Comparison of the clinical effect between the lower sternal incision and the left parasternal fourth intercostal incision in the transthoracic closure of ventricular septal defect.

BACKGROUND: To analyze the clinical effect of two different ways of minimally invasive transthoracic closure in children with ventricular septal defect (VSD). METHODS: From January 2015 to July 2019, 294 children with VSD were enrolled in the Fujian Medical University Union Hospital. Patients were divided into two groups - those who underwent VSD closure through the left sternal fourth intercostal incision (group A: n = 95) and the lower sternal incision (group B: n = 129). RESULTS: The operation time, bleeding volume, postoperative mechanical ventilation time, postoperative intensive care unit (ICU) monitoring time, postoperative hospitalization time and complication rate in group A were significantly lower than those in group B (P < 0.05). There was no significant difference between the two groups in the operation success rate, mechanical ventilation time and total hospitalization cost (P > 0.05). CONCLUSION: The transthoracic closure of ventricular septal defect through the left sternal fourth intercostal incision is feasible, safe, cosmetic, and worth popularizing.

Muscle-sparing thoracotomy: Anatomy and technique.

The thoracotomy incision is essential for many thoracic surgery procedures. A number of different variations exist, and different techniques can be used, depending both on the patient and on the technical factors. The muscle-sparing technique was first described by Noirclerc et al. in 1973. [1] Initially, it was thought that preservation of the muscular structures compared with the results of a traditional posterolateral thoracotomy, in which the latissimus dorsi and sometimes the serratus anterior are often divided, would benefit long-term outcomes.  However, subsequent study results  have not demonstrated any difference in postoperative outcomes. The unequivocal benefit of a muscle-sparing approach is to preserve the latissimus dorsi for any future intervention, such as a procedure involving the chest wall and the intrathoracic flaps. In this video tutorial, we describe our approach to this commonly used incision, including the anatomy and the technical aspects used to provide optimal operative exposure and minimal postoperative complications while preserving the underlying musculature.

Use of a skin perforator flap pedicled by the intercostal muscle for reconstruction of a posterior cervical defect.

A posterior cervical defect featuring exposed spinal and occipital bone can be covered in various ways. The "ideal" flap should be a low-morbidity, pedicled locoregional flap that can reach the occiput. Cervical adjuvant radiation therapy may limit the coverage options, because many pedicles are located in areas that are often irradiated. Here, we describe a new surgical technique; we used a skin perforator flap pedicled by the intercostal muscle to cover a posterior cervical defect in a patient with metastatic squamous cell lung carcinoma. This technique is a valuable option; the flap originated from outside the irradiated area and reached the occiput. It adds to the options for cervical coverage in patients who require head-and-neck reconstruction. EVIDENCE-BASED MEDICINE: Level V: opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Ultrasound versus manipulation to determine an intercostal space for single-port thoracoscopy surgery: a diagnostic accuracy study.

BACKGROUND: Malposition of the intercostal space used for single-port thoracoscopy surgery can lead to problems. This study was to assess the accuracy of point-of-care ultrasound in verifying the position of intercostal space. METHODS: A total of 200 patients, ASA (American Society of Anesthesiologists) physical status I or II, who underwent single-port thoracoscopic lobectomy, were enrolled. After the induction of anesthesia, a thoracic team confirmed the incision position. Firstly, the intercostal space was located by a young resident thoracic surgeon by ultrasound. Secondly, the intercostal space was located by an experienced thoracic surgeon by manipulation. Finally, the investigator verified the location of the intercostal space under direct vision through thoracoscopy, which was recognized as standard method. The time required by ultrasound and manipulation were recorded. RESULTS: The inter-relationships between ultrasound and the standard method and between manipulation and the standard method were consistent. Manipulation positioning showed a sensitivity of 90.6% and specificity of 30% while ultrasound positioning showed a sensitivity of 87.1% and specificity of 60%. The specificity of ultrasound positioning was higher than that of manipulation position. The time required by ultrasound was shorter than that required by manipulation. CONCLUSIONS: Compared with the manipulation method, the ultrasound-guided method could accurately locate the intercostal space. Ultrasound requires less time than manipulation. TRIAL REGISTRATION: ISRCTN10722758. Registered 04 June 2019.

Post-traumatic intercostal and diaphragm hernias following a sneezing episode.

Trauma and sneeze-induced or cough-induced intercostal and diaphragm hernias are both rare phenomena, especially in combination. Management of these hernias is not well described, and there is no good evidence to guide operative management. Here we describe a rare presentation of coexisting intercostal and diaphragm hernias and surgical management with primary repair via a thoracotomy.

