Surgical Options for Pectus Excavatum
Pectus excavatum surgery typically falls into one of two main categories: the minimally invasive Nuss procedure or the traditional open Ravitch technique. The best option is determined by a surgeon after a thorough evaluation, considering factors like the patient's age, the severity and symmetry of the chest wall deformity, and the presence of any associated cardiopulmonary symptoms.
The Minimally Invasive Nuss Procedure
Developed in the 1980s, the Nuss procedure is now the most common surgical method for correcting pectus excavatum, particularly in adolescents and younger adults. This technique is favored for its smaller incisions, reduced blood loss, and faster recovery compared to traditional open surgery.
Steps in the Nuss procedure:
- Anesthesia and preparation: The patient is placed under general anesthesia.
- Incisions: The surgeon makes two small incisions on either side of the chest wall, typically in the mid-axillary line.
- Thoracoscopic guidance: A small fiber-optic camera, or thoracoscope, is inserted through one of the incisions to provide the surgeon with a clear view inside the chest cavity and ensure safety.
- Bar insertion: A curved metal bar, custom-bent to fit the patient's chest, is carefully guided under the sternum through the incisions. The bar is initially inserted with its convexity facing backward, away from the heart and lungs.
- Bar rotation: The bar is then rotated 180 degrees. This action instantly pushes the sunken sternum forward into a more normal position, correcting the deformity.
- Stabilization: The bar is secured to the chest wall with specialized plates or stabilizers on each side to prevent displacement.
- Closure: The small incisions are closed with dissolvable sutures, and the bar remains in place for approximately 2 to 4 years to allow the chest wall to remodel and harden in its new shape.
- Bar removal: A second, simpler outpatient procedure is performed to remove the bar once the chest wall is stable.
The Traditional Ravitch Procedure
The Ravitch procedure is an older, more invasive technique that involves direct, open repair of the chest wall. While less common for routine cases today, it is still used for certain complex or asymmetric deformities, or for older patients with less flexible chest walls.
Steps in the Ravitch procedure:
- Anesthesia and preparation: The patient undergoes general anesthesia.
- Incision: A larger, horizontal incision is made across the front of the chest, directly over the sternum.
- Cartilage resection: The deformed costal cartilages that connect the ribs to the sternum are surgically removed. The perichondrium, the membrane covering the cartilage, is typically preserved to allow new cartilage to regrow in the correct shape.
- Sternum adjustment: A cut, or osteotomy, is made in the sternum to make it more mobile. The sternum is then repositioned forward.
- Fixation: A temporary metal strut or plate may be used to support the sternum in its new position until the bone and cartilage heal.
- Closure: The surgeon closes the incision, sometimes placing drainage tubes to prevent fluid buildup.
Comparison: Nuss vs. Ravitch
| Feature | Nuss Procedure | Ravitch Procedure |
|---|---|---|
| Invasiveness | Minimally invasive | Traditional open surgery |
| Incisions | Two small, lateral incisions | One larger, horizontal chest incision |
| Bar/Support | Single or multiple bars inserted, flipped, and stabilized | Cartilage removed, often with a temporary stabilizing strut |
| Bone/Cartilage | No cartilage or bone removed | Deformed cartilage resected, sternum cut |
| Recovery | Generally shorter hospitalization (2-5 days) and quicker return to normal activity | Longer hospitalization (5-7 days) and more extended recovery period |
| Scarring | Minimal scarring from small incisions | Larger, more visible chest scar |
| Bar Removal | Requires a second, simpler outpatient procedure | Temporary strut removed in a follow-up outpatient procedure |
| Ideal Patient | Adolescents and younger adults with flexible chest walls | Older patients or those with complex, asymmetric defects |
Pre- and Post-Operative Considerations
Before surgery, a comprehensive evaluation is necessary, including imaging like CT scans, pulmonary function tests, and an echocardiogram to assess heart function. Post-operatively, pain management is crucial. Techniques like cryoanalgesia (freezing nerves) or epidural catheters are often used to control pain effectively, allowing for faster mobilization. Physical therapy is a vital part of recovery, helping patients regain mobility and encouraging deep breathing exercises.
What to Expect During Recovery
Recovery from pectus excavatum surgery requires patience and adherence to the surgeon's instructions. A hospital stay is necessary, typically lasting several days. The pain is most intense during the initial days and is managed with medication.
Activity restrictions are critical to protect the surgical site and the implanted bar. For the first few weeks, strenuous activity, heavy lifting, and contact sports are strictly prohibited. Over the following months, activities can be gradually reintroduced as the surgeon advises.
Ultimately, both the Nuss and Ravitch procedures aim to correct the chest wall deformity, improving both physical function and a patient's self-confidence. The surgical choice is a collaborative decision between the patient, family, and a qualified thoracic surgeon.
For more detailed information on surgical approaches, consult a specialized medical center like the UCSF Benioff Children's Hospitals.
