Thoracoscopy-Assisted Minimally Invasive Surgical Stabilization of the Anterolateral Flail Chest Using Nuss Bars

doi:10.1016/j.athoracsur.2013.08.066

The Annals of Thoracic Surgery

Volume 97, Issue 6, June 2014, Pages 2179-2182

https://doi.org/10.1016/j.athoracsur.2013.08.066 Get rights and content

Flail chest is caused by complex fractures of multiple ribs as a result of severe chest injuries, which results in paradoxical chest movements that severely compromise respiratory function. We report our experience of thoracoscopically assisted, minimally invasive surgical stabilization of massive anterolateral flail chest using a Nuss bar in three patients. This technique offers effective stabilization while having the advantages of short surgical time, minimal blood loss, less trauma, quicker recovery, and small and inconspicuous incisions.

Section snippets

Surgical Technique

Chest measurements were performed before surgery, and steel bars of appropriate length were selected. Steel bars were bent using anvil bar benders according to the three-dimensional reconstruction of their CT images. Using general anesthesia, a 1.0-cm incision was made in each uninjured chest wall on both sides of the flail segment. The pleural cavities were inspected using video-assisted thoracoscopy. Blood clots were removed and the pleural cavities were irrigated. Submuscular tunnels were

Comment

All three patients in this report had anterolateral flail chest with a highly mobile flail segment and intense pain. Therefore, they were good candidate for surgical stabilization.

Several techniques have been described for surgical stabilization, including the use of Judet's or other struts, acetabular reconstruction plates, intramedullary K-wires, resorbable plates, and Vicryl sutures. All surgical stabilization methods require a long incision with muscle dissection to expose the fractures.

References (5)

M.L. Metzelder et al.
Self and parental assessment after minimally invasive repair of pectus excavatum: lasting satisfaction after bar removal
Ann Thorac Surg
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J.C. Mayberry et al.
Long-term morbidity, pain, and disability after repair of severe chest wall injuries
Am Surg
(2009)

There are more references available in the full text version of this article.

Cited by (14)

The Chinese consensus for surgical treatment of traumatic rib fractures 2021 (C-STTRF 2021)
2021, Chinese Journal of Traumatology - English Edition
Citation Excerpt :
Theoretically, thoracoscopic SSRF is superior to thoracotomy of SSRF in the following aspects: a wide surgical field of view, no scapular retraction, no touching on chest wall plate after cortical internal fixation, less structural damage in the pleural cavity, and expanding surgical indications for posterior rib fracture (near the spine). Total thoracoscopic SSRF is clinically applicable, which has been reported in the literature at home and abroad.52–55 In China, the devices and instruments designed for total thoracoscopic SSRF have been developed, by which sufficient reduction and fixation can be achieved.
Rib fracture is the most common injury in chest trauma. Most of patients with rib fractures were treated conservatively, but up to 50% of patients, especially those with combined injury such as flail chest, presented chronic pain or chest wall deformities, and more than 30% had long-term disabilities, unable to retain a full-time job. In the past two decades, surgery for rib fractures has achieving good outcomes. However, in clinic, there are still some problems including inconsistency in surgical indications and quality control in medical services. Before the year of 2018, there were 3 guidelines on the management of regional traumatic rib fractures were published at home and abroad, focusing on the guidance of the overall treatment decisions and plans; another clinical guideline about the surgical treatment of rib fractures lacks recent related progress in surgical treatment of rib fractures. The Chinese Society of Traumatology, Chinese Medical Association, and the Chinese College of Trauma Surgeons, Chinese Medical Doctor Association organized experts from cardiothoracic surgery, trauma surgery, acute care surgery, orthopedics and other disciplines to participate together, following the principle of evidence-based medicine and in line with the scientific nature and practicality, formulated the Chinese consensus for surgical treatment of traumatic rib fractures (STTRF 2021). This expert consensus put forward some clear, applicable, and graded recommendations from seven aspects: preoperative imaging evaluation, surgical indications, timing of surgery, surgical methods, rib fracture sites for surgical fixation, internal fixation method and material selection, treatment of combined injuries in rib fractures, in order to provide guidance and reference for surgical treatment of traumatic rib fractures.
Modifications to the Nuss procedure for pectus excavatum repair: A 20-year review
2018, Seminars in Pediatric Surgery
Citation Excerpt :
The frequency of success using the Nuss procedure (with no additional open or hybrid variant) for repair of recurrent pectus after open Ravitch procedure varies from 29% to 100%, and appears to be dependent on patient factors such as intrathoracic adhesions, chest wall defects, malunion, pseudoarthrosis, chronic pain, and acquired thoracic dystrophy (see Fig. 3).7,33–37 A modification of the Nuss procedure to stabilize flail chest has been reported by multiple authors across the world.56–61 The procedure often involves placing the Nuss bar laterally, rather than in a retrosternal position, although anterior placement has also been reported (Fig. 4).
Addition of Video-Assisted Thoracoscopic Surgery to the Treatment of Flail Chest
2017, Annals of Thoracic Surgery
Video-assisted thoracoscopic surgery (VATS) is increasingly used in chest trauma for diagnostic and therapeutic purposes. In this report we describe our single-institutional experience with VATS in the surgical treatment of patients with flail chest after high-energy trauma.
From January 2013 to July 2014, 15 patients with flail chest after high-energy trauma were treated in our hospital. The Injury Severity Score (ISS) ranged from 16 to 44. Rib fixation was performed with precontoured plates or intramedullary splints. In all, patients we additionally used VATS to explore the thoracic cavity and evacuate any hemothorax.
In 10 patients a prominent hemothorax was present, which needed evacuation. The median operative time was 120 minutes (range, 60 to 180 minutes), with a median blood loss of 150 mL (range, <100 to 400 mL). The mean stay in the intensive care unit was 5.27 days (SD 6.79). Ten patients were extubated directly after operation in the operating room. The other 5 patients were extubated after 1 to 13 days. The mean duration of mechanical ventilation was 2 days (SD 4.17). No patient required a tracheostomy. Three patients had minor postoperative adverse events. All patients were discharged after 6 to 44 days (mean, 11.9 hospitalization days) (SD 9.57).
We believe VATS is effective and safe and can be of additional value by providing the possibility to adjust the planned incision for rib fixation and decrease the area of muscle destruction. Additional pulmonary or mediastinal pathologic conditions can be identified and complete evacuation of hemothorax can be achieved simultaneously.
Chinese consensus on diagnosis and treatment of traumatic rib and sternal fractures
2023, Chinese Journal of Thoracic and Cardiovascular Surgery
Minimally invasive surgery for anterior flail chest injury in the acute phase: series of 10 cases
2023, General Thoracic and Cardiovascular Surgery
Surgical Methods of Chest Stabilization in Multiple Rib Fractures
2023, Russian Sklifosovsky Journal of Emergency Medical Care

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Case reportThoracoscopy-Assisted Minimally Invasive Surgical Stabilization of the Anterolateral Flail Chest Using Nuss Bars

Section snippets

Surgical Technique

Comment

Ann Thorac Surg

Long-term morbidity, pain, and disability after repair of severe chest wall injuries

Am Surg

Case report
Thoracoscopy-Assisted Minimally Invasive Surgical Stabilization of the Anterolateral Flail Chest Using Nuss Bars