1. Chest Wall:

A. Anatomy, Physiology and Embryology 

Objectives: This section teaches the student; the anatomy, physiology, and embryology of the chest wall and interprets diagnostic tests.
  1. Understands the anatomy and physiology of the cutaneous, muscular, and bony components of the chest wall and their anatomic and physiologic relationships to adjacent structures.
  2. Understands the anatomy of the vascular, neural, muscular, and bony components of the thoracic outlet.
  3. Knows all operative approaches to the chest wall.
  4. Knows the surgical anatomy, neural, vascular, and skeletal components of the chest wall, as well as the major musculocutaneous or pedicled flaps used in the chest.
Contents:
  1. Chest wall embryology
    a. Ectodermal, mesodermal, endodermal

  2. Chest wall anatomy
  3. a. Skeletal
    b. Muscular
    c. Neural
    d. Vascular
    e. Relationships to adjacent structures

  4. Diagnostic tests to define chest wall anatomy
        a. Chest x-ray 
        b. CAT scans
        c. MRI scans
        d. Nuclear scans
       e. Pulmonary function tests

  5. Major flaps of the chest wall and their vascular pedicles
       a. Latissimus dorsi 
       b. Pectoralis major
       c. Serratus anterior 
       d. Trapezius
       e. Intercostal 
       f. Pleural
      g. Pericardial fat pad
      h. Rectus abdominis
      i. Omental
      j. Vascularized rib graft

Clinical Skills: During the training program the resident will acquire knowledge and proficiency in;
  1. Recognises the normal and abnormal anatomy of the chest wall.
  2. Reads and interprets tests to diagnose chest wall abnormalities.
  3. Assists/Performs (5/1) operations utilizing major chest wall flaps and learns the importance of correct selection and application of prosthetic materials. 

B. Acquired Abnormalities and Neoplasms 

Objectives: This section teaches the student; acquired abnormalities and neoplasms of the chest wall and performs biopsy, incision, resection, reconstruction, and stabilization of the chest wall.
  1. Understands the diagnosis and management of various chest wall infections.
  2. Evaluates and diagnoses primary and metastatic chest wall tumors, knows their histologic appearance, and understands the indications for incisional versus excisional biopsy.
  3. Knows the radiologic characteristics of tumors.
  4. Knows the indications for and methods of prosthetic chest wall reconstruction (e.g., methyl-methacrylate, Marlex®, Gortex®, Vicryl®, and Dacron® mesh).
  5. Knows the types of chemotherapy and radiotherapy (induction neo-adjuvant and adjuvant therapy) of chest wall tumors and the indications for preoperative and postoperative therapy.
  6. Knows the management of osteoradionecrosis of the chest wall.

Contents:
  1. Malignant neoplasms of the chest wall
    a. Chondrosarcoma
    b. Osteogenic sarcoma
    c. Malignant fibrous histiocytoma
    d. Rhabdomyosarcoma
    e. Lymphoma
    f. Myeloma
    g. Ewing's sarcoma
    h. Metastatic lesions
    i. Lung cancer invading the chest wall

  2. Benign neoplasms of the chest wall a. Fibrous dysplasia
    b. Chondroma
    c. Osteochondroma
    d. Eosinophilic granuloma

Clinical Skills: During the training program the resident:
  1. Assists/performs (5/2) a variety of surgical incisions to expose components of the chest wall and interior thoracic organs. 5/1
  2. Assist/Performs (1surgical resections of primary and secondary chest wall tumors.
  3. Identifies the need for major flaps of the chest wall.
  4. Identifies the need for prosthetic replacement of the chest wall.
  5. Assists/Performs surgical reconstruction of chest wall defects.

C. Congenital Abnormalities & Thoracic Outlet Syndrome

Objectives: This section teaches the student; congenital abnormalities, including those leading to thoracic outlet syndrome, and uses operative and non-operative therapy.
  1. Recognizes pectus excavatum and pectus carinatum, understands possible physiologic disturbances, and interprets diagnostic tests to identify such physiologic disturbances.
  2. Understands the indications for the operative treatment of congenital chest wall abnormalities.
  3. Knows the complications of reconstruction of congenital chest wall abnormalities and their management.
  4. Understands the etiology, evaluation, differential diagnosis, and diagnostic criteria for thoracic outlet syndrome.
  5. Knows the operative and non-operative management of thoracic outlet syndrome. 

Contents: 
  1. Pectus excavatum
    a. Components
    b. Evaluation and management (operative and non-operative)
            1. Nuss procdure
                 2. Conventional repair (Ravitch)
        c. Plastic surgical alternatives
   2.   Pectus carinatum
        a. Components
        b. Evaluation and management (operative and non-operative)

   3. Thoracic outlet anatomy
        a. Skeletal, muscular, vascular, neural

  4. Diagnostic tests
       a. Clinical examination and physical exam
       b. Nerve conduction studies
       c. Angiography
       d. CT scan
       e. MRI
       f. Non-invasive vascular studies

  5. Forms of conservative management
       a. Physical therapy 
       b. Weight reduction

 6. Surgical management
     a. First rib resection (operative approaches)
     b. Cervical ribs
     c. Associated vascular abnormalities
     d. Management of intraoperative complications
     e. Re-operation

Clinical Skills: During the training program the resident:
  1. Recognizes the varied presentations of thoracic outlet syndrome and interprets diagnostic tests.
  2. Evaluates and treats patients with congenital chest wall malformations.
  3. Reads and interprets diagnostic x-ray and performs physiologic examinations for congenital chest wall defects and thoracic outlet syndromes.
  4. Performs the operative reconstruction of selected chest wall defects.
  5. Performs first rib and cervical rib resection and repairs or releases vascular and neural abnormalities associated with thoracic outlet syndrome.
  6. Manages intraoperative and postoperative complications associated with the repair of congenital chest wall abnormalities and thoracic outlet syndrome.
  7. Performs re-operations for thoracic outlet syndrome.