Goals:

• Enhance Technical Proficiency with Thoracic Exposures

• Promote Critical Decision-Making with Rib Plating Patient Selection

• Foster the Integration of Technology with Surgical Practice

Objectives:

• Chest Tube Placement: Residents will demonstrate safe and accurate chest tube placement, adhering to anatomical landmarks and procedural best practices. They will also practice thoracic irrigation with the CLR thoracic irrigation system. 

• Thoracotomy and Thoracic Closure: Residents will perform thoracotomies with emphasis on proper incision placement, tissue handling, and subsequent thoracic closure techniques.

• Thoracic Nerve Cryoablation: Residents will learn the indications, techniques, and intraoperative considerations for thoracic nerve cryoablation as part of multimodal pain management.

• Rib Fixation: Residents will perform rib fixation with internal and external plating systems with both open/direct and minimally invasive techniques. 

• Sternotomy and Sternal Closure: Residents will practice midline sternotomies and execute sternal closures using both traditional wiring techniques and plate fixation, ensuring secure and stable repairs.

• Emergent Re-entry Protocols: Residents will simulate emergent re-entry scenarios requiring rapid plate and wire cutting, focusing on time-sensitive decision-making and operative safety.

• (Optional) Clavicle Plating/Wiring: Residents will practice the principles of clavicle plating, including appropriate plate selection, contouring, and fixation to optimize fracture stabilization.

• (Optional) Augmented Reality Integration: Residents will utilize augmented reality tools to visualize underlying thoracic anatomy through the patient’s skin, enhancing their spatial understanding and procedural planning.

Scenario #1:

A 45-year-old male was the unrestrained driver in a high-speed motor vehicle collision. EMS had to extricate the patient and the stearing wheel was bent. He presented with severe chest pain as his only complaint. He is protecting his airway. He has blunted breath sounds bilaterally, crepitus over the right chest with paradoxical motion of his right lateral chest and saturations at 90% despite 15L O2 on a non-rebreather mask. He has good distal pulses with a blood pressure of 145/90 and a heart rate of 110 bpm without ectopy. There are no other signs of trauma. Initial chest x-ray demonstrates multiple rib fractures bilaterally including left 4-7 non-displaced anterolateral rib fractures and right 3-9 displaced anterolateral rib fractures with 4-8 broken posteriorly with minimal displacement. He has a hemopneumothorax on the right and a pneumothorax on the left. 

Scenario #2:

A 32-year-old male is brought to the emergency department by ambulance after sustaining a gunshot wound to the left anterior chest during an altercation. On arrival, he is visibly pale and diaphoretic. His vital signs are: blood pressure is 85/55 mmHg, heart rate 135 beats per minute, and respiratory rate 28 breaths per minute. He is protecting his airway but has tracheal deviation to the right. On auscultation, breath sounds are diminished on the left side, and there is evidence of subcutaneous emphysema. Chest examination reveals a 2-cm gunshot wound just below the left nipple. 1 unit of whole blood increases the blood pressure to 95/60, but his heart rate stays at 135 bpm. eFAST demonstrates a left pneumothorax with a large associated pleural effusion, no pericardial effusion, and no intraabdominal fluid. 

Scenario #3:

A 28-year-old female presents to the emergency department following a stab wound to the precordial region sustained during an altercation at a local gas station. Upon arrival, she is confused and in significant distress. Her initial vital signs reveal a blood pressure of 80/50 mmHg, a heart rate of 130 beats per minute, and a respiratory rate of 26 breaths per minute. Physical examination shows a 1.5-cm stab wound located just inferior to the left nipple, with surrounding ecchymosis. Cardiac auscultation reveals distant heart sounds, and there is evidence of jugular venous distension. A focused assessment with sonography for trauma (FAST) reveals a pericardial effusion with signs of tamponade physiology. 

Primary resources:

• Chest Anatomy: 

  • Right thoracic anatomy - narrated and Robotic thoracoscopic review of left thoracic anatomy 

  • Mastering Bronchoscopy for Thoracic Surgery: Chapter 2 

• Basics of Thoracic Surgery:

  • The Atrium: Basics of Thoracic Surgery 

  • CTSNet Step-by-Step Series: Posterolateral Thoracotomy 

• Ribs/Chest:

  • Education Resources – Chest Wall Injury Society 

    • SSRF Criteria video - YouTube <- 100% Review this video prior to the course

    • Inframammary exposure video 

    • Paraspinal exposure video 

    • Subscapular exposure video 

    • Axillary exposure video 

    • Sternal exposure video - YouTube 

    • Keyhole exposure video 

  • EAST Guidelines: Rib Fractures, Open Reduction and Internal Fixation of (UPDATE IN PROCESS) - Practice Management Guideline 

  • Rib Plating:

    • RibFix Advantage: RibFix® Advantage Animation | Zimmer Biomet

      • Minimally invasive demonstration: RibFix Advantage Intrathoracic Rib Fixation - YouTube 

    • RibFix Titan: ribfixtitan_Lateral Extra.mp4 - Google Drive 

• Sternum:

  • Sternotomy: CTSNet Step-by-Step Series: Midline Sternotomy 

  • Sternotomy closure with wires: CTSNet Step-by-Step Series: Sternal Closure Using Stainless Steel Wires 

  • Sternal Wire Closure: DoubleWire Sternal Closure - YouTube 

  • Sternal Plating: SternaLock® Blu Primary Closure System 

Additional resources:

• Open Chest Tube Placement: 

  • Surgeon Shows How to Place a CHEST TUBE | Behind the Knife - Bedside Procedures Episode 1 

• Epicardial Pacing Wire Placement:

  • CTSNet Step-by-Step Series: Pacing Wires 

  • CTSNet Step-by-Step Series: Chest Drains 

• Thoracic irrigation: 

  • How to use the CLR Irrigator 

  • CLR-enabled thoracic irrigation for management of hemothorax 

• PGY1 and PGY2 Residents:

  • Learn about chest wall/rib anatomy and surgical planning with the use of the Immersive Touch AR/VR platform.

  • Learn about and practice cryoablation on Atricure mannequins. 

  • Practice chest tube placement and thoracic irrigation with the CLR irrigation system and CLR mannequins. 

  • Practice the fundamentals of rib fixation on sawbones. 

  • If time allows, rotate through the cadaveric stations to practice sternotomy and thoracotomy incisions and closures. 

• PGY3/4 Residents:

  • Practice with the RibFix Advantage and RibFix Titan systems on cadaveric models. 

  • Practice sternotomy with a sternal saw or Lebsche knife and practice sternal closure with wires and plates. 

    • Learn about and practice emergency chest access in recently wired or plated patients. 

  • Practice thoracotomy and thoracic closure with sutures. 

  • If time allows, rotate through the CLR, Cryoablation, and Immersive Touch stations. 

• PGY5 Resident Volunteers: 

  • Rotate as educators throughout the stations.