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The Extra-Pleural and Pleural Spaces, including Plombages, Pleural Tumours and the Effects of Asbestos.
Published in Fred W Wright, Radiology of the Chest and Related Conditions, 2022
Im et al. (1989) used HRCT to study the posterior costal pleura in normal subjects, cadavers and persons who may have been exposed to asbestos. They found in normal subjects, a 1 to 2 mm thick line of soft tissue (the 'pleuralline') at the point of contact between the lung and chest wall, representing the visceral and parietal pleura, pleural contents, endothoracic fascia and the innermost part of the intercostal muscle. They pointed out that paravertebrally there is no intercostal muscle, and the thin line here represents pleura and endothoracic fascia. Transverse muscle slips lie anteriorly, subcostal muscle slips inferiorly, and extrapleural fat pads posteriorly, where a thin layer of fat is usually thicker posteriorly than anteriorly - this lies internal to the ribs. When mild pleural thickening is present, the pleura is normally separated from the muscle by a thin layer of extra-pleural fat.
Chest wall deformities
Published in Mark Davenport, James D. Geiger, Nigel J. Hall, Steven S. Rothenberg, Operative Pediatric Surgery, 2020
Robert E. Kelly, Marcelo Martinez-Ferro, Horacio Abramson
Repair of the bifid sternum is best performed through a longitudinal incision extending the length of the defect (Figure 20.39a). Directly beneath the subcutaneous tissues, the sternal bars are encountered. The pectoral muscles insert lateral to the bars (Figure 20.39b). The endothoracic fascia is mobilized off the sternal bars posteriorly with blunt dissection to allow safe placement of the sutures (Figure 20.39c). In many cases, excision of a wedge of cartilage from the most inferior portion of the defect will facilitate approximation of the two sternal halves during suture closure. Closure of the defect is achieved with 2/0 Tevdek or PDS sutures (Figure 20.39d).
Spine
Published in Bobby Krishnachetty, Abdul Syed, Harriet Scott, Applied Anatomy for the FRCA, 2020
Bobby Krishnachetty, Abdul Syed, Harriet Scott
Endothoracic fascia divides the thoracic paravertebral space into an anterior subserous compartment and a posterior subendothoracic compartment. Neural tissue surrounded loosely by areolar and adipose tissueSpinal nerves: with white and grey rami communicantesSympathetic chain: lies at the neck of the rib anterior to the intercostal neurovascular bundle
“Undercutting of the corresponding rib”: a novel technique of increasing the length of donor in intercostal to musculocutaneous nerve transfer in brachial plexus injury
Published in British Journal of Neurosurgery, 2023
Kuntal Kanti Das, Jeena Joseph, Jaskaran Singh Gosal, Deepak Khatri, Pawan Verma, Awadhesh K Jaiswal, Arun K Srivastava, Sanjay Behari
The patient was placed in a supine position with the arm abducted 50-60 degree. A roll was placed beneath the ipsilateral back and shoulder provided a good platform to work. The incision extended along the anterior axillary fold to the lower edge of the pectoralis major muscle and curved towards the xiphisternum. This is fairly a standard procedure in the literature as well as our institute. Elevation of the skin flap, retraction of the pectoralis major and identification of ribs 3rd to 5th by following the attachment of pectoralis minor was performed in a standard way. Using the standard technique, we then exposed the rib and then identified the intercostal nerve after opening the posterior periosteum, over the transparent endothoracic fascia. The nerve was then dissected out and looped (Figure 1(A,B)). The nerves were dissected till the costochondral junctions distally. Proximally, the dissection proceeded till the serratus anterior digitations.
Extrapleural pneumonectomies for pleural mesothelioma
Published in Expert Review of Respiratory Medicine, 2020
Eleonora Faccioli, Alice Bellini, Marco Mammana, Nicola Monaci, Marco Schiavon, Federico Rea
As far as surgical treatment is concerned, according to the European Society for Medical Oncology (ESMO) guidelines, the indications for surgery in MPM are: a) for palliation of pleural effusion, when chest tube drainage is not successful, b) to obtain diagnostic samples of tumor tissue and to stage the patient, c) as part of a multimodality treatment, in the setting of a clinical study, d) to perform a macroscopic complete resection [14]. The two main surgical techniques are extra-pleural pneumonectomy and pleurectomy/decortication (P/D). Currently, there is no evidence in the literature to suggest the superiority of one operation over the other; therefore, the decision on which procedure to perform is based more on the preference of the surgeon than on scientific data [15].EPP involves an en-bloc resection of the lung, parietal pleura, hemi-pericardium, and diaphragm, leaving as interface with the disease only the endothoracic fascia and the mediastinum. A complete nodal dissection is considered an integral part of the operation [16]. It was originally reported as a procedure for the management of tuberculosis infections not amenable to other treatments [17], and only in 1976, it was adopted for the treatment of MPM [18]. Over time, some evidence suggested that EPP in conjunction with chemotherapy and radiotherapy improved local disease control and survival [9], and for many years it has been regarded as the most appropriate curative-intent surgical treatment in patients affected by MPM. The role of EPP was somewhat challenged after the publication of the MARS trial, which concluded that EPP within trimodality approach in MPM offers no benefit and possibly harms the patients [19]. However, the MARS trial was highly criticized owing to the low number of included cases, a higher than expected peri-operative mortality (18%), and other biases in the study design [20] .In contrast with pleurectomy/decortication, EPP may provide a more radical cytoreduction [21], but it is associated with higher morbidity and mortality rates, for this reason, it should be performed only in selected patients and in highly specialized centers [4].