Chest Wall Resection
What the Examiner Expects
Full-thickness resection of the chest wall including ribs, intercostal muscles, and potentially the underlying pleura, performed for primary chest wall tumors or en bloc resection of invasive thoracic malignancies. The examiner expects you to know that chondrosarcoma is the most common primary malignant chest wall tumor (arising from costal cartilage), that wide resection with 2 cm margins is the standard, and that reconstruction depends on defect size and location. Defects involving more than 2 ribs or > 5 cm in diameter require rigid reconstruction (methyl methacrylate sandwich between Marlex mesh, or Gore-Tex patch) to prevent paradoxical chest wall motion and respiratory compromise.
Key Examiner Focus Points
- Indications: primary chest wall tumors (chondrosarcoma most common), locally invasive lung/breast cancer
- Must achieve wide margins (≥ 2 cm) for sarcomas
- Reconstruction required for defects > 5 cm or > 2 ribs: prosthetic mesh (Marlex/Gore-Tex) + soft tissue coverage
- Posterior defects covered by the scapula may not need rigid reconstruction
- Soft tissue coverage: latissimus dorsi, pectoralis major, serratus anterior, or omental flap
Common Curveballs
The tumor involves the sternum
Sternal resection and reconstruction is feasible but complex. Reconstruction options include titanium plates, methyl methacrylate, or mesh-cement sandwich technique. Soft tissue coverage typically requires bilateral pectoralis advancement or rectus abdominis flap. These are best performed at specialized centers.
Postop the patient develops respiratory failure from paradoxical chest wall motion
Inadequate rigid reconstruction of a large anterior/lateral defect. May require ventilatory support (positive pressure ventilation stents the defect). If mechanical support is insufficient, revision surgery to add rigid fixation may be needed.