Since the first pectus repair was reported by Meyer in 1911, several different techniques have been described.1,2 The Ravitch procedure, first described in 1949,3 became the mainstay of repair until Nuss described a minimally invasive repair in the early 1990s.4 The techniques for primary repair of congenital chest wall deformities, including pectus excavatum, are described in Chapter 140. None of these techniques is perfect, however, and recurrences do occur. Although the incidence of recurrent pectus excavatum in the adult population is most rare, it is usually a consequence of technical failure. The rate of recurrence, although significantly reduced in the hands of a more experienced surgeon, ranges from 2% to 10%.
The open repair, described by Ravitch and modified by Haller,5 involves the excision of all deformed costal cartilages from the sternum to the costochondral junctions. The overlying perichondrium is left intact. This procedure is combined with a transverse sternal osteotomy at the point of maximal declination, elevation of the inferior sternal fragment, and placement of a transverse metal bar or rod to maintain the sternum in this elevated position. The ends of the bar are supported on either side by the bony ribs of the lateral chest wall.4,6 The bar is left in place until the costal cartridges have regenerated and the chest wall has become firm and rigid. This process usually takes 6 to 9 months in adults.
The rates of recurrence from a series of experienced centers are depicted in Table 141-1. The most common reasons for recurrence may be divided into two categories: technical and disease-related. As with any operation associated with remodeling in which there are several sequential steps to which one needs to adhere, there is a learning curve. Failure to tackle the full extent of the deformity aggressively, inadequate stabilization of the bar resulting in early displacement, premature removal of the bar before adequate healing has taken place, failure to resect the xiphoid process and mobilize the retrosternal space, significant injury to the perichondrial sheaths, and failure to pay sufficient attention to the asymmetry of the defect, all can result in a technical failure of the primary repair.
Table 141-1Rates of Recurrence From Various Series of Initial Repair |Favorite Table|Download (.pdf) Table 141-1Rates of Recurrence From Various Series of Initial Repair
|SOURCE ||METHOD OF REPAIR ||NUMBER OF PATIENTS ||RECURRENCE RATE (%) ||REDO OPERATION (%) |
|Fonkalsrud et al. (2000)10 ||Modified Ravitch with and without bars ||375 ||1.3 (without) ||0.8 |
|Gilbert and Zwiren (1989)11 ||Modified Ravitch with and without bars ||Without 50 With 32 (14 mesh + bar) ||10 (without) 0 (with) || |
|Haller et al. (1989)5 ||Modified Ravitch, tripod fixation, use of bar in teenagers ||460 ||3 ||3 |
|Saxena and Willital (2007)12 ||Willital-Hegemann procedure (transsternal and parasternal ...|