The ideal intercostal space for internal mammary vessel exposure during total rib-sparing microvascular breast reconstruction: A critical evaluation.

BACKGROUND: Total rib-preserving free flap breast reconstruction (RP-FFBR) using internal mammary vessel (IMV) recipients usually involves vessel exposure in the second or third intercostal spaces (ICS). Although the third one is more commonly used, no direct comparisons between the two have hitherto been performed. OBJECTIVES: To compare the in-vivo topography and vascular anatomy of second and third ICSs in patients undergoing FFBR using the rib-preservation technique of IMV exposure. METHODS: An analysis of prospectively collected data on intercostal space distance (ISD), number and arrangement of IMVs, location of venous confluence, and vessel exposure time was conducted on a single surgeon's consecutive RP-FFBRs. RESULTS: A total of 296 RP-FFBRs were performed in 246 consecutive patients. The second, third, or both second and third spaces were utilized in 282, 28, and 22 cases, respectively. The ISDs were 20.6 mm ±â€¯3.52 for the second ICS and 14.0 mm ± 4.35 for the third ICS (p<0.0001, CI = 5.17-7.97, t-test). The second versus third ICS vein content was as follows: single 81.4% vs. 74%, dual 18.6% vs. 26%, and confluence 3.7% vs. 13%. The second ICS single vein was medial to the artery in 92.6%. The third ICS single vein was medial to the artery in 88.2% Vessel exposure times for second (47.2 mins ±â€¯26.7) and third (46.5 mins ±â€¯31.4) spaces were similar (p = 0.93). The overall intraoperative anastomotic revision rate was 9.1%, and the postoperative flap re-exploration rate was 4.0%, with 99.7% overall flap success. DISCUSSION AND CONCLUSION: Preferential use of the second ICS is supported by its more predictable vascular anatomy, a broader space for performing the microanastomoses and a higher frequency of a single postconfluence (and thus larger) vein facilitating the microsurgery.

Unifying classification for transdiaphragmatic intercostal hernia and other costal margin injuries.

OBJECTIVES: Taxonomy of injuries involving the costal margin is poorly described and surgical management varies. These injuries, though commonly caused by trauma, may also occur spontaneously, in association with coughing or sneezing, and can be severe. Our goal was to describe our experience using sequential segmental analysis of computed tomographic (CT) scans to perform accurate assessment of injuries around the costal margin. We propose a unifying classification for transdiaphragmatic intercostal hernia and other injuries involving the costal margin. We identify the essential components and favoured techniques of surgical repair. METHODS: Patients presenting with injuries to the diaphragm or to the costal margin or with chest wall herniation were included in the study. We performed sequential segmental analysis of CT scans, assessing individual injury patterns to the costal margin, diaphragm and intercostal muscles, to create 7 distinct logical categories of injuries. Management was tailored to each category, adapted to the individual case when required. Patients with simple traumatic diaphragmatic rupture were considered separately, to allow an estimation of the relative incidence of injuries to the costal margin compared to those of the diaphragm alone. RESULTS: We identified 38 patients. Of these, 19 had injuries involving the costal margin and/or intercostal muscles (group 1). Sixteen patients in group 1 underwent surgery, 2 of whom had undergone prior surgery, with 4 requiring a novel double-layer mesh technique. Nineteen patients (group 2) with diaphragmatic rupture alone had a standard repair. CONCLUSIONS: Sequential analysis of CT scans of the costal margin, diaphragm and intercostal muscles defines accurately the categories of injury. We propose a 'Sheffield classification' in order to guide the clinical team to the most appropriate surgical repair. A variety of surgical techniques may be required, including a single- or double-layer mesh reinforcement and plate and screw fixation.

Subxiphoid versus lateral intercostal approaches thoracoscopic thymectomy for non-myasthenic early-stage thymoma: A propensity score -matched analysis.

