Thorax: first published as 10.1136/thx.4.4.224 on 1 December 1949. Downloaded from Thorax (1949), 4, 224. PNEUMONOPLASTY: PERIOSTEO-PLASTIC PNEUMONOLYSIS BY F. RONALD EDWARDS Fromn the Thoracic Slugical Service of the Liverpool Regional Hospital Board and the Department of Surgery, University of Liverpool For many years thoracoplasty with extrafascial sad one, although the newer plastic materials apicolysis has been the major surgical procedure appear to be better tolerated by the tissues. of choice in applying collapse therapy to the treat- The following features are considered to be ment of pulmonary tuberculosis. The results of advisable in a collapse operation. this operation have been considered to be satis- (1) The collapse should be really permanent- factory, producing sputum-conversion figures of i.e., the collapsed lung should be covered by an 70-80% in various hands. The recent advances unexpandable medium of which the only natural in chemotherapy and surgical technique have one is bone. enabled excision therapy to take a gradually (2) The apical space should be ultimately filled increasing place in the surgical treatment, as it with fibrous tissue, and not air, fluid, or a foreign must inevitably do, for it is basically a sounder surgical principle. Nevertheless, collapse therapy body. is likely to remain for a long time one of the main (3) The thoracic cage should remain as intact copyright. forms of treatment of the disease. as possible so that deformity is minimal. Having undertaken various forms of thoraco- (4) The operation should be done in one stage. plasty on some 500 patients during the last 13 These desirable features can be combined years, consideration and reflection upon the opera- together in an operation, which I have termed tion and the types of disease on which it has been "pneumonoplasty " in preference to "periosteo- http://thorax.bmj.com/ performed leads me to the opinion that it should plastic pneumonolysis," which, although a truer be possible to produce a similar permanent col- description of the procedure, is cumbersome. lapse of the lung in cases of apical disease without In this operation an extensive extrapleural pneu- the destructive changes to the thoracic cage that monolysis is performed, the only ribs resected are the features of this operation. These destruc- being the fourth and fifth. The second to the tive changes tend not only to a deformity of one sixth or seventh intercostal bundles with the rib side of the chest which is aesthetically undesirable, periostea are mobilized, detached posteriorly, and but to difficulties of coughing and raising secretion re-attached to the side of the vertebral column in the post-operative stages which may lead to an at a lower level. on September 26, 2021 by guest. Protected extension of the disease to the lower lobe. The position of the bundles and periostea over Extrapleural pneumothorax is a kinder opera- the upper part of the lung is adjusted so that when tion to the patient, but it is not a permanent form recalcification occurs re-expansion of the lung is of collapse therapy, and the frequency of com- prevented (Figs. la, lb, and lc). Before this re- plications, among which the most serious are calcification the lung is held down by the liquid haemorrhage into the space, late tuberculous space which collects in the extrapleural space, and, if infection, and gradual re-expansion of the lung, absorption of this liquid is too rapid, temporary has led to its falling into disfavour, at least in most air refills are established. centres in Great Britain. Bailey in 1941 described an operation which he Maintenance of lung collapse by the introduction called extraperiosteal pneumonolysis which had of various solid or fluid media within the thoracic certain similar features to the pneumonoplasty, cage has been tried: fat, muscle, paraffin wax, but he did not free the lung anteriorly, nor was oil, and more recently lucite balls and polythene, any attempt made to re-attach the posterior ends but the fat absorbs, the muscle atrophies, and the of the bundles at a lower level. Furthermore, as history of the use of the foreign bodies has been a the intercostal bundles were not detached from the Thorax: first published as 10.1136/thx.4.4.224 on 1 December 1949. Downloaded from FIG. IC. copyright. .Subclavian artery. - - - - -Subclavian vein. http://thorax.bmj.com/ - . 3--2nd rib deperiostealized except for upper surface. _Z)___- 2nd bundle to 6th vertebra via mediastinum. -- 3rd rib deperiostealized. 3rd bundle to 6th vertebra. -4th rib removed. on September 26, 2021 by guest. Protected _ _ __. 4th bundle to 7th vertebrz. - - - t - 5ethrib removed. t<.5t8-h bundle to 7th vertebra. -- - ----6th rib partially deperiostealized. -- --- - - _6th bundle to 7th vertebra. - - - - - - - 7eh rib partially deperiostealized. FIG. la. Fully expanded lung. 44 Fici. I b.