Perimammary uniportal video-assisted thoracoscopic surgery rib resection with posterior accessory disarticulation of a large bone hemangioma: a case report

Introduction

Rib tumors are uncommon, accounting for around 10% of all primary bone tumors and having a 50% malignancy rate (1). The most common benign rib tumors are fibrous dysplasia and cartilaginous tumors, while hemangiomas are remarkably rare, with a paucity of cases reported in the literature (1-6).

Bone hemangiomas are very rare, with a prevalence of about 1% of all bone tumors. Rib hemangiomas are extremely infrequent benign tumors which are associated with osteolytic changes and must be differentiated from other malignant or metastatic bone lesions (7).

Most of the patients are asymptomatic and may be incidentally discovered during a radiological examination of the chest. However, when present, symptoms may vary from chest pain, shortness of breath, pain of the back, and features of thoracic outlet syndrome (8,9). Also, a limited number of patients might develop rapid unilateral pleural effusion mimicking malignant pleurisy (1).

Chest computed tomography (CT) and magnetic resonance imaging (MRI) identify the size of tumor and its extent. Needle biopsy has been described as a safe and effective diagnostic tool for confirming hemangioma (10). In contrast, some studies promote that needle biopsy should be avoided due to the potential risk of bleeding (11). When a hemangioma is confirmed, complete surgical resection of the affected rib is generally advised. Nevertheless, alternative treatment options, including conservative management, alcohol injection, transarterial embolization, and radiotherapy, have also been reported (12).

The classic approach for rib tumor resection has traditionally been open surgery (13), which provides excellent exposure but is associated with significant morbidity, including greater postoperative pain and prolonged recovery times, overall when disarticulation of the rib is required.

Over the years, surgical management has shifted toward minimally invasive techniques, including multiportal video-assisted thoracic surgery (VATS), which has been described in a limited number of rib tumor resections (10,14). Only a few cases have reported rib tumor resection using the standard uniportal VATS (UVATS) technique or the subxiphoid UVATS approach (15-17). However, to the best of our knowledge, rib resection requiring costovertebral disarticulation has not been previously described using these minimally invasive techniques.

Hereby, we present, for the first time, a case of a large rib hemangioma involving the costovertebral joint that was successfully resected using a perimammary UVATS approach combined with posterior accessory disarticulation. We present this article in accordance with the CARE reporting checklist (available at https://shc.amegroups.com/article/view/10.21037/shc-2025-2/rc).

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient’s legal guardian (and assent from the patient where appropriate) for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

A 15-year-old female patient without comorbidities or history of trauma, presented with a 1-year history of progressive right-sided pleuritic chest pain and new onset of shortness of breath at rest. The patient was seen in our clinic in June 2021. The chest X-ray revealed a well-defined chest mass without calcifications involving the right 6^th rib (Figure 1A). The patient had no family history of malignancy, and her physical examination was unremarkable.

Figure 1 Radiology findings. (A) Chest X-ray showing right chest mass. (B) Chest CT (red arrow indicates the right chest mass) and (C) MRI showing a posterior 6^th rib lytic mass measuring about 3.4 cm × 4.2 cm (green arrow indicates) with involvement of the vertebral body effecting on adjacent right lung causing minimal atelectasis. CT, computed tomography; MRI, magnetic resonance imaging.

Further evaluation with CT and MRI revealed a lytic mass of the posterior 6^th rib measuring 3.4 cm × 4.2 cm, with involvement of the corresponding costovertebral joint and a mass effect on the adjacent right lung, resulting in minimal atelectasis (Figure 1B,1C). A CT-guided biopsy was subsequently performed, demonstrating the presence of a giant cell tumor compatible with hemangioma.

The patient was admitted on the day of surgery in July 2021 to undergo a perimammary UVATS segmental resection of the right 6^th rib with posterior accessory disarticulation.

Under double-lumen endotracheal intubation, the surgery started with a 3 cm perimammary utility incision placed along the perimammary fold over the sixth intercostal space (Figure 2). The mass was identified along the posterior aspect of the 6^th rib extending toward the costovertebral joint (Figure 3). The pleura was incised using the electrocoagulation hook, and the neurovascular bundle was isolated and preserved. The rib was dissected free from the adjacent intercostal muscles along both its superior and inferior borders. After confirming adequate margins, the rib was transected anteriorly using a VATS rib cutter (Scanlan International, Saint Paul, Minnesota, USA).

Figure 2 Surgical incisions. (A) Intraoperative view of the perimammary incision and the posterior accessory port for disarticulation. (B) Complete heal of the surgical site after 1 month.

Figure 3 Intraoperative imaging from the perimammary approach. (A) Mass visualized on the posterior 6^th rib. (B-D) Dissecting the rib with the hook. (E) Dividing the superior border of the rib with the rib cutter. (F) Final view of the resection. (G) Resected right 6^th rib.

