Ann Thorac Surg 2005;80:1951-1954
© 2005 The Society of Thoracic Surgeons
How to do it
A Novel Surgical Correction Through a Small Transverse Incision for Pectus Excavatum
Liang-Shun Wang, MD
a
,
*
,
Kuang-Tai Kuo, MD
a
,
Hao-Wei Wang, MD
a
,
Chia-Hsin Yang, MD
a
,
Taiwai Chin, MD
b
a Division of Thoracic Surgery, Taipei, Taiwan
b Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
Accepted for publication May 7, 2004.
* Address correspondence to Dr Wang, Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-pai Rd, Taipei 112, Taiwan (Email: lswang{at}vghtpe.gov.tw).
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Abstract
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Surgical correction of pectus excavatum (PE) has been well established since Ravitch's publication in 1949. However, Ravitch's procedure, even if modified, was associated with the relatively radical nature of the operation. The aim of this study was to report our early experience and results in treatment of PE by a novel less invasive surgical technique through a small skin incision. From 1998 to 2003, a novel surgical correction through a small transverse incision was performed for 11 patients with PE, including 9 males and 2 females. The mean age was 9.2 years (range, 3 to 17 years). The less invasive surgical technique consisted of a small transverse skin incision over the deepest part of the PE deformity, subcutaneous dissection to the margin of the depressed deformity, elevation of pectoralis musculature from the midline toward the lateral border of the operative field, subperichondrial resection of the short segment (1 to 2 cm) of the involved costal cartilages, detachment of the xiphoid process and elevation of the sternum with sharp or blunt dissection, retrosternal titanium miniplate strutting, placement of drainage tubes in the mediastinum or pleural spaces, and closure of the operative wound. No sternal osteotomy was performed in this series. The average length of the skin incision was 3.2 cm. The number of the resected cartilages varied from 3 to 6 ribs on each side. The average blood loss was 41 mL (range, 10 to 80 mL), and the operation time was 3.1 hours. The duration of hospitalization was 4.4 days on average. There was no surgical complication or mortality. All patients were satisfied with their cosmesis, and no migration of the retrosternal strut was found in chest radiographs until the date of analysis. This less invasive surgical technique, which did not require osteotomy, could be effectively performed through a small skin incision and was associated with steady recovery of chest wall deformity, as well as excellent cosmetic results.
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Introduction
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Pectus excavatum (PE) is the most common chest wall deformity referred for surgical correction. As a congenital lesion, it is a highly visible anomaly and is easily diagnosed. Its anatomic severity can be readily assessed by visual measurement [1]. The aim of surgical treatment is multifold: (1) to relieve abnormal compression of anterior chest and allow normal growth of the thoracic cage, (2) to prevent cardiopulmonary dysfunction, and (3) to improve cosmesis and alleviate psychological problems [2]. Surgical correction of PE has been well established since Ravitch's [3] publication of the open technique in 1949. After several modifications, this technique has become well accepted by most pediatric and thoracic surgeons as the standard treatment of PE. Ravitch's technique was associated with the fairly radical nature of the operation, which consisted of an extensive anterior chest wall exposure, creation of muscle and skin flaps, extensive cartilage resection, and sternal osteotomy. However, the latest methods for surgical correction of PE are based on the principle that the sternum is an innocent bystander and that the real culprit is the deformed overgrowth of costal cartilages [1, 4]. Moreover, the experience with the Nuss technique [5, 6], or the minimally invasive repair of pectus excavatum, has shown that the chest wall deformity, being quite malleable, can be corrected by a convex steel bar without sternal osteotomy and cartilage resection. Besides, Haller and colleagues [7, 8] further reported the possibility of the development of so-called acquired Jeune's syndrome after too-extensive and too-early operation for PE. These considerations provided the rationale for a novel less invasive operation to perform reconfiguration of the funnel chest with a miniplate strutting after the limited resections of abnormal rib cartilages through a small transverse skin incision without sternal osteotomy. This report presents the surgical technique and our early results obtained with this less invasive procedure.
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Technique
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With the patient under endotracheal anesthesia, a small transverse skin incision 2 to 4 cm long (approximately the width of sternum) was made over the deepest part of chest wall deformity. Subcutaneous undermining dissection was then extended to the margin of the depressed deformity (Fig 1A). The pectoral major muscle was detached bilaterally from the midline toward the lateral border of the operative field. The deformed cartilages were exposed, and subperichondrial resection of short segments (1 to 2 cm) of the involved costal cartilages was performed (Fig 1B). The xiphoid process was detached from the sternum, and the sternum was elevated with sharp and blunt dissection. Sternal depression was corrected with a retrosternally placed titanium miniplate (Medicon, Tuttlingen, Germany). The sternum was moved upward and forward to a slightly overcorrected position. The retrosternal strut was properly secured to the sternum and bilateral ribs to prevent migration (Fig 1C). No transverse sternal osteotomy was performed. The wound was then flooded with warm saline to remove clots and inspect for a pleural entry. A single-limb medium Hemovac drain (Zimmer, OH) was placed for adequate drainage. The pectoral muscle flaps were approximated to the midline of the sternum, and the rectal muscles were then joined to the pectoral muscle flaps. The skin was closed with an intracutaneous running suture (Fig 1D).
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Fig 1. Surgical techniques: (A) A small transverse skin incision of approximately 2.5 cm was made over the deepest part of the chest wall deformity, and subcutaneous dissection was extended to the margin of the depressed deformity. (B) The deformed cartilage was individually exposed for subperichondrial short segmental resection after the pectoral (pect.) major muscle was detached. (C) Sternal depression was slightly overcorrected with a retrosternally placed titanium miniplate. The strut was properly secured to the sternum and bilateral ribs to prevent migration. No transverse sternal osteotomy was performed. (D) After completion of the surgical correction, the skin was closed, and a drainage tube was placed.