BACKGROUND: Thymectomy is increasingly being performed via minimally invasive approaches. The present study aimed to assess the safety and feasibility of the subxiphoid approach to video-assisted thoracic surgery (VATS) compared with the lateral intercostal approach VATS. METHODS: Patients who underwent VATS thymectomy via subxiphoid and lateral intercostal approaches in our hospital between 2015 and 2018 were retrospectively analyzed. A series of perioperative outcomes, including clinical and surgical results, postoperative pain scores and cosmetic results, was compared in a propensity score matching analysis. RESULTS: A total of 98 patients diagnosed with non-myasthenic early-stage thymoma underwent complete thymectomy by VATS. Propensity score analysis revealed that 28 patients treated with the subxiphoid approach and 28 patients treated with the lateral intercostal approach had the same baseline characteristics. Compared with those in the lateral intercostal approach group, patients in the subxiphoidapproach group yielded lower pain scores and shorter postoperative hospital stays. Other advantages of the subxiphoid approach included decreased inflammatory cytokine response and superior cosmesis. There were no significant differences in postoperative complications between the two groups. All these patients recovered well when discharged. There were no perioperative deaths. CONCLUSIONS: Our data suggest that subxiphoid and subcostal arch thoracoscopic radical thymectomy is a less invasive procedure for the treatment of non-myasthenic early-stage thymoma and provides a satisfactory cosmetic effect. Owing to the limitation ofour retrospective study, further prospective studies are needed to evaluate long-term and oncologic outcomes of subxiphoid approach VATS thymectomy.

Laparoscopic IPOM repair of an acquired abdominal intercostal hernia.

Acquired abdominal intercostal hernia (AAIH) is an infrequent occurrence whereby intra-abdominal contents herniate into intercostal space directly from the peritoneal cavity through an acquired defect in the abdominal wall musculature and fascia. These hernias are difficult to diagnose and should always be suspected when a chest wall swelling occur after major or minor trauma. Surgical repair is warranted in symptomatic patients. The majority of AAIHs are repaired through an open approach using tension-free mesh, with significant recurrence risk. Recently, laparoscopic and robot-assisted repairs have been proposed. We discuss a 49-year-old man presented through outpatient setting with a 5-year history of ongoing left subcostal discomfort and a reducible lump. His history included a workplace accident 5 years ago. Contrast-enhanced abdominal CT confirmed AAIH with omentum herniation into the sac. A successful laparoscopic repair with intraperitoneal onlay mesh technique using composite mesh was performed.

Indocyanine green fluorescence/thermography evaluation of intercostal muscle flap vascularization.

BACKGROUND: During anatomical lung resection in high-risk patients, the bronchial stump is covered with tissue flaps (e.g. pericardial fat tissue and intercostal muscle) to prevent bronchopleural fistula development. This is vital for reliable reinforcement of the bronchial stump. We evaluated the blood supply of the flap using indocyanine green fluorescence (ICG-FL) and thermography intraoperatively in 27 patients at high risk for developing a bronchopleural fistula. METHODS: Before reinforcing the stump with a flap, the fluorescence agent was intravenously injected and the blood supply was evaluated. The surface temperature of the flap was measured with thermography. The two modalities were then compared. RESULTS: ICG-FL intensity and surface temperature on the distal compared to the proximal side of the flap decreased by 32.6 ± 29.4% (P < 0.0001) and 3.5 ± 2.0°C (P < 0.0001), respectively. In patients with a higher ICG-FL intensity value at the tip than the median, the surface temperature at the tip decreased by 2.7 ± 1.7°C compared to the proximal side. In patients with a lower ICG-FL value at the tip, the surface temperature decreased by 4.6 ± 1.7°C (P = 0.0574). The bronchial stump reinforced the part of the flap with adequate blood supply; none of the patients developed a bronchopleural fistula. CONCLUSIONS: ICG-FL confirmed variation in the blood supply of the intercostal muscle flap, even if prepared using the same surgical procedure. Thermography analysis tends to correlate with the fluorescence method, but may be influenced by the state of flap preservation during surgery.

A Single Intercostal Space Thoracoscopic Approach for Minimally Invasive Ivor Lewis Esophagectomy.

OBJECTIVE: We present a laparoscopic and single intercostal space thoracoscopic approach (SICS group) for Ivor Lewis minimally invasive esophagectomy (MIE) and provide postoperative analgesia with a continuous multiple intercostal nerve blocking technique. The characters of this technique are evaluated. MATERIALS AND METHODS: From October 2015 to April 2016, 18 consecutive patients with esophageal cancer were treated with Ivor Lewis MIE by a SICS group. Moreover, from July 2014 to September 2015, 48 patients with esophageal cancer received Ivor Lewis MIE by four-port video-assisted thoracic surgery (VATS) approach. Among those patients, by using propensity-score matching, 18 matched patients who underwent four-port VATS MIE (four-port group) were retrospectively selected for further statistical analysis. Patient demographics, short-term postoperative outcomes were recorded. RESULTS: None of the patients in the SICS group required conversion to an open procedure. No failure of the intrathoracic esophagogastrostomy occurred. No perioperative mortality or readmission was observed in this series. No patient suffered from anastomotic leak or complained remarkable dysphasia during follow-up. SICS group had a shorter duration of both docking procedure and closure of chest incisions compared with four-port group. The visual analog scale (VAS) pain scores on 24 hours after surgery was significantly lower in SICS group than in four-port group, while the values on 6 hours were comparable. The level of creatine kinase on postoperative day (POD) 1 was significantly lower in SICS group than in four-port group. CONCLUSION: Single intercostal space thoracoscopic procedure is safe and technically feasible and can therefore be viewed as an attractive alternative approach for performing Ivor Lewis MIE.

