RED Protocol: Ultrasound for Intraoperative Detection of Pneumothorax and Hemothorax in Rib Remodeling Surgeries

Ribcage remodeling procedures are increasingly used in aesthetic surgery to reduce waist circumference; however, they carry a potential risk of pneumothorax and hemothorax due to proximity to the lung parenchyma. Early intraoperative detection of these complications is critical but currently not standardized.

To evaluate the feasibility and diagnostic performance of the Rib Complication Evaluation and Detection (RED) protocol, an intraoperative ultrasound-based approach for detecting pneumothorax and hemothorax during ribcage remodeling procedures.

A retrospective observational study was conducted including 113 patients undergoing ribcage remodeling between 2023 and 2024. Due to the low incidence of pneumothorax, the protocol was additionally assessed using 250 high-fidelity simulation scenarios with the CAE Vimedix system. Ultrasound findings were standardized, and sensitivity, specificity, and predictive values were calculated.

No cases of pneumothorax or hemothorax were identified in the clinical cohort. In simulation testing, the RED protocol demonstrated a sensitivity of 96% and specificity of 100% for pneumothorax detection, with a positive predictive value of 100% and a negative predictive value of 98%. The protocol successfully differentiated pneumothorax from other thoracic conditions.

The RED protocol provides a structured and reproducible approach for intraoperative lung ultrasound in ribcage remodeling. While simulation was necessary due to the low prevalence of complications, the protocol is based on well-established sonographic signs. Its high negative predictive value suggests utility as a rule-out tool, enhancing intraoperative safety. Further prospective studies are needed to validate its performance in real clinical scenarios.