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The use of an epidural catheter is an important adjunct in patients undergoing reoperation because it will alleviate postoperative pain and reduce morbidity. General anesthesia is necessary because the operation is usually protracted, and there is significant dissection. Hemodynamic monitoring may be necessary depending on the patient's underlying physiologic status. Patients usually are extubated at completion of the repair.
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Reoperative Dissection and Sternal Mobilization
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The task of repairing a recurrent pectus deformity may be formidable depending on the nature of the recurrent deformity and the amount of scar tissue encountered. Few centers have had a vast degree of experience with recurrent operations in the adult population.
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The incision for the open technique is usually made through the old scar. If the old scar is hypertrophied, it should be excised. The skin and muscle flaps are raised superiorly, inferiorly, and laterally to encompass the full extent of the defect by using the electrocautery unit. Scar tissue may render identification of tissue planes more difficult than in a primary operation, but the dissection needs to be carried down to the chest wall to fully expose the sternum and regenerated cartilaginous matrix.
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The subsequent dissection will vary depending on the previous operation. Extensive cartilage resection or injury to the overlying perichondrial sheaths may have resulted in a chaotic array of costosternal connections with no identifiable tissue planes or points of demarcation between one costal cartilage and another. Whereas with a virgin operation, a delicate dissection of the subperichondrial space in a bloodless plane is feasible, in a reoperation, a stone hard outline of the cartilage will be observed, and typically, there is no obvious tissue plane of dissection identified. The goal of the dissection is to excise a sufficient amount of cartilage to achieve adequate anterior mobility of the sternum. (Ideally, a lateral dissection beneath the pectoralis muscles where the territory is less disrupted and the ribs are intact may be pursued.) This frequently also requires detachment of the cartilaginous connections with the sternum and a sternal osteotomy. Both a rongeur and bone cutters can be used to remove the hardened tissue of the fibrocartilaginous plate. Ideally, a layer of scar should be left behind on the chest wall, lateral to the sternum and medial to the osseous portion of the rib, to provide a matrix for hardening and regeneration postoperatively. Careful preservation of the perichondrium is a key maneuver during this stage of the operation.
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Osteotomy and Strut Support
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As with a primary repair, an osteotomy is performed at the angle of maximal declination. In rare circumstances, creation of a second osteotomy may be required to achieve the best apposition. If the cartilaginous–sternal connections have been severed, they should be reapproximated using an absorbable suture. Then a bar/strut is placed beneath both the sternum and the excised fibrocartilaginous plate to maintain the repair in its desired position (Fig. 141-1). It is critical to choose the correct length, position, and contour of the bar. The bar is passed through the fibrocartilaginous matrix to rest on the bony chest wall above the serratus musculature and should extend from midaxillary line to midaxillary line. To accommodate the desired contour of the chest wall, the bar must be positioned beneath the sternum midway between the point of osteotomy and the sternal tip. The bar should not be bent in too much at its ends because it may erode into the intercostal muscles and penetrate the surface of the lung. Neither should the bar be too straight at its ends such that it rubs on the over-lying skin and is uncomfortable for the patient. The bar is held in position by suturing it to the underlying chest wall and sternum on either side with heavy absorbable sutures. Once the bar is deemed to be in the correct position, a closed drainage system is placed beneath and above the sternum. Secure attachment of the xiphoid to support the rectus muscles and cover the lower chest is critical. The pectoralis major and rectus abdominis muscles are then reapproximated in the midline, and the skin is closed (Fig. 141-2).
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Postoperative Management
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The patient is extubated at completion of the operation, and postoperative pain is controlled with the use of a continuous thoracic epidural catheter. Early ambulation is encouraged, and a transition toward oral narcotics is made within 48 hours of the operation. The patient can be discharged with the closed drainage system in place 3 to 5 days after operation. The drains are left in place until the drainage is less than 30 mL per day to prevent seroma formation.
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The metal bar should be left in place for 6 to 9 months after the operation to prevent recurrence of the deformity.9 When the time comes to remove the bar, caution is required because scar tissue overgrowth may render removal hazardous. Continuous, slow traction on one end usually results in ready removal of the bar.