Pectus excavatum repair

Definition

Surgery to correct pectus excavatum, a deformity of the front of the chest wall with depressed breastbone (sternum) and ribs.

Alternative Names

Description

There are two types of surgery to treat this condition -- open and closed. In the more traditional, open approach, the surgeon makes an incision over the sternum (breast bone), removes the deformed cartilage and leaves the rib lining in place to allow the cartilage to regrow correctly.

An incision is made in the sternum and it is repositioned. A rib or metal strut may be used to stabilize the sternum in normal position until healing occurs in 3 to 6 months. A temporary chest tube may be placed to re-expand the lung if the lining of the lung is entered. This procedure is done while the child is deep asleep and pain-free (using general anesthesia).

Metal struts are removed 6 months later through a small skin incision under the arm. This procedure is usually done on an outpatient basis. Most repairs are done when the child is between 18 months and 5 years old, although there has been debate about the best age for the procedure.

The second type of surgery, the "Nuss procedure," is a closed, less-invasive approach. A curved steel bar is placed beneath the sternum, through two small cuts (incisions) made under the arms. This bar is guided into position using a small videocamera (thorasoscope) placed inside the chest.

Once in position, a special instrument helps to rotate the bar and elevate the deformed sternum. No bone or cartilage is removed. The bar is left in place for at least 2 years. This technique, although newer, has shown excellent long-term (10-year) results when it is performed at specialized surgical centers.

Indications

Pectus excavatum repair may be recommended for:

• Improved appearance (cosmetic repair)
• Improved posture
• Improved breathing (the patient may not have noticed a gradual restriction in breathing)
• Improved exercise capacity
• To prevent restrictive lung disease or reduced exercise capacity as an adult, or late in life

Risks

The risks for any anesthesia are:

• Reactions to medications
• Problems breathing

• Bleeding
• Infection
• Scarring

• Lung collapse
• Recurrence of the deformity

Expectations after surgery

Cosmetic results are generally good. The success of the procedure to improve breathing or exercise capacity is variable. Many affected children have other connective tissue disorders, and thus need related surgery.

Convalescence

Hospitalization for 1 week is common. Vigorous activity may need to be restricted for 3 months.