Operative Techniques for Thoracic Wall and Lung Hernias

j. neill¹, M. Martin², S. M. Atay^3
1LAC USC Medical Center, Los Angeles, California ²University of Southern California, San Diego, California ³University of Southern California, Keck School of Medicine, Los Angeles, California

Please explain the educational or technical point that this video addresses.: Thoracic wall hernias (TWH) are uncommon, but may be seen after any thoracic surgery or major chest trauma. Additionally, there have not been studies to evaluate differences in surgical repair methods or materials/meshes to determine a “gold standard”. As a result of the paucity of literature and experience with TWH, as well as the lack of any procedural guidelines or videos, decisions around management and techniques for surgical repair can be extremely challenging. As such, this is still an area of growing knowledge that requires further research with larger study populations.
Effective repairs require a case-by-case approach. However, this video will provide insight into various techniques surgeons can implement for these challenging thoracic wall pathologies.

Please provide a 250 word summary of the surgical video being submitted.: TWH are a unique challenge to thoracic surgeons in terms of the evaluation, initial management, and approach to repair. The video presents a case series, reviewing
three TWH ranging from low to high grade and will highlight the approach to preoperative evaluation and radiologic imaging evaluation. The video will include coverage of the key items to consider during the evaluation and preoperative planning phase, and how these will impact the choice of the surgical approach and repair technique. In the first case, footage from the operative repair of a recent incisional TWH involving the right lung will be included, and will detail the step-by-step approach to exposure, hernia reduction, and repair utilizing a “double-mesh sandwiching” reconstruction technique. The second case provides pre-operative and post-operative photographs and imaging to demonstrate a case in which plating was required due to extensive damage to the rib cage. In the third case, we evaluate pre-operative and post-operative imaging of a repair in which a biologic mesh was used, thus differentiating it from the previous two cases. Finally, we review a proposed grading system for these chest wall hernias from 2018 with an associated suggested repair for each grade.