Chapter 82 Pectus Excavatum
INTRODUCTION
Pectus excavatum is the most common congenital anterior chest wall deformity, occurring in approximately 1 in 700 live births. It is characterized by depression of the sternum and lower costal cartilages, resulting in a funnel-shaped appearance of the anterior chest wall. The exact etiology is unknown. Early investigators attributed the defect to abnormal development of the diaphragm, but there has been little evidence to support this hypothesis except for the rare occurrence of pectus excavatum in association with congenital diaphragmatic hernia. There is frequent association with Marfan’s syndrome, an inherited disorder that affects cartilage and other connective tissue. Approximately 26% of children with pectus excavatum have thoracic scoliosis, and 37% have a family history of an anterior thoracic deformity.1
In the early 1900s, Meyer and Sauerbrach reported the first operative repairs for pectus excavatum.1 In 1949, Ravitch2 reported his technique consisting of excision of all deformed cartilages within the perichondrium, division of the xiphoid from the sternum, division of the intercostal bundles from the sternum, and a transverse sternal osteotomy. Since the original description by Ravitch, several modifications of the open technique have been used successfully. In 1998, Nuss and coworkers3 reported their technique for the minimally invasive repair of pectus excavatum. Currently, the minimally invasive technique is widely accepted as an alternative to the open approach.
INDICATIONS
Note: Cardiac and pulmonary insufficiency in children with pectus excavatum is controversial and difficult to measure with current diagnostic testing, but many clinicians and patients report increased stamina after surgical repair.1
Open Repair (Modified Ravitch)
OPERATIVE STEPS
Subperichondral Resection of Abnormal Costal Cartilages (Figs. 82-1 to 82-4)
Damage to the Perichondrium
• Consequence
Strut Placement for Fixation of the Sternum (Figs. 82-5 to 82-9)
Damage to the Intercostal or Internal Mammary Vessels
• Consequence
Dissection around the Pleura (Fig. 82-10)
• Consequence
• Repair
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