Then, a second posterior skin incision of approximately 2 cm was created to facilitate completion of the rib dissection up to the spinal articulation and to enable en bloc resection. Disarticulation of the costovertebral joint was achieved using a periosteotome, and the specimen was sent for histopathological examination. A 28-French chest tube was inserted through the primary utility incision.

The surgery lasted approximately 3 hours with an estimated blood loss of 100 mL. The final histopathology revealed bone tissue with intramedullary hemorrhage and focal increased vascularity, findings consistent with hemangioma.

Postoperatively, the patient remained clinically stable, experiencing only surgical site pain, which was effectively managed with paravertebral catheter analgesia and pregabalin 75 mg twice daily. A chest X-ray on postoperative day 1 was unremarkable (Figure 4A). Chest tube was removed on postoperative day 2, and the patient was discharged home in good condition on postoperative day 3, continuing with the same pregabalin regimen for over 1 month. At 1-month follow-up, the patient showed a healed surgical site, an unremarkable chest X-ray (Figure 4B), and resolution of pain, allowing discontinuation of pregabaline. Subsequent follow-up over the next 2 years remained unremarkable, and the patient was discharged from further clinical care.

Figure 4 Follow-up radiology images. (A) Chest X-ray on postoperative day 1. (B) Chest X-ray 1 month after the surgery showing the resection site with unremarkable changes.

Discussion

Rib hemangiomas are extremely rare and inherently highly vascular lesions what makes them prone to potential and significant intraoperative bleeding. Therefore, selecting the appropriate surgical approach and technique is essential to ensure meticulous dissection, reducing the surgical trauma and preventing intraoperative complications.

In this context, UVATS has continued to drive the expansion of minimally invasive thoracic surgery, particularly for lung and mediastinal procedures. However, reports of VATS chest wall resections remain limited, and only a few cases of isolated rib resection using the UVATS approach have been described (15,16).

An unconventional perimammary UVATS approach previously described by our group (18) offers several advantages for female patients compared with standard UVATS. These include a slightly wider utility incision, improved exposure of the pleural cavity and target structures, and enhanced access to hilar anatomy, largely due to the more anterior placement of the perimammary approach. Additionally, this technique provides superior cosmetic outcomes, as the incision is concealed within the perimammary fold. However, to our knowledge, this is the first successful application of this unconventional approach for rib resection, as the entire dissection and division of the rib were achieved through the perimammary uniportal approach.

The dissection of the rib borders using electrocoagulation hook is similar to the technique described in previous papers regarding VATS rib resection (10). Particular care was taken when dissecting along the inferior border to avoid injury to the neurovascular bundle.

In previous reports, rib division has been performed using a Gigli saw, rongeurs, or even a drill (11-13,15-18). In contrast, we used a VATS rib cutter, which facilitated the achievement of free margin and provided a sharp, clean transection of the rib, reducing operative trauma compared with previously described methods. Placement of the VATS rib cutter is also simpler and less traumatic, an important consideration when managing highly vascular lesions such as rib hemangiomas, as it helps reduce the risk of tumor bleeding during resection.

Involvement of the costovertebral joint traditionally remains an indication for thoracotomy. Accordingly, none of the previously reported UVATS cases, whether conventional UVATS or subxiphoid VATS, included rib disarticulation. The requirement for disarticulation is still widely regarded as a reason to avoid minimally invasive surgery, particularly in large and vascular tumors such as the one presented here, where inadvertent injury to the lesion may lead to significant intraoperative bleeding.

Finally, in our case, disarticulation was performed at the end of the procedure through a posterior accessory incision, under direct visualization with the thoracoscope positioned through the perimammary uniportal approach. This strategy enabled precise control of the costovertebral joint, minimized the risk of hemorrhage, and contributed to the successful completion of the resection. However, a limitation of this study is that this is a single case report, so we cannot draw definitive conclusions about the optimal indications concerning the size or location of rib hemangiomas.

Conclusions

This novel surgical technique provided excellent visualization and access to the surgical field while minimizing patient morbidity. The approach enabled precise resection and disarticulation of the affected rib with minimal surgical trauma, even in the setting of a large vascular tumor, resulting in an uneventful postoperative course and favorable cosmetic outcomes. Perimammary UVATS with posterior accessory disarticulation may represent a meaningful advancement in the minimally invasive management of rib tumors involving the costovertebral joint in female patients. Further studies are needed to validate the safety, reproducibility, and long-term outcomes of this technique.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://shc.amegroups.com/article/view/10.21037/shc-2025-2/rc

Peer Review File: Available at https://shc.amegroups.com/article/view/10.21037/shc-2025-2/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://shc.amegroups.com/article/view/10.21037/shc-2025-2/coif). N.S.R. serves as an unpaid editorial board member of Shanghai Chest from September 2024 to August 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient’s legal guardian (and assent from the patient where appropriate) for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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