Completely thoracoscopic surgical stabilization of rib fractures: can it be done and is it worth it?

Abstract

Surgical stabilization of rib fractures (SSRF) is now a common operation at most high-volume trauma centers. Increased experience with the procedure has spawned a variety of technical modifications to minimize incision length, muscle division, scapular retraction, and general tissue trauma. The ultimate example of such a minimally invasive approach is completely thoracoscopic SSRF, which refers to using a video-assisted thoracoscopic surgery (VATS) technique to both reduce and fixate rib fractures in an intra-thoracic fashion. The benefits of thoracoscopic SSRF may be divided broadly into those that relate to the repair of the rib fractures themselves, and those that relate to adjuncts to rib fracture repair. With respect to the former, theoretical benefits include improved visualization of rib fractures (particularly in posterior and sub-scapular locations), minimization of trauma to overlying muscles and nerves, minimization of trauma to intra-thoracic structures, and elimination of palpable plates. With respect to the latter, theoretical advantages include evacuation of retained hemothorax, guided placement of loco-regional anesthesia and chest tubes, and identification and repair of associated, intra-thoracic injuries. A VATS may also aid in trainee education. Despite these theoretical benefits, early attempts at thoracoscopic SSRF have been limited by both user inexperience and inadequate instrumentation. Furthermore, there are currently no data comparing the efficacy of completely thoracoscopic SSRF to either contemporary, minimally-invasive, extra-thoracic SSRF or non-operative management.

Keywords: Thoracoscopy; surgical stabilization of rib fractures (SSRF); video-assisted thoracoscopy surgery (VATS).

Conflict of interest statement

Conflicts of Interest: Dr. FM Pieracci is a paid educator for DePuy Synthes and receives research funding from DePuy Synthes.

Figures

Figure 1

“Extra-thoracic VATS” approach to SSRF. (A) Creation of an extra-thoracic space using balloon dilation; (B) placement of securing of plates on ribs. Reproduced with permission from Merchant and Onugha (5). VATS, video-assisted thoracoscopic surgery; SSRF, surgical stabilization of rib fractures.

Figure 2

Thoracoscopic view of subscapular ribs during a VATS right lower lobe wedge resection. VATS, video-assisted thoracoscopic surgery.

Figure 3

Examples of very posterior fractures. (A) Comminuted, right 7th rib fracture, involving both the neck and tubercle. Note the relationship of the fractures to the overlying T7 right transverse process; (B) comminuted left 4th rib fracture, with medial fracture in proximity to the aortic arch.

Figure 4

Dislodged, palpable anterior plate, placed via extra-thoracic approach, causing patient discomfort and requiring removal. (A) A bulge is visible on physical exam (circle); (B) intra-operative picture of the dislodged plate.

Figure 5

Thoracoscopic infiltration of the extra-pleural space with liposomal bupivacaine.

Figure 6

Theoretical port placement for completely thoracoscopic SSRF of lateral fractures of ribs 6–8. The anterior port will eventually be used to pass the chest tube. SSRF, surgical stabilization of rib fractures.

Figure 7

Intra-thoracic plate placement using a right-angled screw driver.

Figure 8

Post-operative chest XRAY following completely thoracoscopic SSRF of left lateral ribs 6–9. SSRF, surgical stabilization of rib fractures.