Novel extra-thoracic VATS minimally invasive technique for management of multiple rib fractures

We report an elderly patient with chronic obstructive pulmonary disease (COPD), Alzheimer's disease and early dementia who presented with multiple displaced rib fractures of left ribs 4 through 9 with flail segments of ribs 4 through 8 and an associated traumatic pneumatocele from rib puncture of the left upper lobe. The decision to treat this patient operatively was based on the presence of flail chest, the patient's age, baseline co-morbidities and limited physiological reserve. Surgical rib fixation is traditionally performed with a thoracotomy incision and open exposure for extra-thoracic rib fixation, however, this patient underwent chest wall stabilization using an extra-thoracic video-assisted thoracic surgery (VATS) technique. We discuss our operative technique using universal rib plating system, optimal retraction for exposure and use of balloon dilation to create an accessible extra-thoracic working space. This surgical approach provided a faster recovery to this patient's baseline with minimal use of narcotics thereby highlighting the impact and importance of this surgical technique for patients presenting with multiple fib fractures, especially the elderly. We show that VATS assisted minimally invasive technique for operative management of multiple rib fractures is a viable surgical option demonstrated by this patient's recovery and return to function with minimal need for pain control despite her advanced age and baseline co-morbidities.