Indications for surgery
Surgery on the rib cage is required when it is necessary to bypass the bony barrier of the chest wall or to remove pathologically altered tissue. The main reasons for performing a subperiosteal resection include the following conditions:
- Creation of expanded surgical access to the thoracic cavity organs for major interventions.
- The need to place a wide drain in the pleural cavity (e.g., in the development of severe purulent process—empyema).
- Presence of specific inflammatory lesions of the bone tissue (rib osteomyelitis).
- Diagnosed neoplasms (tumors) primarily originating from or invading the rib bone.
Surgical access and management of the anterior layer
The operation begins with sequential layered dissection of the soft tissues overlying the selected rib. The surgeon uses a scalpel to divide the skin, subcutaneous fat, and superficial muscle layers. Once the bone is exposed, delicate work on the periosteum begins:
- Incision of the periosteum. The anterior layer is incised in a strictly longitudinal direction using a scalpel or surgical electrosurgical unit. To facilitate subsequent elevation, two short transverse incisions are made at the ends of the longitudinal cut (at the very beginning and end of the surgical wound). As a result, the incision line visually resembles the letter "H" (or a sideways "I").
- Elevation of the anterior layer. Using a standard straight raspatory, the periosteum is gently separated from the anterior surface of the bone. Elevation is then continued onto the upper and lower borders of the rib.
Important surgical rule: When moving the raspatory along the rib border, it is essential to strictly follow the anatomical direction of the muscle fibers attached to the bone. For the external intercostal muscles, the movement should proceed from the spine to the sternum; for the internal muscles, strictly in the opposite direction. Compliance with this vector prevents dangerous slippage of the instrument deep into the intercostal space, reliably protecting the neurovascular bundle from trauma.
Elevation of the posterior layer and bone resection
After the anterior surface and both borders of the rib are completely freed, the technically most challenging step begins: separation of the posterior periosteal layer. This layer is intimately adhered to the underlying tissues, requiring specialized instrumentation.
- Elevation of the posterior layer. For this delicate manipulation, a special curved instrument is used — the Doyen raspatory. Its working end is carefully placed behind the posterior surface of the rib, and with a smooth, gliding motion, the bone is separated from the posterior periosteal layer.
- Resection. Once the required segment of the rib is completely and circularly freed from its periosteal sheath, the bone is transected. Powerful surgical bone cutters — rib shears — are used to excise the isolated fragment. The remaining bed formed by the preserved periosteum subsequently serves as natural protection for the vessels and a framework for healing.
Briefly: answers to topical questions
Which soft tissue layers does the surgeon dissect at the beginning of the approach to the rib?
At the beginning of the surgical approach to the rib, the surgeon dissects the skin, subcutaneous tissue, and superficial muscles.
Dissection of these soft tissue layers is performed directly over the rib. After passing through these layers, access to the periosteum is established; its anterior layer is incised longitudinally with a scalpel or electrosurgical unit, making two transverse cuts at the beginning and end of the incision.
What anatomical structures make up the neurovascular bundle of the rib?
The intercostal neurovascular bundle includes the vein, artery, and nerve.
Anatomically, the bundle includes the following structures:
- Intercostal vein (v. intercostalis) — located highest within the bundle.
- Intercostal artery (a. intercostalis) — situated between the venous and nerve trunks.
- Intercostal nerve (n. intercostalis) — the lowest element of the bundle.
What is the precise topographic location of the neurovascular bundle relative to the rib?
The intercostal neurovascular bundle lies in the costal groove (sulcus costae), which runs along the inferior margin of each rib.
Topographically, the bundle is located between the internal and innermost intercostal muscles. The mutual arrangement of elements within the groove is strictly defined (from top to bottom):
- Intercostal vein (v. intercostalis) — occupies the highest position.
- Intercostal artery (a. intercostalis) — is located in the middle.
- Intercostal nerve (n. intercostalis) — occupies the lowest position.
The nerve often extends beyond the margin of the costal groove into the intermuscular tissue. Anterior to the midaxillary line, vessels and nerves are not covered by ribs.
To remember the correct periosteal incision pattern, recall the letter "H" (Periosteum / Nadkostnitsa): one long longitudinal incision is made along the axis of the rib, along with two short transverse cuts at its ends.
Class and exam questions
Why is this resection specifically called "subperiosteal"?
Because before removing the bone fragment itself, surgeons carefully peel back and fully preserve the periosteum (both anterior and posterior layers). The bone is literally shelled out and removed from the resulting connective tissue "sheath".
Why make transverse incisions when opening the periosteum?
Transverse cuts at the ends of the main longitudinal incision (forming the letter "H") allow the edges of the anterior periosteal layer to be easily folded back like flaps. This provides unobstructed insertion of the raspatory beneath the periosteum for its subsequent safe elevation.
Which instrument is used to free the posterior surface of the rib?
A special curved instrument — the Doyen raspatory — is used for the safe separation of the posterior periosteal layer. Its anatomical shape allows it to gently contour around the back of the rib.
How to prevent injury to the intercostal vessels and nerve during periosteal elevation?
When working with a straight raspatory along the rib borders, the instrument must move strictly along the course of the muscle fibers (from the spine to the sternum for external muscles and vice versa for internal muscles). This prevents the raspatory from slipping into the intercostal space where the neurovascular bundle is located.
What else to study on this topic
- Topographic anatomy and projection of the intercostal neurovascular bundle.
- Technique of pleural cavity puncture after completion of resection.
- Methods and rules for wide drainage in purulent pleural empyema.
- Specialized instrumentation for chest wall surgery (Doyen raspatory, rib shears).
- Features of surgical tactics in osteomyelitis and tumor lesions of the ribs.
Master the complete topic in the "Topographic Anatomy" course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Rib Resection" and 2,777 more subject pages
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 91 video lessons on the subject
Other topics in the section "Operations on the Chest Wall and Thoracic Organs"
Free video lessons: topographic anatomyShort lessons with study notes — no registration required.
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.