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MMCTS
(March 29, 2007). doi:10.1510/mmcts.2005.001784 Copyright © 2007 European Association for Cardio-thoracic Surgery
Procedure Chest wall and sternal resection and reconstructionRegional Department of Thoracic Surgery, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham BS9 5SS, UK * Corresponding author: * Tel.: +44-121-4242561; fax: +44-121-4240562. E-mail: srathinam{at}rcsed.ac.uk
Chest wall resection is performed for a variety of conditions and has been a complex problem in the past due to intraoperative technical difficulties, surgical complications, and respiratory failure. Advances in the fields of surgery and anaesthesia and the team effort of the involved thoracic and plastic surgeons result in more aggressive resections with good results. The surgical technique of sternal excision and reconstruction with a Marlex methacrylate composite prosthesis as a part of chest wall resection and reconstruction series is described here in this chapter.
Key Words: Chest wall resection • Sternal reconstruction • Tumour • Marlex methacrylate mesh
Chest wall resection is performed for a variety of conditions such as primary and secondary tumours of the chest wall or the sternum, lung cancer, infections, radio necrosis and trauma [1]. Chest wall reconstruction has been a complex problem in the past due to intraoperative technical difficulties, surgical complications, and respiratory failure caused by the chest wall instability and paradoxical respiratory movements [2]. Advances in the fields of surgery and anaesthesia and the team effort of the involved thoracic and plastic surgeons result in more aggressive resections. Nowadays neither the size nor the position of the chest wall defect limits surgical management, because resection and reconstruction are performed in a single operation that provides immediate chest wall stability [1]. Chest wall resection involves resection of the ribs, sternum, costal cartilages and the accompanying soft tissues and the reconstruction strategy depends on the site and extent of the resected chest wall defect [3]. Sternal resections and reconstructions have long been a challenge for surgeons, due to the difficulty in making full-thickness resections without compromising the stability and reconstruction of the thoracic wall, but improvements in surgical techniques now make it possible to perform even total sternectomies with good results [4, 5, 6]. Careful radiological investigation is necessary to assess the extent of the tumour, as the mass evident on examination is often part of a much larger tumour invading the sternum. CT scans have become the mainstay of imaging to evaluate the extent of the tumour and search for pulmonary metastases [7]. High-resolution scans and reconstructed images may help assess the extent of the primary tumour, particularly with respect to mediastinal invasion. MRI scans are useful for assessment of mediastinal invasion of the pericardium, heart, or great vessels. Pulmonary function testing is important in patients with chronic obstructive pulmonary disease, in the elderly and in patients needing wider resection, as this will have a bearing on the postoperative chest wall mechanics and respiratory function. Establishing a histological diagnosis is important and this is performed by a core needle biopsy or an incisional biopsy, however, it should be borne in mind to place the biopsy in a site where it will be excised during the surgery. Surgery is now considered the best therapeutic choice in most cases of primary sternal tumours [6]. Various prostheses are available for reconstruction of sternum and anterior chest wall [8, 9]. If the defect is small then a synthetic mesh is used to cover the defect with soft tissue over it. However, if the defect is large then a composite prosthesis is created with methyl methacrylate and Marlex or PTFE mesh. The surgical technique of sternal excision and reconstruction with a Marlex methacrylate composite prosthesis as a part of chest wall resection and reconstruction series is described here in this chapter.
Brief clinical history A 26-year-old female presented with a swelling in the front of her chest of one year duration with a recent increase in size. She had intermittent pain on the swelling on sneezing and coughing. She did not have any loss of appetite or weight. She had a scar in the front of her sternum and with a noticeable swelling measuring 3 cm across which was quite tender on deep palpation. The rest of her physical examination was within normal limits.
Preoperative assessment
Pulmonary function tests, cardiac evaluation are important in assessing operative risk especially in cases involving pulmonary resection as well. Histology is established prior to the procedure either by a trucut or incisional biopsy. If incisional biopsy is performed the scar is placed in such a way it can be excised with the specimen. Our patient had an incision biopsy which was suggestive of a low grade chondrosarcoma.
Positioning of the patient The patient is placed on the table in a supine position with a roll between the scapulae and the chest is prepared and draped.
Incision
The lesion is then identified, defined and the extent of resection is assessed. The extent of the tumour is delineated after dissection of the xiphisternum and dissecting up to the costal cartilages (Video 2).
Division of the costal cartilages and sternum The internal mammary arteries are identified, ligated and divided on both sides (Video 3).
The costal cartilages are then divided giving adequate tumour clearance of 5 cm. The intercostal cartilages are divided with a sternal saw and care is taken to identify, ligate and divide the intercostal vascular bundle (Video 4). The sternum is then divided with the sternal saw and scissors (Video 5).
Assessment of the defect and measurements The resection results in a defect in the anterior chest wall exposing the pericardium and right lung. The defect in the anterior chest wall is then assessed for a good clearance margin on all sides and the prosthesis is sized. Our choice for reconstruction is a composite Marlex methyl methacrylate prosthesis. The Marlex mesh (MMCTSLink 138) is folded and placed on the defect and assessed (Video 6).
The mesh is sewn as a double breast using nylon to create the prosthesis. The Marlex mesh thus created has a small gap to instill the methyl methacrylate. The methyl methacrylate with gentamycin is stirred to a paste-like consistency and instilled into the Marlex pouch. It is carefully smoothed and uniformly spread inside the pouch. The sandwich is moulded to suit the contour of the anterior chest wall (Video 7).
Reconstruction of the defect The sandwich is then fixed to the defect with interrupted O/ vicryl sutures (MMCTSLink 38). After placing the mesh into a satisfactory position, the edges are secured with continuous runs of vicryl sutures to the costal cartilages (Video 8).
Once the composite prosthesis is in place the pectoral muscles are reattached to the costal cartilages and the prosthesis. The pectoral muscles and presternal fascia are sutured together in the midline to cover the composite prosthesis. Redivac drains are positioned in the mediastinum behind the neosternum and behind the pectoral muscles. Both drains come out through separate stab incisions; fixation is provided by purse string suture. After securing haemostasis, the subcutaneous layer is approximated with continuous absorbable suture (1 vicryl), with the closed suction drainage underneath. Skin is closed by a running subcuticular suture using non-absorbable material (4 0 prolene with beads) (Video 9).
The resected specimen is measured and sent for histological examination (Video 10). The histology confirmed the diagnosis of a Grade I chondrosarcoma of the sternum with complete excision margins. The patient had a satisfactory cosmetic and function outcome and the prosthesis was found to be sitting well in a follow-up CT scan (Photo 4). Her postoperative respiratory function was preserved with an FEV1 of 3 l.
The surgical results of sternal reconstruction are good (Table 1). Though this procedure is surgically demanding and technically challenging, good cosmetic and functional results are achieved with minimal operative mortality [5]. Morbidity includes seroma, local infection, systemic sepsis and graft necrosis and infection [10]. The long-term results in these patients depend on the nature of the primary lesion with five-year survival ranging from 46% to 66% [11].
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Summary
Introduction