Stabilization of multiple rib fractures in a canine model.

BACKGROUND: Operative stabilization is frequently used in the clinical treatment of multiple rib fractures (MRF); however, no ideal material exists for use in this fixation. This study investigates a newly developed biodegradable plate system for the stabilization of MRF. METHODS: Silk fiber-reinforced polycaprolactone (SF/PCL) plates were developed for rib fracture stabilization and studied using a canine flail chest model. Adult mongrel dogs were divided into three groups: one group received the SF/PCL plates, one group received standard clinical steel plates, and the final group did not undergo operative fracture stabilization (n = 6 for each group). Radiographic, mechanical, and histologic examination was performed to evaluate the effectiveness of the biodegradable material for the stabilization of the rib fractures. RESULTS: No nonunion and no infections were found when using SF-PCL plates. The fracture sites collapsed in the untreated control group, leading to obvious chest wall deformity not encountered in the two groups that underwent operative stabilization. CONCLUSIONS: Our experimental study shows that the SF/PCL plate has the biocompatibility and mechanical strength suitable for fixation of MRF and is potentially ideal for the treatment of these injuries.

Intercostal muscle flap and intracostal suture to reduce post-thoracotomy pain.

BACKGROUND: Thoracotomy is considered to be the most painful surgical access, the main culprit being intercostal nerve injury. Despite the use of many techniques, this remains a major problem, pointing towards prevention as a better strategy. The effect of protecting both the upper and lower intercostal nerves during surgery has attracted many researchers. METHOD: A prospective study spanning 15 months was undertaken in 48 patients randomized to a conventional group (n = 25) and a study group (n = 23). Pericostal sutures in the former and intracostal sutures in the latter were used for closure. An intercostal muscle flap was harvested at the start of the operation in the study group only. The groups were comparable in terms of baseline characteristics. With a similar pain protocol, pain scores and analgesic consumption were recorded and analyzed. RESULTS: Times for pedicle harvest, intracostal suture, and pericostal suture were 5.2 ± 1.56, 3.65 ± 0.71, and 6.4 ± 1.20 min, respectively, in the study group. Total operative time was similar in both groups. Postoperative pain scores and the overall frequency of pain were consistently lower in the study group. CONCLUSION: these techniques lead to a reduction in the acute and chronic post-thoracotomy pain, without increasing complications.

A new suture technique avoids rib fractures and intercostal nerve trauma in thoracotomy.

This article describes an alternative suture technique for thoracotomy incisions. A modified mattress suture technique is used to fix the intercostal muscles. The described technique can prevent rib fractures and reduce the incidence of intercostal nerve injury. Also, this technique is easy to perform and is effective.

Acquired abdominal intercostal hernia: case report and systematic review of the literature.

PURPOSE: The protrusion of abdominal viscera through an intercostal space under an intact diaphragm is a very rare condition. The aim of this study is to elucidate the etiology, clinical features, and therapeutic options on what several authors call "abdominal intercostal hernia" (AIH). METHODS: A typical case of AIH of the 9th left intercostal space in a 48-year-old man is presented. A literature search was conducted on the Medline and Scopus databases. Only acquired AIHs (AAIHs) were considered, while lung, transdiaphragmatic, and congenital intercostal hernias were excluded. RESULTS: Eighteen studies met selection criteria and a total of 20 patients were useful for analysis. Etiology was related mainly to traumatism (65 %) or to previous surgery (20 %). The intercostal defects were mostly located under the 9th rib without significant differences as to side. The main symptom was chest swelling (85 %), often associated with discomfort or pain (76 %). Acute complications such as incarceration and strangulation occurred in three patients. CT was the most employed diagnostic tool (80 %). Early diagnosis was made in 25 % of cases. Seventeen patients underwent hernia repair with either open (73 %) or laparoscopic approach (28 %), and various techniques with and without prosthesis were described. Recurrence occurred in 28.6 % of patients, during a mean follow-up of 8.6 months. CONCLUSIONS: AAIH should be always suspected when chest swelling occurs after a minor or major trauma, and CT must be promptly performed to rule out diaphragmatic or abdominal viscera injury. This condition requires surgery to prevent serious complications, the first-choice technique should be mesh tension-free repair.