Rib Plating

The patient was correctly identified and brought to the operating room. They were given 2nd generation cephalosporin prophylactic antibiotics. They are on DVT prophylaxis. General anesthesia was administered and the patient was intubated with single lumen ETT. We began with fiberoptic bronchoscopy that revealed minimal secretions and no mucus plugging.

Next, anesthesia changed the ETT to a left sided double lumen ETT. The placement was confirmed with bronchosocpy. The patient was position [left] lateral decubitus on bean bag with table break at the hips. The arms and legs were appropriately padded. The chest was prepped and draped in sterile fashion and an ioban drape was placed.

We began by opening the prior chest tube site and inserting a port. The [] lung was let down. We next made an incision in the [] chest wall and cut down to enter the [] in the area of the fractures. A third port was placed in order to triangulate the area of the fractures.

The hemothorax was evacuated with suction. 

Cryotherapy was then performed using the ArtiCure Cryo Nerve Block system to the 3-9th intercostal spaces in the posterior chest wall.

We then began rib fixation. The fractured ribs were palpated in the posterior-lateral chest wall. Rib fractures [] were identified on palpation and an incision was made longitudinally along this fracture line. We elevated prefascial planes and inserted the Alexis Wound Protector. We were able to perform muscle splitting incisions along the latissimus dorsi and serratus muscles down to the rib fractures. 

We then placed 90mm plates intrathoracially using the Ribfix Advantage system on ribs []. The plates were secured in position to ribs as the fractures were reduced. The plates were palpated as stable. Thoroscopy was used throughout to ensure proper placement of plates.

The Intercostal nerves 7[] were then anesthetized using rib blocks with Exparel.

32F chest tubes were placed. A straight tube was placed inferiorly and posteriorly. A right angle tube was placed superiorly through the prior chest tube site (anterior). The lung was let up and had no leaks visualized.

The chest wall was then closed using 2-0 vicryl for serratus fascia, anterior and posterior latissiumus fascia, subcutaneous tissue. The skin was then closed with 4-0 vicryl and dermabond.

The patient tolerated the procedure well and is extubated in the OR. 

Rib Plating Preferences

• Equipment:

  • Balloon Hassan trocar

  • VATS / thoracotomy instruments

  • ioban

  • two split sheet drapes

  • 18G needle and 10ml syringe

  • 10F drains or red rubber for zimmer intrathoracic plating

• Patient:

  • lateral decubitus with axillary roll and bean bag

  • position lower arm up

  • upper arm on elevated arm board or prepped into field

  • double lumen ETT

  • plan bronchoscopy before or after 

RibFix Titan:

The patient was correctly identified and transferred to the operating room table prone. He was padded and secured in place. General anesthesia was administered. He is on SCDs (no lovenox due to TBI). 

I performed left SSRFs and Dr Ouyang performed right side. See his dictation for that procedure.

An incision was made in the left chest longitudinally along the line of fractures. This line was determined by ultrasound identification of rib fractures. Cauatery was used to dissect down through subcutaneous tissue. The latissimus dorsi muscle was split along its fibers and the area of the 9th rib fracture was identified inferiorly. 

We used the Ribfix Titan system for surgical fixation of fractured ribs. We used a combination of alexis wound retraction and Bookwalter retractor for visualization of accessible fractures 9-6. 

For the 9th rib, the area around the fracture was cleared of tissue, we tried to leave periosteal tissue in place. We then drilled through the rib proximal and distal to the fracture ~1cm. We placed a ribbon retractor through the intercostal space to protect the diaphragm and lung. We then chose a 60mm exxtrathoracic plate. The white lines were placed through the osteotomies. We then pulled the white lines through brining the plate to the rib. Washers were placed over the white lines and fixed onto the black jugerknot lines. The white lines were removed and the black juggerknots were tightened by hand first then with the knot tightener. The rib fracture was stabalized.

For the 8th rib, the area around the fracture was cleared of tissue, we tried to leave periosteal tissue in place. We then drilled through the rib proximal and distal to the fracture ~1cm. We placed a ribbon retractor through the intercostal space to protect the diaphragm and lung. We then chose a 60mm exxtrathoracic plate. The white lines were placed through the osteotomies. We then pulled the white lines through brining the plate to the rib. Washers were placed over the white lines and fixed onto the black jugerknot lines. The white lines were removed and the black juggerknots were tightened by hand first then with the knot tightener. The rib fracture was stabalized.

For the 7th rib, the area around the fracture was cleared of tissue, we tried to leave periosteal tissue in place. We then drilled through the rib proximal and distal to the fracture ~1cm. We placed a ribbon retractor through the intercostal space to protect the diaphragm and lung. We then chose a 60mm exxtrathoracic plate. The white lines were placed through the osteotomies. We then pulled the white lines through brining the plate to the rib. Washers were placed over the white lines and fixed onto the black jugerknot lines. The white lines were removed and the black juggerknots were tightened by hand first then with the knot tightener. The rib fracture was stabalized.

For the 6th rib, we made a separate muscle splitting incision through the latissimus. The area around the fracture was cleared of tissue, we tried to leave periosteal tissue in place. We then drilled through the rib proximal and distal to the fracture ~1cm. The distal drill was placed through a separate skin stab incision. We placed a ribbon retractor through the intercostal space to protect the diaphragm and lung. We then chose a 60mm exxtrathoracic plate. The white lines were placed through the osteotomies. We then pulled the white lines through brining the plate to the rib. Washers were placed over the white lines and fixed onto the black jugerknot lines. The white lines were removed and the black juggerknots were tightened by hand first then with the knot tightener. The rib fracture was stabalized.

The thoracic cavity was irrigated with saline through the small intercostal incisions. I was not able to see or feel the chest tube on this side. The prior chest tube was left in place. 

We then began cryablation with the ArtiCure cryo nerve block. This was done posterior to the rib plating but at least 4cm from the spine. We ablated intercostal nerves 9-4 on the left. 

The wounds were irrigated and closed in layers with 2-0 vicryl, 3-0 vicryl, followed by 4-0 monocryl for skin. Wound was dressed with dermabond.