Intercostal muscle flap to reinforce the bronchial stump after video-assisted thoracic surgery pneumonectomy

Davide Tosi, Shehab Mohamed, Sara Pieropan, Cristina Diotti, Mario Nosotti


In open surgery, the buttressing of bronchial stump is a common procedure, in order to prevent the occurrence of bronchopleural fistula after anatomic resections in high-risk patients (i.e., chemotherapy, inflammatory disease, diabetes mellitus). Several techniques have been proposed for the prophylactic coverage of the bronchial stump, most of them using parietal pleura, pericardial fat pad, or intercostal muscle flap (IMF). In our Institution, we routinely cover the bronchial stump with an IMF, usually prepared before ribs spreading, for maintaining an adequate blood flow. IMF in video-assisted thoracic surgery (VATS) surgery is rarely utilized, there are only few descriptions in Literature. We describe a VATS procedure of protecting the bronchial stump with an IMF, harvested with an harmonic scalpel from the utility incision. We evaluated a patient for VATS pneumonectomy after induction chemotherapy. The patient was a 54-year-old woman, with an adenocarcinoma of the right lung, previously treated with chemotherapy for a huge hilar nodal involvement. The patient had a three-ports technique approach. In this case, the IMF was harvested with an harmonic scalpel from the under surface of the fifth rib, paying attention to not injure the vascular structures. The flap was transacted and sutured to the bronchial stump. The time required for harvesting the flap was very short, almost 5 minutes. This procedure helped to avoid negative consequences of pneumonectomy, without providing technical difficulties. In conclusion, we believe that IMF is a valid choice, increasing the vascularity of the bronchial stump; the procedure is easy to perform, even in VATS.