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Resection of Costal Exostosis Using Piezosurgery Associated With Uniportal Video-Assisted Thoracoscopy

2015; Elsevier BV; Volume: 99; Issue: 3 Linguagem: Inglês

10.1016/j.athoracsur.2014.04.132

1552-6259

Mario Santini, Alfonso Fiorelli, Mario Santagata, Gian Paolo Tartaro,

Elbow and Forearm Trauma Treatment

We report a case of a 35-year-old woman affected by costal exostosis, originating from the posterior arc of the left fifth rib, who complained of a persistent intractable neuralgia in the left T5 dermatome. Both pain and the risk of visceral injury led us to resect exostosis. The procedure was performed using a uniportal videothoracoscopic approach without additional incisions. For bone resection, we used Piezosurgery, a soft tissue-sparing system based on ultrasound vibrations. Piezosurgery allowed the complete resection of exostosis without injuring the intercostal nerve and vessels. The histologic analysis confirmed the diagnosis of osteochondroma and showed no sign of malignancy. The patient was discharged 2 days after the operation. Considering the lack of symptoms, the low risk of degeneration, and the absence of recurrence at 12-month follow-up, the simple resection of exostosis without performing a more extensive rib resection was judged to be optimal. We report a case of a 35-year-old woman affected by costal exostosis, originating from the posterior arc of the left fifth rib, who complained of a persistent intractable neuralgia in the left T5 dermatome. Both pain and the risk of visceral injury led us to resect exostosis. The procedure was performed using a uniportal videothoracoscopic approach without additional incisions. For bone resection, we used Piezosurgery, a soft tissue-sparing system based on ultrasound vibrations. Piezosurgery allowed the complete resection of exostosis without injuring the intercostal nerve and vessels. The histologic analysis confirmed the diagnosis of osteochondroma and showed no sign of malignancy. The patient was discharged 2 days after the operation. Considering the lack of symptoms, the low risk of degeneration, and the absence of recurrence at 12-month follow-up, the simple resection of exostosis without performing a more extensive rib resection was judged to be optimal. Costal osteochondroma or exostosis is an unusual condition, and it is generally asymptomatic despite complications that can result from mechanical interference with adjacent structures [1Marco A. Mohib M. Thierry M. An unusual cause of hiccup: costal exostosis. Treatment by video-assisted thoracic surgery.Eur J Cardiothorac Surg. 2003; 23: 1056-1058Crossref PubMed Scopus (24) Google Scholar, 2Hajjar W.M. El-Medany Y.M. Essa M.A. Rafay M.A. Ashour M.H. Al-Kattan K.M. Unusual presentation of rib exostosis.Ann Thorac Surg. 2003; 75: 575-577Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar]. We report a case of costal exostosis successfully resected through the use of Piezosurgery (Mectron, Carasco, Italy), a soft tissue-sparing system for bone resection, combined with a uniportal video-assisted thoracoscopic surgery (VATS) approach. A 35-year-old woman was admitted to our hospital suffering from an intractable neuralgia, which presented 5 months before the admission. The pain was localized around the fifth left intercostal space, and it was irradiating to the left breast (T5 dermatome). The patient's medical history was unremarkable, and no familial multiple exostoses or previous trauma were reported. No lung lesions (e.g., pneumothorax or pleural effusion) were detected with chest radiography. Conversely, chest computed tomography revealed an exostosis originating from the posterior arc of the left fifth rib (Fig 1A). Irritation of the intercostal nerve by exostosis was the most likely cause of thoracic pain. Pain and the risk of visceral injury led us to resect exostosis. The procedure was performed using general anesthesia with selective intubation. The patient was placed in a right lateral decubitus position with her left upper arm loosely hanging to the front. A 2% lidocaine solution was injected locally at the side port 5 min before the incision [3Fiorelli A. Vicidomini G. Laperuta P. et al.Pre-emptive local analgesia in video-assisted thoracic surgery sympathectomy.Eur J Cardiothorac Surg. 2010; 37: 588-593Crossref PubMed Scopus (33) Google Scholar]. Next, a single 2-cm incision was made in the anterior left fifth intercostal space without rib spreading. A 30-degree lens thoracoscope (Karl Stortz, Tuttlingen, Germany) was used. LigaSure (Valleylab, Boulder, CO) was introduced through the same camera incision and was used to dissect the adhesions between the exostosis and the lung. Using Piezosurgery, we progressively resected the exostosis from its base (Fig 1B) and smoothed the resection surfaces after extirpation. During surgery, the intercostal nerve was identified; at the end of the procedure, it was completely released from the base of the resected exostosis. There was no evidence of intercostal nerve injury after the resection. The wound was closed over a chest drain, which was removed the following day. Overall, the surgical procedure lasted 50 minutes. The postoperative course was unremarkable. The patient was discharged on postoperative day 2. The histologic analysis confirmed a diagnosis of osteochondroma without signs of malignancy (Fig 2A). At 12-month follow-up, the patient was asymptomatic and free from relapse. No other treatment was required.Fig 2(A) It was well evident that cartilage capped subperiosteal bone (black arrows; original magnification ×20; hematoxylin and eosin staining). The insert (original magnification ×40; hematoxylin and eosin staining) showed the presence of binucleated chondrocytes (asterisk) without signs of atypia. (B) At 12-month follow-up, the chest computed tomographic scan showed no local recurrence (white arrow).View Large Image Figure ViewerDownload (PPT) Exostosis is a rare condition, characterized by a benign bony growth that is capped by cartilage