Chapter 141: Primary Repair of Pectus Excavatum

BACKGROUND

Pectus excavatum is the most common congenital anterior chest wall defect, characterized by a posterior depression of the sternum and inferior costal cartilages. The deformity can be present at birth or develop during childhood. The sternal depression may worsen as the child grows, often peaking during pubertal growth. Incidence is reported in up to 8 per 1000 children.^1,2 It is more common in males; the male-to-female ratio is 4:1.³ The etiology of the defect is unknown, although there is a suggestion of an intrinsic abnormality of the costochondral cartilage due to the occurrence of pectus excavatum in patients with connective tissue disorders such as Marfan syndrome and Ehlers-Danlos syndrome. Scoliosis is present in up to 20% to 30% of patients with pectus excavatum.³ In addition, a family history of pectus excavatum is present in up to 40% of patients, suggesting a genetic predisposition. Approximately one-third of all children with pectus excavatum have a severe deformity that warrants evaluation for surgical repair.¹

Meyer first attempted surgical repair in 1911, followed by Sauerbruch in 1913.¹ In 1939, Ochsner and DeBakey reviewed the techniques of repair and reported outcomes with high morbidity and mortality.¹ Ravitch described a technique in 1949 involving division of the xiphoid from the sternum, excision of deformed costal cartilages, division of intercostal bundles from the sternum, transverse sternal osteotomy at the junction of the manubrium, and angling of the sternum anteriorly and suturing in position.⁴ Welch modified this technique in 1958, emphasizing the preservation of perichondrial sheaths of costal cartilages and preservation of intercostal bundles. This modified Ravitch technique is the basis of current open repair.^5,6

In 1998, Nuss reported his 10-year experience with a minimally invasive technique for pectus excavatum repair involving placement of an internal stainless steel bar through small bilateral thoracic incisions to reshape the chest wall without excision of costal cartilages or sternal osteotomy.⁷ The Nuss minimally invasive repair of pectus excavatum is now a commonly utilized surgical treatment with comparable outcomes and a similarly low associated morbidity.⁸

GENERAL PRINCIPLES

Pectus excavatum includes a spectrum of deformity severity from mild to severe. Mild to moderate deformities can benefit from an exercise and posture program with yearly follow-up. Those patients with severe deformities should undergo a complete evaluation to define the degree of deformity and physiologic impairments, which will aid in determining candidacy for surgical intervention. Approximately two-thirds of patients are treated nonoperatively.^1,6,9

Although pectus deformities may be present at birth and noticeable in early childhood, it is usually not until older childhood or teenage years that children and their parents seek evaluation and treatment. During puberty, the pectus deformity often deepens and becomes more symptomatic. Patients may describe symptoms of dyspnea at rest or on exertion, exercise intolerance, air hunger, ...