Chest Wall surgery

The details of surgery will vary for each person and the cut needed for the operation will depend on what needs to be done during surgery. There are two main parts to the surgery – removal of the disease and providing support for the gap.

Removal of the disease

The tumour or infection is cut out. This may involve lobectomy or wedge resection if the tumour is in the lung. Sections of the ribs, breastbone, spine, muscle or diaphragm may be removed with the lung or on their own if the lung is not affected. We cannot always tell exactly what will need to be done during the surgery until the operation has started but ask your surgeon what they expect will be done. The reason there may be uncertainty is that scans cannot always show whether a tumour is stuck to parts of the body next to it.

Supporting the gap

In some cases, where a gap is small, this can be fixed by stitching the hole back together. Larger gaps cannot be stitched together but not all gaps on the chest would cause a problem. For example if part of a rib is removed underneath the shoulder blade you can still live normally without noticing; the shoulder blade, skin and muscles cover the gap well.

If the gap does need extra support metal plates or plastic meshes may be used to cover the area, your skin and muscles cover over the metal or plastic.

In some cases metal or plastic are not suitable, for example if an infection has been present. Your own muscles and skin can be used to cover the gap, this procedure is known as a flap. The most common types of flap use the large muscle on your side (latissimus dorsi or ‘lats’) or the large muscle on the front of your chest (pectoralis major or ‘pecs’). The muscle is lifted out of its normal position and moved to the area that needs to be covered.

We work in a team with specialist spinal surgeons and reconstructive plastic surgeons to give the best result by sharing expertise. This type of surgery is only done in specialist hospitals.

Recovery is very individual, depending on the operation you have had.

Recovery after removing part of the lung along with sections of rib will be similar to lobectomy, you may even have less pain than expected for this procedure.

Flaps require very close monitoring in the first few days after surgery to check the blood supply is working. You will be kept warm and hydrated, the skin over the flap will be checked regularly. Medications to thin the blood are commonly used to prevent a clot forming in the flap. You will be allowed to move around more gradually to avoid strain on the flap, commonly arm movements need to be limited at first after the operation.

If you have metal or plastic supports you will be monitored closely for any signs of infection, such as fever.

The risks here are a guide; your own risk may vary. You should discuss the risks and benefits of surgery with your surgeon, especially if you are worried.

 General risks of thoracic surgery apply to chest wall surgery. The risk of death from chest wall resection is low: 4 in 1000 (0.4%) nationally, this means 9996 people in 1000 recover from surgery.

In addition, the following are risks of chest wall surgery:

Minor more common risks – if part of the lung is removed

• Air leaking from the lung into the chest drain for a few days is common after lung surgery. Occasionally this lasts for longer, possibly weeks. A chest drain will need to be in place until this settles, you may be able to go home with the chest drain still in and come back for regular check-ups until the air leak settles.
• Your kidneys may not work as well after surgery, but this is usually temporary and gets better with extra fluid.

Major less common risks – if part of the lung is removed

• Some people are more short of breath after surgery. Part of your preop assessment is assessing your risk of being breathless after surgery. If you already have lung disease there is a higher risk of being breathless, including needing to have oxygen at home.

Shortness of breath may severe enough to require help from a ventilator machine. This can be with a face mask with you fully awake. It may also be need via a tube in your windpipe with you under sedation. If you need help breathing via a tube for a long time it may be better to have a temporary tracheostomy. This is a tube put in through the neck which is removed once breathing improves.

• A hole may form near the staples (bronchopleural fistula), this is usually only happens with an infection. It causes air to keep coming out of the lung but can be difficult to diagnose.  You may need antibiotics and another operation to fix the hole.
• Fatty fluid may collect in the chest (chyle leak), it is rare. You may require a temporary change in diet, a chest drain or another operation to treat this.

Specific risks if you have metal or plastic supports

Infection can be serious if you have metal or plastic supports. The metal or plastic may need to be removed in another operation if it becomes infected. This is because the body cannot fight off all the infection when it is on metal or plastic. A long course of antibiotics may be needed.

Specific risks if you have a flap

If the blood supply to flap stops working the flap may fail, we give medications to prevent clots for this reason. Thinning the blood means a higher risk of bleeding which may require another operation to stop the bleeding. If the flap stopped working due to a clot another operation would be necessary to remove the flap and options would be discussed about how else to cover the gap, such as doing another flap from a different part of the body.

This will depend a lot on your own circumstances.

If you do not have cancer you may be content to live with the condition affecting your chest, sometimes people need more time to consider whether surgery is right for them so please take as much time as you need.

If you have cancer and do not want surgery, or are not fit enough to have an operation other options may include:

• Radiotherapy
• Chemotherapy
• Palliative care

It is your choice whether to go ahead with surgery or choose another kind of treatment. We will respect your wishes and support you in choosing the treatment that suits you. You are always welcome to seek a second opinion.