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 Table of Contents  
Year : 2022  |  Volume : 7  |  Issue : 1  |  Page : 15-20

Minimal invasive approach for rib fractures: Feasibility and safety in a single-center experience

1 Medical Center, ISSEMYM (Social Security Institute from Mexico State and Municipalities) Toluca, Mexico
2 Department of Thoracic Surgery and Pneumology
3 Department of Cardiovascular Surgery and Hemodynamics Service
4 Department of Thoracic Surgery

Date of Submission11-Jan-2022
Date of Acceptance12-Jan-2022
Date of Web Publication30-Dec-2022

Correspondence Address:
Miguel Alejandro Martinez Arias
Baja Velocidad Avenue km. 57.5, Number 1519, Postal Code 52170, Metepec, San Jeronimo Chicahualco, State of Mexico, Medical Center, ISSEMYM, Toluca
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jctt.jctt_6_22

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Background: Current pathologies and the concepts applied for chest trauma, both for revision of thoracic cavity and to solve same traumatisms, have allowed to develop minimal surgery approach techniques for the resolution of multiple nosologies, thanks to their various benefits, currently this has been classified as a vanguard surgical technique worldwide.
Material and Methods: Patients undergoing ribs fixation with minimal invasive technique, at ISSEMYM Medical Center, Thoracic Surgery Service, were analyzed according to age, gender, number of ribs fixed, days of hospital stay, days with endopleural tube, type of anesthesia, and complications. We present a series of cases with retrospective, descriptive design in a period of 72 months.
Results: This is the largest case series reported for fixing ribs by minimal invasive approach, a final sample n = 103 was used, and favorable results and description of the same technique were described. The analyzed number of fixed ribs presented an average of 3.8 ribs fixed per patient. The average of hospital stay days was 5.08 days, after the procedure. Moreover, the oldest patient undergoing this procedure was 89 years old and the youngest was 23 years old.
Conclusions: The technique of fixing ribs by minimal invasive approach continues to be a choice technique to reduce postoperative complications and reduce days of hospital stay, it is a reproducible, safe and pioneering technique for chest surgery, even in geriatric patients.

Keywords: Minimally invasive approach, rib fixation, thoracic surgery

How to cite this article:
Martinez Arias MA, Garcia UL, Omana Toledo JA, Mercado Mercado Sanchez LS. Minimal invasive approach for rib fractures: Feasibility and safety in a single-center experience. J Cardiothorac Trauma 2022;7:15-20

How to cite this URL:
Martinez Arias MA, Garcia UL, Omana Toledo JA, Mercado Mercado Sanchez LS. Minimal invasive approach for rib fractures: Feasibility and safety in a single-center experience. J Cardiothorac Trauma [serial online] 2022 [cited 2023 Jun 3];7:15-20. Available from: https://www.jctt.org/text.asp?2022/7/1/15/366398

  Introduction Top

We report the largest case series for fixing ribs by minimal invasive approach. This procedure has the objective of surgically stabilizing simple and multiple rib fractures. The rib fixation by minimal invasive approach (MARF technique) is indicated in patients with flail chest, which is defined as that with 2 or more fracture sites, in contiguous ribs and/or the sternum, and in patients with inability to wean from ventilator and unremitting pain after 48 h of medical treatment.[1]

Thoracic trauma is frequently associated with ribs fractures, especially trauma caused by automobile accidents.[2],[3] In Mexico, during 2020, 301,678 accidents were reported, of which 245,297 registered only had material damage (81.3%); 52,954 wound victims (17.6%) were identified, and the 3,427 remaining accidents corresponded to events with at least one deceased person (1.1%) at the accident site. The total number of dead and injured victims occurred in urban areas during 2020 was 75,761 people, of which 3,826 died at the accident site (5.1%) and 71,935 presented some type of injury (94.9%).[4]

The morbidity increases in relation to the number of fractured ribs and the age of the patients, most of these patients have important pain with respiratory movements, worsening the prediction and recovery.[5],[6] 30 days after trauma, almost all the patients continue to need analgesia, and the days of work or normal activity lost, reach 70 days of average; in patients with more severe injury of the chest wall, as in a flail chest, disability can be permanent.[6]

Nowadays surgical rib fixation is a procedure that is commonly carried out, improving in less days of mechanical ventilation, less reported cases of pneumonia, less long-term pain and disability; shortening the hospital stay and reimbursing the patient to normal activities at a shorter time.[7]