and protrudes from a bone. Exostosis is generally asymptomatic, although complications can arise because of mechanical injury to adjacent tissues [1Marco A. Mohib M. Thierry M. An unusual cause of hiccup: costal exostosis. Treatment by video-assisted thoracic surgery.Eur J Cardiothorac Surg. 2003; 23: 1056-1058Crossref PubMed Scopus (24) Google Scholar, 2Hajjar W.M. El-Medany Y.M. Essa M.A. Rafay M.A. Ashour M.H. Al-Kattan K.M. Unusual presentation of rib exostosis.Ann Thorac Surg. 2003; 75: 575-577Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar]. For example, the spurs of costal exostosis, because of the mediastinum and lungs movements during breathing, can irritate the intercostal nerve causing thoracic pain or damage the lung, the diaphragm, the pleura, or the heart, with episodes of pneumothorax or hemothorax, or both [2Hajjar W.M. El-Medany Y.M. Essa M.A. Rafay M.A. Ashour M.H. Al-Kattan K.M. Unusual presentation of rib exostosis.Ann Thorac Surg. 2003; 75: 575-577Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar]. Costal exostosis is usually diagnosed with a computed tomographic scan. Surgery is not indicated for asymptomatic cases, whereas resection is necessary when the tumor limits or impairs tissue functions or causes pain [1Marco A. Mohib M. Thierry M. An unusual cause of hiccup: costal exostosis. Treatment by video-assisted thoracic surgery.Eur J Cardiothorac Surg. 2003; 23: 1056-1058Crossref PubMed Scopus (24) Google Scholar]. Before the advent of VATS, thoracotomy was the standard approach for resecting exostosis. Currently, VATS is the mainstay of treatment because of earlier functional recovery and better cosmetic results [1Marco A. Mohib M. Thierry M. An unusual cause of hiccup: costal exostosis. Treatment by video-assisted thoracic surgery.Eur J Cardiothorac Surg. 2003; 23: 1056-1058Crossref PubMed Scopus (24) Google Scholar, 4Nakano T. Endo S. Tsubochi H. Tetsuka K. Thoracoscopic findings of an asymptomatic solitary costal exostosis: is surgical intervention required?.Interact Cardiovasc Thorac Surg. 2012; 15: 933-934Crossref PubMed Scopus (6) Google Scholar]. To our knowledge, no other case of exostosis resection through uniportal VATS was previously reported. The goal of minimizing the surgical trauma led us to apply a mini-invasive approach, such as uniportal VATS without additional incisions. To preserve the intercostal nerve during osteotomy, we used Piezosurgery, a soft tissue-sparing system for bone resection. Because of various advantages, Piezosurgery has been used largely in oral and maxillofacial surgery and in other surgical fields [5Pavlíková G. Foltán R. Horká M. Hanzelka T. Borunská H. Sedý J. Piezosurgery in oral and maxillofacial surgery.Int J Oral Maxillofac Surg. 2011; 40: 451-457Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar]; however, so far, there are reports of its use for thoracic surgery. Compared with traditional osteotomy devices, the handpiece of the Piezosurgery device does not contain any rotating parts or drill attachments; its working principle is based on ultrasonic vibrations of different frequencies, specifically designed to resect the bone without injuring soft structures. The vibrations that are generated through a power supply are amplified and transferred to a vibration tip which, when applied with slight pressure on the bone tissue, results in a cavitation phenomenon. This ultimately leads to a mechanical cutting effect that occurs exclusively on mineralized tissue. Piezosurgery was chosen for the present case in which the exostosis needed to be resected carefully without injuring the adjacent tissue, in particular the irritated intercostal nerves and vessel. We used a frequency of 25 to 29 kHz because the micromovements that are created at this frequency (between 60 to 210 m) resect only the mineralized tissue, whereas neurovascular and other soft tissues are affected at frequencies higher than 50 kHz [5Pavlíková G. Foltán R. Horká M. Hanzelka T. Borunská H. Sedý J. Piezosurgery in oral and maxillofacial surgery.Int J Oral Maxillofac Surg. 2011; 40: 451-457Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar]. In agreement with other experiences [5Pavlíková G. Foltán R. Horká M. Hanzelka T. Borunská H. Sedý J. Piezosurgery in oral and maxillofacial surgery.Int J Oral Maxillofac Surg. 2011; 40: 451-457Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar, 6Sham M.E. Kiran S. Efficacy of Piezo-Electric surgery for optic canal unroofing: our experience with two cases.Open Neurosurg J. 2011; 4: 24-27Crossref Scopus (1) Google Scholar], Piezosurgery allowed a precise and complete resection of the exostosis in close proximity to the intercostal nerve and vessel. At the end of the procedure, the intercostal nerve was decompressed and released. The lack of symptoms at 12-month follow-up supported the evidence that exostosis was the only cause of thoracic pain and that no damage to the intercostal nerve occurred during the intervention. Histologic studies showed no malignant abnormalities, and radiologic follow-up showed the absence of recurrence (Fig 2B). Thus, the simple resection of exostosis without performing a more extensive rib resection was considered optimal. Finally, according to Nakano and colleagues [4Nakano T. Endo S. Tsubochi H. Tetsuka K. Thoracoscopic findings of an asymptomatic solitary costal exostosis: is surgical intervention required?.Interact Cardiovasc Thorac Surg. 2012; 15: 933-934Crossref PubMed Scopus (6) Google Scholar], if the aim of the operation is to prevent intrathoracic visceral injury or to decompress intercostal nerves, the uniportal VATS approach might be optimal because it allows exostosis resection without additional incisions and with excellent cosmetic results. Overall, our positive experience supports the future implementation of the use of Piezosurgery in thoracic surgery. However, in cases in which the risk of recurrence or degeneration is elevated, more invasive approaches should be adopted to perform an extensive resection of the rib adjacent to the exostosis.