc Surg 1996;8:214-220.[Medline]
- Ohtsuka T, Wolf RK, Dunsker SB. Port-access first-rib resection Surg Endosc 1999;13:940-942.[Medline]
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Abstract
Introduction
