Chest Wall Resection and Reconstruction for Ewing’s Sarcoma of the First Rib

J. Choi, S. Bramer, S. Begum
Royal Brompton Hospital, London, England

Please explain the educational or technical point that this video addresses.: This video shows a complex resection and reconstruction of Ewing's sarcoma of the 1st rib. It demonstrates how multidisplinary team working can result in an excellent resection and preservation of vital anatomical structures. It demonstrates very clearly how to access the tumour via an appropriate incision, how to safely perform the chest wall resection and how to preserve vascular and nerve structures. A particular highlight is an easily reproducible technique for chest wall reconstruction with mesh that results in excellent tension and can be taught to trainees. It also addresses one example of a muscle flap reconstruction for an anterior chest wall resection.

Please provide a 250 word summary of the surgical video being submitted.: We present the case of a 14 year old child initially presenting with a 3 to 4 week history of a cough, increasing dyspnoea and right shoulder discomfort. Imaging showed a large right sided chest wall mass. A biopsy showed a Ewing’s sarcoma. He underwent chemotherapy and had good response. Imaging post chemotherapy showed good response to treatment with a marked reduction in the size.

We made a supraclavicular, median and anterior thoracotomy incision. The second rib was divided laterally. The suprasternal notch to the top of the sternal body was divided with an oscillating saw.

The vascular structures of the superior mediastinum and base of the neck were dissected to access the tumour and the first rib. The subclavian artery, vein and their tributaries were slung. The phrenic nerve was preserved. The clavicle was divided with an oscillating saw at the lateral two thirds. The first rib was dissected and disarticulated from the T1 vertebra.

The underlying defect was measured. First, the plastic surgeons raised a pectoralis muscle flap. Interrupted 1 prolene sutures were placed around the chest wall defect with the aid of a rib punch. Guiding markers were drawn on to the mesh with a surgical marker pen. This allowed easy and exact placement of the sutures and gave excellent, even tension across the mesh. The most superior portion of the mesh was stitched to the muscle layer. The chest wall was then reconstructed with the pectoralis flap and the skin closed over the flap.