Incision: An incision is made over rib of the
corresponding vertebrae. The ribs can be counted from above downwards or vice versa. While counting from up it must be remembered
that the first rib appears inside the second and is difficult to trace.
The skin and sub cutaneous tissue is opened over
the rib and the muscles are cut using an electro cautery to achieve hemostasis. The rib is dissected sub periosteally using
a periosteal elevator. The intercostals nerves present inferior to rib should be preserved. The rib can then be disarticulated
from the transverse process of the corresponding vertebrae or it can be cut at point between the costotransverse joint and
angle of the rib. The rib may be preserved for later use as bone graft. The bone wax applied at ends helps to control bleeding.
The Parietal pleura can be seen below the rib bed after the inner periosteum is opened. The parietal pleura can be opened
and reflected off spine, the lungs can be retracted medially with retractors. Ocassionally adhesions present between the pleura
and lung may need to be bluntly dissected with a finger. The retraction of lung should be left off every half hour so as to
allow the lung expansion and prevent postoperative atelectasis.
The parietal pleura covers the spine and surrounding
structures and can be opened with help of scissors, after this it can be reflected off the vertebral bodies and discs using
The disc, the intercostals artery and the vein
can be identified at this point. The intercostals vessels can be isolated, and cut between the ligatures. It is preferable
to tie and cut these vessels a little away from aorta so as to avoid the injury to aorta while clamping the vessels.
The periosteal elevator is then used to elevate
the soft tissue and expose the disc and the vertebral body. If the access to the posterior disc space and spinal canal is
inadequate, the rib head can be resected to increase the exposure.
Before closing it is important to ensure that
entire lung is fully expanded. The parietal pleura should be closed over the spine. The chest is closed over a chest tube.
The ribs may be approximated using a strong non-absorbable suture like Dacron.
Injury to intercostals vessels.
Lung contusion/ injury.
Injury to azygos vein.
Injury to Aorta.
Uncontrolled Hemorrhage from segmental vessels.
Postoperative Lung atelectasis.
Injury to thoracic duct/ chylothorax.
Injury to long thoracic nerve.