Diaphragm resuspension to titanium neo-ribs: A technique for chest-wall reconstruction involving the costal margin

Chest-wall reconstruction with titanium neo-ribs and PTFE to suspend native diaphragm.

Central Message.

Diaphragm resuspension using PTFE mesh over titanium neo-ribs provides adequate chest-wall reconstruction after costal margin resection.

Costal margin resection poses a significant reconstruction challenge. Its resection creates a thoracoabdominal defect with a pleural-peritoneal communication and a detached diaphragm (Figure 1). Thus, the principles of reconstruction are to (1) restore abdominal and chest-wall integrity, (2) separate the peritoneal and pleural cavities, and (3) restore continuity of the diaphragm with the chest wall to potentially preserve diaphragmatic mechanics.

Figure 1.

Chest-wall reconstruction with titanium neo-ribs and polytetrafluoroethylene to suspend native diaphragm.

Although various approaches for chest-wall reconstruction exist,¹ techniques for chest-wall reconstruction involving the costal margin are limited. Our specific technique has not been previously described. Here, we present 2 patients who underwent costal margin resection and describe our technique of diaphragm resuspension to titanium “neo-ribs.”

Case Presentation

Both patients presented with a left-sided chest-wall tumor involving the costal margin. (Figures 2, A, and 3, A). En bloc resection included chest wall, partial diaphragm, and abdominal wall with defects measuring 11 cm × 11 cm and 15 cm × 10 cm in cases 1 and 2, respectively. Because the diaphragm inserts into the costal margin, the limited anterior diaphragm resection left a free edge of diaphragm. The phrenic nerve insertion into the diaphragm was undisturbed and the heart was not exposed. Rigid chest-wall reconstruction was carried out by contouring titanium plates (Synthes), specifically chosen given the ease in contouring them to the chest wall, to create “neo-ribs.” GORE DUALMESH polytetrafluoroethylene (PTFE) was sutured to the free edge of the diaphragm with interrupted No. 0 PROLENE suture and secured to a neo-rib with No. 0 PROLENE to simulate native diaphragm insertion at the costal margin (Figure 2, C). A rigid chest-wall reconstruction was preferred to resuspend the diaphragm to a rigid point to potentially preserve diaphragmatic mechanics. The abdominal fascia was secured to the inferior neo-rib with interrupted No. 0 PROLENE suture. In patient 2, the abdominal fascia would not reach the neo-rib without tension. Therefore, we used a 2-patch technique where the first PTFE mesh bridged the abdominal fascia to the free edge of the diaphragm to separate the pleural and peritoneal cavities. The second PTFE patch resuspended the diaphragm to the neo-ribs (Figure 3, C). Soft-tissue coverage was performed with pectoralis major and rectus muscle advancement flaps. Both patients received a 28-Fr chest tube and two 19-Fr Blake drains in the subcutaneous space.

Figure 2.

A, 8.5- × 2-cm recurrent epithelioid mesothelioma. B, Resection defect. C, Final reconstruction.

Figure 3.

A, 4.3- × 4.2-cm chondrosarcoma. B, Extension of second patch to reconstruct parietal pleura. C, Two-patch method.

Both patients were extubated in the operating room and had uncomplicated postoperative courses. However, both developed delayed chest-wall infection––patient 1 at 1.5 years and patient 2 at 3 months––necessitating removal of prosthetic material. In both cases, tissue capsules had formed and tissues were frozen. At last follow-up (1.8 years and 8 months, respectively) both are well and remain free from visceral or lung herniation. Institutional review board approval was waived, and the patients provided written informed consent for publication.

Discussion

Reconstruction after chest-wall resection involving the costal margin is rarely described. Liu and colleagues² described a reconstruction after lateral thoracoabdominal wall resection in which the diaphragm was sutured to the seventh rib whereas the thoracoabdominal defect was reconstructed with a single polypropylene mesh. This method is unsuitable when the diaphragm cannot reach a native rib.

In cases in which the costal margin is no longer available for anchoring, alternative methods must support diaphragm resuspension. Rathinam and colleagues³ used a Marlex methyl methacrylate sandwich with extension of the mesh leaflets, which were sutured to the abdominal fascia and the diaphragm. However, ideal contouring of methyl methacrylate on the back table is technically challenging.

Our technique incorporates titanium plates for a rigid chest-wall reconstruction with the PTFE mesh to resuspended the diaphragm. This “neocostal margin” restores diaphragm continuity with the chest wall to preserve diaphragm mechanics. Both patients in our series were extubated in the operating room and did not have any respiratory complications.

Although both patients experienced infection requiring prosthesis removal, the underlying tissues were fixed, thus maintaining chest-wall reconstruction principles long term. Synthetic materials, particularly PTFE, carry a high risk of infection. In a 27-year single-center study, 17% of PTFE chest-wall reconstructions experienced infection, and 88% of meshes were explanted.⁴ Polypropylene mesh may have a lower risk of infection and could be a suitable alternative to PTFE.¹

In summary, diaphragm resuspension with PTFE mesh to titanium neo-ribs is a viable option to achieve the principles of chest-wall reconstruction involving the costal margin. Alternate mesh selection may reduce infection risk.

Conflict of Interest Statement

R.F. is supported by an AATS Foundation grant. All other authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.