Approach to Posterior Lateral Thorax for Excision of Ribs

Position

  • prone on operating table
  • position bolsters longitudinally on either side of patient from ASIS to shoulders
    • chest expansion

Landmarks

  • ribs

Incision

  • midline longitudinal incision centred over most prominent apical rib
  • Start
  • End

Internervous Plane

  • Trapezius
    • Spinal accessory nerve
  • Latissimus dorsi
    • Thoracodorsal nerve

Superficial Dissection

  • Continue incision down to fascia
  • Using retractors to retract skin & fasica laterally at least 12 cm from midline

Deep Dissection

  • Identify lateral border of trapezius & retract it medially
  • Identify the thoracolumbar fascia & latissimus dorsi
    • Incise medially border & retract laterally
  • Split iliocostalis muscles longitudinally over each involved rib that is being removed
  • Incise periosteum in line with each rib
    • Strip the intercostal muscles subperiosteally to expose the rib
  • Ask anaesthetist to stop the patient’s breathing the lung before excising ribs

Dangers

  • Neurovascular bundle
    • Lower edge of each rib
  • Pneumothorax
    • Treatment: chest tube
  • Haemothorax
    • Chest tube