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Total Pectus Excavatum Repair: Open Approach

Open ArchivePublished:October 28, 2014DOI:https://doi.org/10.1053/j.optechstcvs.2014.10.002
      Pectus excavatum is the most common congenital abnormality of the chest wall and frequently requires repair and reconstruction. Historically, the open repair has been the standard approach, though the minimally invasive Nuss bar approach has become more common over the last two decades. Our operative description of the Ravitch-type repair with modifications remains a valuable tool in complex cases and re-do operations.

      Keywords

      Introduction

      The congenital anterior chest wall deformities encompass a wide variety of abnormalities. They range in severity from minor cosmetic defects to life-threatening conditions with cardiopulmonary compromise. Although the diagnosis is readily made by examination, the indications for and timing of surgical intervention remain debated in all but the most dramatic cases.
      Pectus excavatum is the most common congenital anterior chest wall deformity seen in clinical practice. It occurs in 1 of 400 live births with a 5:1 male-to-female ratio. Although several familial cohorts have been reported, most cases are sporadic and a genetic basis has not been established. This disorder is often accompanied by other congenital abnormalities. The incidence of associated musculoskeletal abnormalities ranges from 15%-20%. Scoliosis is the most commonly associated abnormality and affects approximately 15% of patients. Concomitant congenital cardiac abnormalities also occur and should be considered for simultaneous correction when pectus repair is planned.
      The diagnosis of pectus excavatum is based on the clinical examination. It is characterized by a “funnel” chest and the severity of the deformity can be quite variable. Almost all of these defects are recognized within the first year of life. The deformity is well tolerated from a physiological standpoint through childhood and most patients are asymptomatic. During rapid growth phases, the deformity becomes more pronounced. This is especially evident around puberty. Despite decades of study, no consistently reproducible cardiopulmonary measurements have documented preoperative impairment or postoperative improvement after surgical repair. Nevertheless, the literature is replete with reports of significant symptomatic improvement, both physically and psychologically after repair.
      The indications for open repair of pectus excavatum remain elusive. In our practice, most candidates for open repair present after puberty. Many patients are asymptomatic, and at times it can be challenging to tease out whether their symptoms are related to the pectus vs the psychological aspects of the pectus. A number of classification systems have been proposed to assist in grading the severity of the deformity and selecting patients for operative repair. The Congenital Heart Surgery Nomenclature and Database Project classifies deformities of less than 2 cm in depth as mild, those 2-3 cm in depth as moderate, and those greater than 3 cm as severe. No clear-cut surgical recommendations based on this classification have been established. The most commonly used classification system is based on the “Haller index.” The index is calculated by dividing the inner width of the chest at its widest point by the distance between the posterior table of the sternum and the spine. The measurements can be taken from either an anteroposterior (AP) and lateral chest radiograph or a computed tomographic scan of the chest. A Haller index score of greater than 3.2 suggests severe disease that should be corrected. Although these classification systems are useful when classifying and comparing among series of patients reported in the literature, we have not found them always helpful in determining which patient to offer corrective surgery.
      The optimal age for correction of pectus excavatum also remains unclear. Corrective procedures involving cartilage resection are clearly easier in children between 2 and 5 years of age; however, concern exists over subsequent malformation of the chest wall with a resultant chest wall constriction. Open repair in young children was far more common in the past, but the incidence of chest wall restriction has significantly decreased the performance of this operation in the younger age group. In general, open operative repair is offered to patients older than 10 years.
      We obtain AP and lateral chest radiographs for preoperative and postoperative comparison; however, we do not routinely calculate radiographic indices of sternal depression finding them to have little use in clinical decision making. The diagnosis is confirmed on physical examination. The assessment of spinal curvature is also undertaken. Other associated conditions such as Marfan disease are ruled out clinically. The patient and the parents are counseled as to the details of the procedure and the expected outcomes .

