The role of thoracoplasty in modern thoracic surgery: a narrative review with three illustrative cases

Background and Objective: Thoracoplasty, defined as the surgical resection of ribs to reduce pleural space volume, was first introduced in the late nineteenth century for the management of chronic empyema. Its use declined with the advent of effective antimicrobial therapy and advances in thoracic surgery. However, interest in thoracoplasty has reemerged in recent years. Tuberculosis and its sequelae remain prevalent globally, and complex pleural space infections continue to pose significant management challenges, particularly in patients who are not candidates for resection or in whom prior interventions have failed. In this setting, thoracoplasty serves as an important salvage strategy. This narrative review aims to examine the historical evolution of thoracoplasty, summarize its current indications and techniques, and highlight the importance of maintaining this skillset within the modern thoracic surgical repertoire.

Methods: A comprehensive search of PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar was conducted to identify peer reviewed articles on thoracoplasty. Both Medical Subject Headings (MeSH) and free text terms were used. No strict date restrictions were applied, although emphasis was placed on literature published between 2000 and 2025. Eligible studies included randomized controlled trials, observational studies, case series, systematic reviews, and expert opinion articles. Data on clinical indications, operative techniques, adjunctive procedures, and outcomes were extracted and qualitatively synthesized.

Key Content and Findings: Thoracoplasty has evolved from a primary treatment for destructive pulmonary tuberculosis and related empyema to a selective salvage procedure in modern thoracic surgery. Contemporary applications focus on chronic empyema, postpneumonectomy space complications, and bronchopleural fistula (BPF), particularly in patients with limited surgical options. Modern techniques emphasize tailored rib resection, preservation of chest wall function, and integration with adjunctive strategies such as muscle or omental flap transposition. Reported outcomes demonstrate acceptable morbidity and mortality, with effective pleural space obliteration and preservation of quality of life in appropriately selected patients.

Conclusions: Thoracoplasty remains a relevant and effective option in carefully selected patients with complex pleural space disease. Contemporary modifications have improved functional and cosmetic outcomes, supporting its role as a valuable salvage technique. Maintenance of familiarity with thoracoplasty is important to ensure optimal management of challenging cases in modern thoracic practice.