Overview
Definition:
Chest wall reconstruction is a surgical procedure aimed at restoring the structural integrity and function of the chest wall following extensive resections due to trauma, infection, tumors, or congenital deformities
It often involves the use of prosthetic materials like synthetic mesh and metallic bars to provide rigidity and support.
Epidemiology:
Incidence varies widely depending on the etiology
large segment resections are most commonly necessitated by malignancies, followed by trauma and infection
Congenital deformities like pectus excavatum/carinatum also represent a significant patient population requiring reconstruction, though often with different techniques.
Clinical Significance:
Adequate chest wall reconstruction is crucial for protecting intrathoracic organs, facilitating effective ventilation, and preventing paradoxical motion
Failure to achieve stable reconstruction can lead to severe respiratory compromise, chronic pain, and increased morbidity and mortality.
Indications
Resection For Malignancy:
Primary chest wall tumors (sarcomas, chondrosarcomas, desmoid tumors) or metastatic disease requiring en bloc resection of involved ribs, sternum, or musculature.
Trauma:
Severe flail chest with instability, large segmental defects resulting from blunt or penetrating trauma, or debridement of infected necrotic tissue.
Infection Or Osteomyelitis:
Chronic osteomyelitis of the sternum or ribs, necrotizing infections (e.g., post-sternotomy mediastinitis), or fungal infections requiring extensive debridement.
Congenital Deformities:
Severe pectus excavatum or carinatum cases where less invasive techniques are insufficient, or after failure of previous reconstructions
Congenital absence of chest wall segments.
Revisional Surgery:
Management of complications from previous chest wall surgeries, such as dehiscence, infection, or loss of structural integrity.
Preoperative Preparation
Detailed Imaging:
CT scans with 3D reconstruction are essential for assessing the extent of defect, involvement of adjacent structures, and planning the size and shape of reconstructive materials.
Nutritional Assessment:
Optimizing nutritional status, especially in patients undergoing extensive cancer surgery, to promote wound healing.
Pulmonary Evaluation:
Assessment of respiratory function
aggressive pulmonary toilet and physiotherapy are initiated preoperatively.
Blood Product Availability:
Ensuring adequate availability of blood products due to potential for significant intraoperative bleeding.
Multidisciplinary Team Discussion:
Involving thoracic surgeons, oncologists, plastic surgeons, intensivists, and anesthesiologists for complex cases.
Surgical Management
Mesh Selection And Placement:
Non-absorbable synthetic mesh (e.g., polypropylene, Marlex, Gore-Tex) is commonly used to provide a rigid framework
It is typically sutured to the remaining intact bone or soft tissues, creating a stable scaffold.
Bar Fixation Techniques:
Metallic bars (e.g., stainless steel, titanium) or specialized plating systems are used to reinforce the mesh, particularly in cases of significant sternal or rib defects
They are anchored to stable bone structures proximal to the defect.
Sternal Reconstruction:
For sternal defects, a composite reconstruction with mesh and potentially strut bars may be employed, often combined with autologous grafts or flaps for soft tissue coverage.
Rib Reconstruction:
Individual ribs may be reconstructed using mesh or pre-contoured plates and bars, depending on the segmental loss and required stability.
Soft Tissue Coverage:
Coverage of the reconstructed chest wall with vascularized flaps (e.g., latissimus dorsi, pectoralis major) or skin grafts is crucial to prevent infection and promote healing.
Postoperative Care
Intensive Monitoring:
Close monitoring in an ICU setting is mandatory to assess respiratory status, hemodynamics, and pain control.
Mechanical Ventilation:
Patients may require prolonged mechanical ventilation postoperatively to ensure adequate oxygenation and ventilation, especially after extensive reconstructions.
Pain Management:
Aggressive pain management using multimodal approaches, including epidural analgesia, patient-controlled analgesia (PCA), and judicious use of opioids.
Chest Tube Management:
Chest tubes are typically placed for pleural drainage and are monitored closely for output and air leaks.
Mobilization And Physiotherapy:
Early mobilization and aggressive pulmonary physiotherapy are vital to prevent atelectasis, pneumonia, and venous thromboembolism.
Complications
Early Complications:
Wound infection
Mesh dehiscence or extrusion
Pneumonia
Acute respiratory failure
Hemorrhage
Pleural effusion or empyema.
Late Complications:
Chronic pain
Persistent paradoxical motion
Mesh-related complications (e.g., seroma, late infection)
Impaired respiratory function
Psychological distress.
Prevention Strategies:
Meticulous surgical technique with adequate debridement and sterile handling of mesh
Aggressive wound care and early institution of antibiotics
Optimal pain control and early mobilization
Use of antibiotic-eluting mesh or beads
Ensuring adequate soft tissue coverage.
Key Points
Exam Focus:
Understand the indications for mesh and bar reconstruction
Differentiate between various prosthetic materials and their applications
Recognize common complications and their management
Be familiar with reconstructive techniques for sternal and rib defects.
Clinical Pearls:
Pre-operative CT with 3D reconstruction is indispensable for planning
Adequate soft tissue coverage is paramount to prevent infection and dehiscence
Multidisciplinary approach is key for complex cases.
Common Mistakes:
Inadequate assessment of defect size leading to insufficient material
Poor fixation of bars or mesh
Insufficient soft tissue coverage
Underestimating the need for prolonged mechanical ventilation and aggressive physiotherapy.