1. GENERAL THORACIC SURGERY CHAPTER 62
THORACOPLASTY
GENERAL THORACIC SURGERY
CHAPTER 62

2. Thoracoplasty
Operative removal of the skeletal support of a portion of the chest.
Subperiosteal removal of a varying number of ribs segment.
Unsupported portion of chest wall to sink in toward the mediastinum and reduces the size of hemithorax.
At present, thoracoplasty is used in treatment of chronic thoracic empyema without remaining pulmonary tissue to obliterate the pleural space.

3. Operative technique
Conventional thoracoplasty— Standard procedure, Alexander.
One stage for chronic empyema.
Two stage for tuberculosis.

4. Conventional thoracoplasty
Patient in lateral decubitus position, parascapular incision.
Seven ribs are resected (1st to 7th ribs, subperiosteraly,
Division of costotransverse ligment.), allow the scapula and extracostal musculature to drop into the space help to maintain collapse.
Attention– Postoperatively be paid to ensure proper functioning the ipsilateral shoulder girdle.

5. Axillary thoracoplasty
Apical thoracoplasty.
Skin incision as the operation for thoracic outlet syndrome, removed first rib.
Varing portion of 2nd, 3rd, 4th ribs are removed subperiosteraly to obtain the desired degree of collapse to obliterate the residual apical space.
Less traumatic, better tolerated.

6. Thoracomyopleuroplasty
Thoracomediastinal plication.
Only the ribs overlying the empyema space are resected.
Empyema space was entered, debridement, cavity is obliterated by suturing the pleuromusculo-periosteal wall to the mediastinal or visceral pleura.
Wound close without drainage.
Procedure– Much smaller than standard thoracoplasty, well tolerated by poor-risk patient.

7. Plombage thoracoplasty
Foreign body（paraffin, polyethylene bag, fiberglass）was inserted in a space created between the ribs and thoracic fascia
Freed periosteal and intercostals musculature to maintain the optimal collapse.
Contraindicated in management of chronic empyema.
Now be discarded.

8. Schede thoracoplasty
1890.
Radical unroofing the empyema space by resecting the overlying ribs, intercostals bundle, subjacent parietal pleural peel.
Extracostal muscle and skin partially closed over gauze packing at intervals.
Freshly granulating tissue set up an obliterative healing process and eventually close the space.

9. Physiologic changes after thoracoplasty
Related to the development of an area of paradoxic motion of chest wall.
Effort of breathing increase.
Pendelluft （air flow from one lung to the other during ventilatory cycle）occur.
Cough mechanism reduced in effectiveness– As a result of inability to generate a high positive pressure in pleural space– Because of the unsupport portion of chest wall.

10. Physiologic changes after thoracoplasty
Postoperative problems were directly proportional to the number and lenth of the segments of ribs resected.
Skeletal deformity,
Rotoscoliosis,

11. Physiologic changes after thoracoplasty
Lung function test— Loss 27% vital capacity, 21% maximal voluntary ventilation of contralateral lung, 50% loss in both vital capacity, 60% loss in FEV1, 40% loss in total lung capacity.
Sacrifice the intercostals nerve result in paresis of the ipsilateral abdominal wall.

12. Morbidity and Mortality
Morbidity— Related to the type of thoracoplsaty and disease process present. Injury to the nerve during removed first ribs, injury to thoracic duct, septic complication.
Mortality—related to the underlying chronic disease, 5.4%-13%.
Result—failure rate 33% before 1976, 12-17% now.