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Between January 1998 and July 2003, a novel surgical correction through a small transverse incision was performed for 11 patients with PE. There were 9 males and 2 females with a mean age of 9.2 years (range, 3 to 17 years). Clinically, all patients had moderate to severe sternum depression by visual measurement and chest radiography. Four patients had symmetrical deformity, and the other 7 patients had asymmetrical deformity. The preoperative workup consisted of blood cell counts, biochemistry study, chest radiography, echocardiography, and pulmonary function tests. All patients were regularly followed up in outpatient clinics after surgical correction for a median of 2.6 years (range, 0.5 to 6 years).
The results of these 11 patients are demonstrated in Table 1, and a representative case is shown in Figure 2. Before operation no patient had abnormal physical daily activity with cardiopulmonary distress during exercise, nor was there any marked impairment of cardiopulmonary function. The average length of skin incision was 3.2 cm (range, 2.5 to 4 cm), and the number of resected cartilages varied from 3 to 6 ribs on each side. The average blood loss during operation was 41 mL (range, 10 to 80 mL), and the average operation time was 3.1 hours (range, 2.5 to 4.0 hours). The duration of drainage tube placement was 3.4 days on average. The duration of hospitalization varied from 3 to 6 days, with an average of 4.4 days. There was no surgical complication or mortality. After regular follow-up in outpatient clinics until the date of analysis, all patients were satisfied with their cosmesis, and no migration of the retrosternal strut was observed on chest radiography.
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Fig 2. (a) The anterior chest wall status 1 year after surgical correction. The sternum was moved upward to a slightly overcorrected position. (b) The chest radiograph examined before operation. (c) The chest radiograph examined 1 year after surgical correction. The titanium miniplate was in position, and no migration was found.
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Comment
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Since 1950, costal cartilage resection and sternal osteotomy, combined with a variety of internal fixations, have been widely used as the procedure of choice in the treatment of PE [1–3]. This standard procedure is long and complex, with considerable blood loss, a considerable complication rate, and a nontrivial failure rate of 5% to 36% [5, 6]. Besides, this procedure is generally inversely influenced by the occurrence of large surgical wound problems. Although the cosmesis of funnel chest is much improved, the large skin incisional wound simultaneously creates another cosmetic problem. It is believed that in PE, it is not the bones but the cartilages that are deformed. Several previous reports have shown that sternal osteotomy can be avoided in the surgical correction of PE [5]. Additionally, extensive operative procedures for PE repair could remove or prevent growth center activity, including the sternum, which might result in a restriction of chest wall growth, with marked limitation of respiratory function [7]. Without sternal osteotomy, my colleagues and I believe that PE could be surgically corrected with the limited resection of the deformed cartilages and retrosternal strut support through a small transverse skin incision. It fact, our experience demonstrated that a small skin incision at the deepest depression of the lower sternum is enough for completion of a less invasive surgical procedure if the undermining dissection is adequate, because the skin is quite elastic and movable.
From the experiences of the so-called Nuss technique, or a minimally invasive technique, we recommended that one could achieve excellent correction of PE deformity without rib cartilage resection and sternal osteotomy. The advantages of this minimally invasive procedure include (1) no anterior chest wall incision and no need to raise pectoralis muscle flaps; (2) a short operating time, minimal blood loss, and an early return to full activity; and (3) excellent cosmetic result and normal pulmonary ventilation. However, the deformed costal cartilages might continue to grow slowly after the Nuss technique, and the overgrowth of cartilage is thought to be the major cause of chest wall deformity in PE. Thus, an appropriate resection of the deformed cartilages must be seriously considered.
Several factors are important to ensure a successful outcome of this less invasive surgical technique. After the small skin incision is made, the subcutaneous dissection along the pectoris major muscle should be performed to the entire area of depressed chest wall. Limited resections of deformed cartilages, as well as the fixation of retrosternal struts, can be easily performed with adequate undermining dissection. The number of resected cartilages should be 5 or fewer on each side, especially for young children. The xiphoid process should be detached so that the sternum can be elevated freely. The proper positioning of the strut is important. We prefer to move the sternum upward to a slightly overcorrected position. Then the pectoral muscle flaps and abdominal rectus muscle have to be properly approximated to the midline of the sternum. The pleura should be carefully checked to prevent hemopneumothorax before closure of the muscle layers. For the PE with rotation asymmetry and sternal body incurvation, we suggested that all deformed costal cartilages should be resected and that the retrosternal strut should be properly placed and fixed for adequate sternal support.
With refined experience, we believe that this less invasive surgical repair for PE can be completed within a much shorter time through a small skin incision to risk less than 40 mL of blood loss. Without sternal osteotomy, the corrected chest wall after the procedure was steady. The patients could therefore slowly resume mild exercise 2 to 3 weeks after operation, and in 1 month they were able to resume their usual daily activities. The results were excellent in our 11 patients: the titanium miniplates were in position in the chest radiographs and had induced no tissue reaction up to the date of analysis. This experience has demonstrated conclusively that PE can be corrected with excellent cosmetic results and early return to full activity through a less invasive technique.
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Acknowledgments
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This study was supported in part by Taipei Veterans General Hospital (VGH-272) and in part by Lite-On Cultural Foundation (LF2003MOD01), Taiwan.
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References
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Abstract
Introduction