      Operative Technique

      Figure thumbnail gr1
      Figure 1The open repair is performed under general anesthesia with the patient in the supine position. The arms are tucked at the side. The procedure can be performed through a vertical midline or an inframammary transverse incision. We prefer the inframammary incision, as we feel it provides superior cosmetic results. In prepubescent girls, care is taken to keep the incision in the inframammary folds to avoid disturbance of future breast development. Skin flaps are raised with electrocautery to the sternal notch superiorly, the anterior axillary line laterally, and the costal margin inferiorly. The incisions used for pectus repair: inframammary and vertical midline incisions are shown. The vertical incision provides good exposure but an inferior cosmetic result.
      Figure thumbnail gr2
      Figure 2The pectoralis muscles are elevated off the sternum and anterior chest wall with electrocautery and reflected laterally to expose the involved costal cartilages. All dissection is superficial to the intercostal muscles to avoid inadvertent entrance into the pleural cavity, especially in thin patients. The use of small retractors aide in establishing the dissection planes.
      Figure thumbnail gr3a
      Figure 3The pectus excavatum deformity usually spares both the first and the second costal cartilages. The cartilage resection is begun at the level of the third costal cartilage, with the intent to remove the abnormal cartilage in a subperichondrial fashion, leaving the perichondrial sheath relatively intact. The anterior perichondrium is scored with electrocautery as shown (A).
      Figure thumbnail gr3b
      Figure 3The pectus excavatum deformity usually spares both the first and the second costal cartilages. The cartilage resection is begun at the level of the third costal cartilage, with the intent to remove the abnormal cartilage in a subperichondrial fashion, leaving the perichondrial sheath relatively intact. The anterior perichondrium is scored with electrocautery as shown (A).
      Figure thumbnail gr3c
      Figure 3The pectus excavatum deformity usually spares both the first and the second costal cartilages. The cartilage resection is begun at the level of the third costal cartilage, with the intent to remove the abnormal cartilage in a subperichondrial fashion, leaving the perichondrial sheath relatively intact. The anterior perichondrium is scored with electrocautery as shown (A).
      Figure thumbnail gr3b
      Figure 3(Continued) The edge of the perichondrial sheath is grasped with fine mosquito clamps. The plane between the perichondrium and costal cartilage is developed with a freer perichondrial elevator (B). Once both the superior and the inferior edges of the perichondrium have been mobilized, the cartilage is divided at its lateral aspect with a knife and removed. The cartilage division is facilitated and performed more safely by passing a Matson periosteal elevator posterior to the cartilage and cutting through the cartilage down to the elevator.
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      Figure 3(Continued) A similar technique is used to remove all the remaining abnormal costal cartilages bilaterally down through the costal margin (C).
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      Figure 4The costal cartilage resection is complete. During a routine modified Ravitch-type repair of a pectus excavatum deformity, the xiphoid process is excised from the lower edge of the sternum.
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      Figure 5A bone hook is used to elevate the lower sternum, allowing establishment of the retrosternal space. This is accomplished by gently sweeping away the pericardium and the pleural membranes.
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      Figure 6An anterior wedge osteotomy is performed on the sternum between the insertion of the second and the third costal cartilages. The osteotomy violates only the outer table of the sternum.
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      Figure 7Gentle upward pressure is applied to the distal end of the sternum to provide anterior sternal rotation. The sternum is overcorrected as reapproximation of the pectoralis muscle results in attenuation of the correction angle.
      Figure thumbnail gr8a
      Figure 8A number of sternal fixation techniques have been reported. These include use of a temporary retrosternal strut, the so-called pectus bar (A). This technique is probably the most common technique used in clinical practice. Pectus bars are temporary bars and typically removed 1-3 years after repair.
      • Fonkalsrud E.W.
      Open repair of pectus excavatum with minimal cartilage resection.
      Figure thumbnail gr8b
      Figure 8A number of sternal fixation techniques have been reported. These include use of a temporary retrosternal strut, the so-called pectus bar (A). This technique is probably the most common technique used in clinical practice. Pectus bars are temporary bars and typically removed 1-3 years after repair.
      • Fonkalsrud E.W.
      Open repair of pectus excavatum with minimal cartilage resection.
      Figure thumbnail gr8b
      Figure 8(Continued) Alternatively, one can use an orthopedic fixation technique with microfragment stainless steel or titanium plates and screws (B). Unlike traditional pectus bars, the plates do not require removal.
      Figure thumbnail gr9a
      Figure 9The pectoral muscles are brought together in the midline with a running no. 0 VICRYL suture. The rectus sheath is secured to the inferior aspect of the pectoralis muscle with interrupted no. 0 VICRYL sutures. A no. 10 Jackson-Pratt drain is brought out through the skin and placed under the skin flaps. The remaining portions of the wound are closed in layers. The skin is closed with a subcuticular stitch. (A) The closure of the muscle layer overlying the pectus bar.
      Figure thumbnail gr9b
      Figure 9The pectoral muscles are brought together in the midline with a running no. 0 VICRYL suture. The rectus sheath is secured to the inferior aspect of the pectoralis muscle with interrupted no. 0 VICRYL sutures. A no. 10 Jackson-Pratt drain is brought out through the skin and placed under the skin flaps. The remaining portions of the wound are closed in layers. The skin is closed with a subcuticular stitch. (A) The closure of the muscle layer overlying the pectus bar.
      Figure thumbnail gr9c
      Figure 9The pectoral muscles are brought together in the midline with a running no. 0 VICRYL suture. The rectus sheath is secured to the inferior aspect of the pectoralis muscle with interrupted no. 0 VICRYL sutures. A no. 10 Jackson-Pratt drain is brought out through the skin and placed under the skin flaps. The remaining portions of the wound are closed in layers. The skin is closed with a subcuticular stitch. (A) The closure of the muscle layer overlying the pectus bar.
      Figure thumbnail gr9d
      Figure 9The pectoral muscles are brought together in the midline with a running no. 0 VICRYL suture. The rectus sheath is secured to the inferior aspect of the pectoralis muscle with interrupted no. 0 VICRYL sutures. A no. 10 Jackson-Pratt drain is brought out through the skin and placed under the skin flaps. The remaining portions of the wound are closed in layers. The skin is closed with a subcuticular stitch. (A) The closure of the muscle layer overlying the pectus bar.
      Figure thumbnail gr9b
      Figure 9(Continued) (B) Final layer of skin closure.
      Figure thumbnail gr9c
      Figure 9(Continued) (C and D) Postoperative chest radiograph. The fixation plate in good position can be noted.

