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 majority of children, the abnormality becomes apparent in the first year of life. As the child grows, the deformity may become progressively worse. Typical symptoms are chest pain and exercise intolerance, attributable to the restrictive effect of the deformity on the cardiopulmonary system. Occasionally, children experience palpitations or syncope related to an underlying cardiac abnormality, such as mitral valve prolapse. As children become older, they become self-conscious about their physical appearance, often prompting a surgical evaluation.

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.

In this chapter, both the open and the minimally invasive repairs are discussed separately. Selection of an approach should be based not only on the ultimate results and long-term recurrence rates but also on the potential complications. Factors influencing the decision to perform an open versus a minimally invasive pectus excavatum repair include the severity of the defect, symmetry of the deformity, prior failed operation, and prior cardiac or thoracic surgery. Long-term results and recurrence rates have yet to be reported for the minimally invasive technique.