Today there are several prosthetic materials for fixing ribs safely; however, conventional technique for fixing rib fractures can develop complications, due to the extensive dissection that has to be made for the placement of prosthetic material, this complications can include dehiscence and infection of surgical wound, longer period of postsurgical time and late start of physical and pulmonary rehabilitation due to postsurgical pain; so with this minimally invasive approach, this procedure seeks to innovate in current techniques to reduce these complications, having better results in the short and long term, including in patients with multiple rib fractures or with different sites of injury.[8],[9]

Minimally invasive approach can be carried out in patients with unstable chest with double approach, not >6 ribs by approach, with pneumothorax and/or hemothorax, as well as in cases of fractured ribs, not >6 thoracic arches with pain (unremitting pain after 48 h of medical treatment) and in cases of nonstabilized fractures, which frequently present chronic pain and pseudoarthrosis that requires remodeling and fixation.[10]

The medical purpose of the minimally invasive approach seeks that the patient gets immediate recovery. Which, therefore, causes a decrease in hospital stay days after the procedure, assertive pain management with the start of immediate rehabilitation, avoiding chest wall seroma, that generates infection in the surgical site, a decrease in possibility of re-intervention; and added to this, it is also possible to use this technique, with nonintubated patients, which prevents lower risk of postsurgical atelectasis, and less adverse effects of anesthesia.[10]

Preoperative studies that include computed tomography with thoracic wall reconstruction for planning, must be carried out, to always identify the anatomical points that serve as a reference to choose the boarding site, the scapula is the most important reference to determine the place of incision.[10]

In this second series of cases, reported for fixation of fractured ribs, by minimally invasive approach, criteria are described for fixing ribs with this method, the favorable benefits of this technique and our experience with favorable results for the patient and their quality of life.

  Materials and Methods Top

We present the second series of cases reported for the fixation of fractured ribs by minimal invasion; this was a retrospective, descriptive design, which was analyzed in a period of 72 months, from 2016 to 2021. The inclusion criteria were standardized, and descriptive statistics were carried out, by measures of central trend, percentages, and charts. We confirm that our institutional review board and ethics review committee approved this research, along with the informed consent for surgical procedure, of each patient included in this research, and the authorizations to review our data base, to include the patients for this research. The patients included in this research were those with antecedent of thoracic trauma, that caused rib fractures; and that were subjected to surgical treatment by the minimally invasive approach. This surgical technique is described below.

It is defined rib fixation by minimally invasive approach, a procedure that begins with an incision of approximately 3–5 cm in length, central to the fractured site, using osteosynthetic material to stabilize the ribs.

The strategy and surgical procedure go hand in hand with a multidisciplinary team where each patient is complied with pre anesthesia assessment, preoperative assessment for corresponding services of internal medicine, geriatrics, and cardiology as well as preoperative studies, in specific image, with computed tomography and chest wall reconstruction, as well as surgical planning with these tools and the individualization of each patient for approach.

At the time of surgical planning anatomical points serve as a reference, especially the scapula, which is the most important reference to determine the area of incision and locate according to the axillary midline, the anterior, lateral, and posterior site of the fractures. The skin incision and subcutaneous tissue of 30–50 mm central to the fractured ribs are made horizontally, which is carried out, following a natural line of a thoracotomy, with the patient in variation of positions, which depends on the location of the fractures, supine decubitus in anterior fractures or lateral decubitus for lateral, and posterior fractures [Figure 1].
Figure 1: Possible distance for fixation

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To expose the fractures, after the incision, cell tissue dissection, by means of the separation of muscle plane and identification of virtual space between subsequent muscle fascia and above, same space that is mostly committed by a cell tissue composed of hematoma, platelets, fibrinoid tissue and interstitial fluid; it should be removed to obtain greater mobility and ability to explore full cost of chest wall trauma, fractured ribs and thoracic cavity [Figure 2] and [Figure 3].
Figure 2: Photograph of minimal invasive approach

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Figure 3: Illustration of front view, surgical items placement for fixation

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After releasing adhesions, each rib should be reviewed digitally, identifying the exact fractured site, for planning fixing and placing the wound protector corresponding to the length of the dissection, the clip entry site is arranged, which it must surround completely the determined area for fixing, including, in its middle part, the fractured site, thus avoiding a complete dissection of the periosteum and the section of the thoracic wall muscles.