      Results

      Patients are managed in the hospital for 5-7 days postoperatively. The limiting factor for their discharge is pain management and resolution of pleural effusions. During the hospital stay, we obtain a portable AP chest x-ray on postoperative day 1. Then, before discharge, we obtain a high-quality posteroanterior and lateral chest x-ray. Patients are transitioned from an epidural catheter to oral pain medications on postoperative day 2 or 3.
      After discharge, patients are instructed to stay on oral antiinflammatories (ie, ibuprofen), oxycodone, and muscle relaxants as needed. They are encouraged to not lie on their side and avoid bending over for 3 weeks. We also have patients perform deep breathing exercises several times throughout the day and emphasize the need for a straight posture. After 3 months, patients are permitted to resume light aerobic activity and then upper body lifting by 6 months postoperatively. Patients are strongly discouraged from engaging in contact sports for several years.
      Open repairs based on modifications of the original technique as described by Ravitch provide excellent results. Several series have supported these open procedures as the gold standard producing acceptable results with very low complication and recurrence rates. Fonkalsrud recently reported on 275 patients operated on with his minimal cartilage resection procedure over a 3-year period. All but 5 patients had results that were very good to excellent and there were no major complications or deaths. The most common intraoperative complication from any of the open procedures is pneumothorax due to inadvertent entrance into the pleural cavity. Usually, this is resolved with aspiration and a formal chest tube is not required. Common postoperative complications include wound infection and seroma formation. These almost always respond to conservative measures.

      Reference

        • Fonkalsrud E.W.
        Open repair of pectus excavatum with minimal cartilage resection.
        Ann Surg. 2004; 240: 231-235