The Institute of Chest Wall Surgery
The Third Surgery for A 60-year-old Patient with Chest Wall Infection
Medical History
The patient is a 60-year-old male who has undergone two surgeries due to chest wall infection. In 2015, the patient underwent a decortication procedure for empyema. However, his incision did not heal properly after the surgery and persistently oozed pus, causing him great pain. In 2017, to treat the recurring chest wall infection, he underwent a second operation. Regrettably, the incision once again failed to heal and continued to ooze pus.
Preoperative Examination
A 30-centimeter-long scar from previous surgeries is present on the right chest wall, with two areas of ulceration—one near the xiphoid process and the other along the anterior axillary line—both of which oozing pus. A part of the right pleura thickens, and the sixth rib has deformed and fused with the seventh rib. Additionally, structural change is observed in the right costal arch. The patient was conclusively diagnosed with chest wall infection after chest wall surgery.
Surgical Steps
1. An incision was made along the previous scar, and two fusiform incisions were performed around the wound dehiscences. The focus of infection was observed within the chest wall and was limited in extent, with visible necrosis to varying degrees on the right chest wall, including the 5th, 6th, and 7th ribs, the right costal arch, and the lower part of the sternum.
2. Parts of the right 5th, 6th, and 7th ribs, the costal arch, and the sternum were surgically removed to thoroughly clear all potentially necrotic bone structures.
3. The right diaphragm was elevated and sutured to the 4th rib.
4. The drainage tubes were placed in the wound, and the other incisions were sutured, marking the end of the surgery.
Related Photos
Surgical Analysis
Due to this patient's long medical history, although the visible lesion appears localized, the underlying lesions are considerably larger in scope. The infected regions involve the 5th, 6th, and 7th ribs, the intercostal muscles, the costal arch, and the lower part of the sternum. If these potential lesions are not completely removed, the incisions may initially heal but are likely to rupture and ooze pus again. Thus, the surgical approach involved not only excising the lesions but also extensively removing all necrotic tissue to ensure a successful outcome.
Significant removal of bone structure can result in chest wall defect. Large defect typically requires chest wall reconstruction. However, reconstruction involves the use of synthetic materials, which could potentially interfere with the healing of the surgical site. Therefore, reconstruction was not performed in this case. Chest wall defects, however, could lead to abnormal breathing, which may even impair the patient’s respiratory function. To avoid this situation, the diaphragm was artificially lifted upwards to bring it as close as possible to the 4th rib, thereby strengthening the chest wall at the defect and preventing abnormal breathing after the surgery.