Since the reduction of all fractures was identified and made, it is decided according to the size and position, the use of titanium fixation system clips, with 6 or 9 segments. For its placement, anatomical curvature corresponding to the site of the injury is given and with the help of specific clamp, the segments are fixed, surrounding perimeter of the affected rib, identifying, and protecting internal rib pedicle to avoid injury [Figure 3], [Figure 4], [Figure 5].
Figure 4: Photograph of placement of surgical instruments and skin protector

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Figure 5: Illustration of surgical items placement

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The site with the skin protector can be moved in a circular shape 360° to cover greater extension of fixation [Figure 1]; it is also possible to reach a distance corresponding to 6 ribs for the fixation [Figure 5] and [Figure 6]. In case of unstable chest, it is possible to perform 2 incisions in the manner described, to reduce the dissection of surrounding tissue, and to avoid the placement of subcutaneous drainage.
Figure 6: Illustration of minimal invasive approach

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Once the fractured ribs have been fixed and the stability of the chest wall verified, the procedure is complemented with an exploration of the thoracic cavity, by uniportal thoracoscopy, and the placement of drainage in the affected hemithorax, through the wound, if necessary. The closure is made with subcutaneous suture, through the tissue and skin, no chest wall drain is needed.

Subsequently to the surgical procedure, the patient remains in vigilance, in the recovery unit and then in hospitalization with pulmonary physiotherapy protocol, based on inspiratory incentive, antimicrobial and analgesic scheme; with consecutive images, by a postoperative chest X-ray, 24–48 h, after the surgical procedure [Figure 7].
Figure 7: X-ray of the chest, after ribs fixation

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  Results Top

The final sample was 103 patients. The masculine genre predominated by 75.5% (n = 77), and 24.5% (n = 25) for the female gender [Supplemental Figure 1], so the feasibility of the management of rib fractures by minimally invasive approach was 100%. No transoperative complications were presented in any patient.

Seventeen patients (16.50%) were conducted by regional blockage and support with supplementary oxygen at 3 l/min throughout the procedure (fixation of fractured ribs and thoracic cavity review with thoracoscopy approach) without reporting adverse events; 86 patients (83.50%) were given balanced general anesthesia; in 38 cases (36.8%), selective intubation of contralateral side was performed on the bronchus of the affected hemithorax; in 48 patients (46.6%), conventional laryngeal mask was carried out without reporting side effects [Supplemental Figure 2].

The age range of the patients was from 23 years to 89 years, with an average of 54.3 years. With the Pareto chart, it is possible to organize these data, so that the ages are represented in descending order, the oldest patient undergoing minimal invasive approach for rib fixation, was 89 years old and the youngest was 23 years old [Supplemental Figure 3]. The statistical mode was 45 years old; meanwhile, the statistical median was 52.5 years old [Supplemental Figure 4].

According to the analyzed data, the number of fixed ribs presented an average of 3.8 ribs. From 103 patients, the minimum number of fixed ribs was 1 rib, and the maximum number of fixed ribs, with minimally invasive approach, was 6 ribs [Supplemental Figure 5].

Within the total number of patients undergoing rib fixation procedure by minimally invasive approach, the results in data analysis showed, that the number of rib, that was most fixed due to a fracture, was rib number 6, and the second rib, most fixed, was the rib number 5, with 38 patients and 26 patients, respectively [Supplemental Table 1].

The average of hospital stay days was 5.08 days, the minimum days of hospital stay was 1 day, and the maximum was 24 days of hospital stay [Supplemental Figure 6], initiating pulmonary and physical rehabilitation within the first 24 postsurgical hours.

A follow-up was carried out, of all patients evaluated, for a period between 7 and 10 days, and later at 1, 3, and 6 months after the surgical procedure, and the hospital discharge, evaluating the probable complications. There were no complications presented, due to the procedure [Supplemental Figure 7].

  Discussion Top

Costal fractures represent a delicate condition in the patient if they are not fixed in a timely manner, with the passage of time the indications for the fixation of costal fractures have not only been proven, but it was also identified that 30% of patients with closed chest trauma and rib fractures will require fixation due to uncontrollable pain despite treatment.[2],[11]

The use of new technologies have clarified the trend in surgical treatments making the minimally invasive approach, be sought as the main objective, being the most important reason that justifies also looking for new ways to fix fractures by minimally invasive approach; Subsequent to the revision of reported cases with fixing rib fractures by this MARF technique, it is recommended the application of this approach for fixing ribs, safely, without increasing surgical time, as long as the surgeon responsible for the patient, follows indications and criteria described in the literature for fixing ribs.

The benefit of this approach is identified, by reducing the inflammatory response caused by surgical trauma, dissecting only the region necessary for the placement of prosthetic material, avoiding the placement of drains in the chest wall, which helps the patient to have less pain, as well as, to start physical and pulmonary rehabilitation earlier, after surgery.