-PneuLnonolysis perfoi-med andi inter-costal bundles stitched down to vertebra. FiGc. 1c.-Operation conipleted by spreading oilt and FIcG. I b. suturing periostetLni. , Thorax: first published as 10.1136/thx.4.4.224 on 1 December 1949. Downloaded from 2226 F. RONALD EDWARDS lung, and re-applied over the apex, it is likely that ward, and the third and second intercostal bundles apical re-expansion would occur. divided posteriorly. These structures with the An account is given herewith of the results in attached periostea provide a further flap which the first 37 patients on whom pneumonoplasty has is turned forward anteriorly after the serratus been performed, and it is demonstrated that the anterior muscle slips have been divided. A linen operation does in fact produce the permanent thread stitch is inserted into the ligamentous struc- collapse effect upon the lung for which it was tures on the side of the sixth vertebra. The suture designed. must be very firmly inserted as it is the anchor for Cases were selected so that some conception the upper flaps. The intercostal vessels and the could be gained of the particular type of disease azygos vein should be clearly located at this stage for which this operation might be safely advised. so that these structures are not damaged by the insertion of the needle. The suture is left lying OPERATIVE TECHNIQUE free. All patients are anaesthetized with pentothal, The second intercostal bundle is now fixed over nitrous oxide and oxygen, and with d-tubocurarine the apex of the lung. The object is to bring this HCI as a relaxant. bundle and its periosteum directly backwards The patient is placed in the usual lateral thoraco- in a true antero-posterior direction close to the plasty position. mediastinum. Unfortunately, the second bundle A curved periscapular incision is made, not cannot be safely freed to its anterior limit because running so high but continued rather more laterally the muscle thins out anteriorly and tension may than the standard first-stage thoracoplasty incision. cause it and the periosteum to rupture. This would The musculature is divided and the scapula interfere with the blood supply of the flap and retracted. The fourth rib is delineated and some re-ossification might not occur. In order to get 20 cm., or more if the patient is of large stature, the second bundle as near to the mediastinum as is removed subperiosteally. The extrapleural space possible it is first taken internally and sutured tocopyright. is then entered by dividing the periosteum, and an the back of the second costal cartilage ; then it is extrapleural strip is made exactly as in performing brought backwards close to the mediastinum to an extrapleural pneumothorax operation. The the side of the sixth vertebra. The suture already strip is continued on the mediastinum down to the in situ is rethreaded on a needle and the second hilum, laterally and posteriorly to the level of bundle stitched with this to the vertebra. The the lower border of the sixth or seventh rib as sutures are put through the periosteum which is http://thorax.bmj.com/ required, and anteriorly to the fourth rib. attached to the muscle as this is the only part of Some 20 cm. of the fifth rib are then removed. the bundle which will stand tension. The third The periosteum of the inner surface of this rib bundle is treated similarly. The lower bundles is raised with great care, and every endeavour is are sutured under slight tension to the side of the made to keep this as intact as possible as it is seventh vertebra in a similar fashion. The lung the regenerated bone from the periosteum which is now held down but tends to bulge up on respira- will form the main framework of the shelf cover- tory movements between the bundles. If the ing and limiting the expansion of the apex of the periosteum has become torn, the loose pieces are on September 26, 2021 by guest. Protected lung. The preservation of this layer of periosteum spread out and sutured by fine interrupted nylon intact is not always easy as the support of the sutures to the adjacent bundles, and the periosteum underlying pleura and lung has been lost. The on the medial surface of the second bundle is outer periosteum of the sixth rib is incised along sutured to any available tissues in the mediastinum. its lower edge and elevated to the upper border At the end of the operation the apex of the lung for a length of 20 cm. The inner periosteum is should be controlled by a firm membrane consist- lifted, and. the fifth bundle with the periosteum of ing of periosteum and intercostal bundles. Obvi- the sixth rib is freed. The seventh rib is similarly ously these flaps would not stay in position for treated if required.