Surgical Management of Pectus Excavatum

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Presentation transcript:

Surgical Management of Pectus Excavatum Eric W. Fonkalsrud, MD Operative Techniques in Thoracic and Cardiovascular Surgery Volume 5, Issue 2, Pages 94-102 (May 2000) DOI: 10.1053/otct.2000.7027 Copyright © 2000 Elsevier Inc. Terms and Conditions

1 Transverse section of the midthorax showing displacement of the heart into the left chest by the mid and lower sternum in a child with a severe pectus excavatum deformity. Operative Techniques in Thoracic and Cardiovascular Surgery 2000 5, 94-102DOI: (10.1053/otct.2000.7027) Copyright © 2000 Elsevier Inc. Terms and Conditions

9 (A) View of the chest of a 17-year-old boy with symptomatic pectus excavatum. (B) View of the chest in the same patient 3 months postoperation. Operative Techniques in Thoracic and Cardiovascular Surgery 2000 5, 94-102DOI: (10.1053/otct.2000.7027) Copyright © 2000 Elsevier Inc. Terms and Conditions

2 The repair of pectus excavatum that we have found to provide the most consistent, good, long-term results with the fewest complications in 385 consecutive patients is a modification of the original procedure described by Brown11 and modified by Ravitch12 and Welch, 13 and extensively detailed in previous reports.14 It begins with a transverse curvilinear incision midway between the nipples and the costal margin extending from the mid nipple line brilaterally. Limited skin flaps are elevated over the pectoralis muscles, using needlepoint electrocautery to minimize blood loss. Operative Techniques in Thoracic and Cardiovascular Surgery 2000 5, 94-102DOI: (10.1053/otct.2000.7027) Copyright © 2000 Elsevier Inc. Terms and Conditions

3 The pectoralis muscles are reflected laterally over a short distance from attachments to the sternum and deformed costal cartilages (usually the lower 4 or 5). The abdominal muscles are mobilized from the lower costal cartilages. Operative Techniques in Thoracic and Cardiovascular Surgery 2000 5, 94-102DOI: (10.1053/otct.2000.7027) Copyright © 2000 Elsevier Inc. Terms and Conditions

4 The perichondrium is incised on the mid anterior surface of the lower 4 or 5 costal cartilages bilaterally, extending from the costochondral junction to the sternum. Abnormal costal cartilages are resected carefully, preserving the intact perichondrium. The xiphoid is detached from the sternum. Operative Techniques in Thoracic and Cardiovascular Surgery 2000 5, 94-102DOI: (10.1053/otct.2000.7027) Copyright © 2000 Elsevier Inc. Terms and Conditions

5 The intercostal muscles and perichondrial sheaths of the resected cartilages are detached from the lower sternum, and the space is mobilized. The pleura is incised on the right side, and a small chest tube is inserted. Operative Techniques in Thoracic and Cardiovascular Surgery 2000 5, 94-102DOI: (10.1053/otct.2000.7027) Copyright © 2000 Elsevier Inc. Terms and Conditions

6 A transverse anterior wedge osteotomy of the sternum is made at the level where the sternum depresses posteriorly. The posterior table of the sternum is gently fractured without displacement and then elevated and twisted to the desired position. Operative Techniques in Thoracic and Cardiovascular Surgery 2000 5, 94-102DOI: (10.1053/otct.2000.7027) Copyright © 2000 Elsevier Inc. Terms and Conditions

7 Nonabsorbable sutures are placed through the anterior table of the sternum across the osteotomy. A stainless steel strut is placed across the lower anterior chest to support the tip of the sternum and is wired to the appropriate rib on each side (fifth or sixth). The bar often will skewer through the perichondrium to prevent a localized depression. The xiphoid and perichondrial sheaths are sutured back to the sternum. Operative Techniques in Thoracic and Cardiovascular Surgery 2000 5, 94-102DOI: (10.1053/otct.2000.7027) Copyright © 2000 Elsevier Inc. Terms and Conditions

8 The pectoralis and abdominal muscles are sutured together over the sternum. Thorough hemostasis is achieved with needlepoint electrocautery, and the wound is copiously irrigated with antibiotic solution. A small chest tube is placed into the right pleural space. The skin is closed with subcuticular absorbable sutures and steri strips or staples and a loose dry dressing is applied. Operative Techniques in Thoracic and Cardiovascular Surgery 2000 5, 94-102DOI: (10.1053/otct.2000.7027) Copyright © 2000 Elsevier Inc. Terms and Conditions