To our knowledge nowadays, there is no system for rib fixation, specifically designed for the purpose of minimally invasive approach, in order to fix fractured ribs. The experience reported in this study is based on the application of instruments designed for a conventional approach and applied to a uniportal approach. We recommend a maximum fixation of 6 possible ribs arches for the application of the technique.

The absence of complications within the review carried out could be due to the lower tissue dissection, which prevents the placement of drainage in the chest wall, as well as the early recovery of the patient, the start of physical and pulmonary rehabilitation exercises, which led to a decrease in days of hospital stay, after the surgical procedure.

With this second case report of patients, with minimally invasive approach for rib fixation, the implementation of criteria for this approach, for rib fixation, can be proposed, this is included below [Supplemental Table 2].[10]

The use of this minimally invasive approach, must be carried out after the recommended learning curve in conventional rib fixation. We believe that patients should be followed up, within this review in a greater period, to understand the stability and dynamic function of the thorax, after its fixation and behavior of the prosthetic material system, for longer periods.

  Conclusions Top

The rib fixation by minimal invasive approach continues to be a choice technique to reduce days of hospital stay.

This technique is a reproducible, safe, and pioneering technique for chest surgery, even in geriatric patients.

This approach is useful for the management of the patient with rib fractures, by immediately stabilizing the thorax, helping to reduce controlled ventilation, improving pain tolerance and rehabilitation.

Minimally invasive approach requires a learning curve for the surgeon, and it reduces recovery time and allows early hospital discharge, which favors the patient and the hospital resources; however, this will be determined by different dependent variables, as the age of the patient, the number of fractured ribs, as well as, with the comorbidities and associated injuries, of each patient.

The technique for minimal invasive approach is an excellent alternative approach, for the thoracic surgery and ribs fixation.

The fixation of fractured ribs by this approach, it is a safe and reproducible technique, that manages to reduce postoperative complications and chronic pain, due to minimally soft tissue handling. Which improves the patient's quality of life and prompt recovery.

Ethical clearance

Approval from the Ethics Committee at the Medical Center, ISSEMYM, Toluca, Mexico, was given.


Special thanks to the Thoracic Surgery and Pneumology Service at Medical Center, ISSEMYM, Toluca, who provided support and experience for the benefit of this work. There were no organizations involved that funded our research.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Stanford Health Care, Stanford medicine and Lucile Packard Children´s Hospital. Trauma Center. Stanford Trauma Guidelines 2016 "Rib Fracture". Stanford California 2016;94305:42.  Back to cited text no. 1
Legome E, Hammel JM. Initial evaluation and management of Chest wall trauma in adults. Netherlands: UpToDate; 2018.  Back to cited text no. 2
Liman ST, Kuzucu A, Tastepe AI, Ulasan GN, Topcu S. Chest injury due to blunt trauma. Eur J Cardiothorac Surg 2003;23:374-8.  Back to cited text no. 3
INEGI. Traffic Accidents. 2021. Last access: august 2022. Available from website INEGI: https://www.inegi.org.mx/temas/ accidentes/. [Last accessed on 2022 Aug].  Back to cited text no. 4
Flagel BT, Luchette FA, Reed L, Esposito TJ, Davis KA, Santaniello JM, et al. Half a dozen ribs: The breakpoint for mortality. Surgery 2005;138:717-23.  Back to cited text no. 5
Kerr-Valentic MA, Arthur M, Mullins RJ, Perason TE, Mayberry JC. Rib fracture pain and disability: Can we do better? J Trauma 2003;54:1058-63.  Back to cited text no. 6
Nirula R, Mayberry JC. Rib fracture fixation: Controversies and technical challenges. Am Surg 2010;76:793-802.  Back to cited text no. 7
Andreani HD, Desiderio WA. Rib fractures: Indications of current surgical repair. Emergency pathology 2013. p. 21.  Back to cited text no. 8
Bemelman M, Poeze M, Blokhuis TJ, Leenen LP. Historic overview of treatment techniques for rib fractures and flail chest. Eur J Trauma Emerg Surg 2010;36:407-15.  Back to cited text no. 9
Martinez M. Minimal invasive thoracic costal fixation. Neumol Cir Torax 2018;77:200-5.  Back to cited text no. 10
Marasco S, Lee G, Summerhayes R, Fitzgerald M, Bailey M. Quality of life after major trauma with multiple rib fractures. Injury 2014;46:61-5.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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