Ann Thorac Surg 2006;81:1103-1104
© 2006 The Society of Thoracic Surgeons
New technology
Invited commentary
Erle H. Austin, III, MD
University of Louisville, 201 Abraham Flexner Way, Suite 1200, Louisville, KY 40202
(Email: ehaustin3{at}aol.com).
Pectus excavatum and carinatum are well recognized cosmetic deformities of the chest wall that are often left untreated. Unfortunately many primary care physicians do not appreciate the physiologic and psychologic benefit that surgery can provide and often advise against an operation that in their minds trades an abnormality in chest wall contour for a prominent scar in the front of the chest. In the case of pectus excavatum, referrals for surgical repair began to increase when the less invasive technique introduced by Donald Nuss became an option. By introducing a curved reinforced stainless steel bar through small lateral incisions, Nuss's minimally invasive technique elevates the depressed sternum without rib resection, sternal osteotomy, or anterior chest incision [1]. Unfortunately the Nuss technique has not been applicable to the less common carinatum deformity, which still requires access to the affected sternum and anterior rib cage to permit cartilage resection and sternal osteotomy, an approach that until now has required a prominent anterior incision.
The authors of this article [2] describe how they have minimized the surgical incision for pectus carinatum without compromising the principles of anterior chest wall reconstruction well described by Ravitch [3], Welch [4], and others [5]. Key to this approach is the use of CO2 insufflation to elevate the chest wall muscles off of the ribs and sternum. Endoscopes then guide transcutaneous detachment of the pectoralis muscles, separation of the sternum from the anterior mediastinum, resection of costal segments on both sides of the sternum, osteotomy of the outer sternal plate, and placement of one or two stainless steel struts to support the sternum. This is a large series of an uncommon chest wall deformity with what seems to be excellent results. The results demonstrated in the patient who is pictured are impressive.
However, the authors have not eliminated the anterior incision as did Nuss with his innovation. Nevertheless they have markedly decreased its size, because according to them, the detachment of the skin and muscles from the chest wall permits mobilization of the small incision to all points required for rib resection and osteotomy. Because this technique requires much more than the insertion of a bar, it is unlikely to save as much time for the surgeon as the Nuss approach has for pectus excavatum. However, these surgeons did experience a decrease in operative time from 3
to 3 hours.
In summary, these authors have developed a less invasive technique for the treatment of an under diagnosed and under treated chest wall deformity that will need to be tested by other surgeons. If this approach is adopted by as many surgeons as with the Nuss operation, then more young people with pigeon breast deformity may be referred for surgical correction.
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References
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- Nuss D, Kelly Jr RE, Croitoru DP, et al. A 10 year review of a minimally invasive technique for the correction of pectus excavatum J Pediatric Surg 1998;33:545-552.[Medline]
- Schaarschmidt K, Kolberg-Schwerdt A, Lempe M, Schlesinger F. New endoscopic minimal access pectus carinatum repair using subpectoral carbon dioxide Ann Thorac Surg 2006;81:1099-1104.[Abstract/Free Full Text]
- Ravitch MM. The operative correction of pectus carinatum (pigeon breast) Ann Surg 1960;151:705-710.[Medline]
- Welch KJ, Vos A. Surgical correction of pectus carinatum (pigeon breast) J Pediatric Surg 1973;8:659.[Medline]
- Saxena AK, Willital GH. Surgical repair of pectus carinatum Int Surg 1999;84:326-330.[Medline]
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