Minimally invasive repair of pectus excavatum

Abstract

Pectus excavatum, an acquired or congenital depression of the anterior chest wall, is the most commonly occurring chest wall deformity. Patients with pectus excavatum experience psychosocial and physiologic consequences such as impaired social development and pulmonary and/or cardiac dysfunction as a result of the deformity. Traditionally, repair of the defect was performed with a major open operation, the most common being based on modifications of the Ravitch procedure. In the late 1990's, the operative approach was challenged with a new minimally invasive technique described by Dr. Donald Nuss. This approach utilizes thoracoscopic visualization with small incisions and placement of a temporary metal bar positioned behind the sternum for support it while the costal cartilages remodel. Since introduction, the minimally invasive repair of pectus excavatum (MIRPE) has become accepted in many centers as the procedure of choice for repair of pectus excavatum. In experienced hands, the procedure has excellent outcomes, shorter procedural length, and outstanding cosmetic results. However, proper patient selection and attention to technical details are essential to achieve optimal outcomes and prevent significant complications. In the following, we describe our perspective on pectus excavatum deformities, operative planning, and technical details of the MIRPE procedure.

Keywords: Nuss; Pectus excavatum; Ravitch; funnel chest; minimally invasive pectus repair; minimally invasive repair of pectus excavatum (MIRPE); pectus bar; thoracoscopy.

Figure 1

Image of an asymptomatic 3-month old infant with a significant pectus excavatum. The condition will typically worsen as the child gets older, becoming much more pronounced after puberty.

Figure 2

A 17-year-old male with severe pectus excavatum; pre-operative Haller index of 6.5.

Figure 3

Adult patient with pectus excavatum and Poland’s syndrome.

Figure 4

A 10-year-old female patient with true Marfan syndrome and a severe pectus excavatum with pre-operative Haller index of 12, as demonstrated on the CT scan of the chest. (A) A 10-year-old female patient with Marfan’s syndrome and severe pectus excavatum; (B) T scan of patient shown in (A). Haller index measured 12.5. Note the lower sternum touching the IVC and the asymmetry of the chest. CT, computed tomography.

Figure 5

MRI of the chest illustrating right atrial compression caused by the pectus excavatum. The degree of compression is variable and depends on the severity of the pectus deformity.

Figure 6

An 8-year-old child with severe pectus excavatum. (A) Pre- and post-operative images of an 8-year-old female with pectus excavatum (Haller index of 5.3). Note the excellent correction immediately after MIRPE; (B) same patient as in (A), now 3 years after repair. Excellent sustained correction of the pectus. The small lateral chest wall incisions are almost invisible. MIRPE, minimally invasive repair of pectus excavatum.

Figure 7

Measurement of the chest at the time of surgery. This will determine the size of the pectus bar necessary for the correction of pectus excavatum.

Figure 8

The Eckart Klobe vacuum bells (complete set)—this device can be used intra-operatively to elevate the sternum during placement of the pectus bar.

Figure 9

Intra-operative technique for using the vacuum bell for sternal elevation (11). By applying negative pressure, the sternum is raised anteriorly which facilitates passage of the pectus bar across the anterior mediastinal space. Sternal elevation is important during MIRPE in order to minimize the risk of injury to the heart or pericardium. MIRPE, minimally invasive repair of pectus excavatum. Available online: http://www.asvide.com/articles/951

Figure 10

Bar bender device utilized for shaping the pectus bar at the time of surgery. The bar is given a smooth curve to conform to the patient’s chest in order to provide maximal correction of the caved-in sternal deformity.

Figure 11

Intra-operative image of the thoracoscopic view (from the right chest) of a pectus excavatum before and after placement of the pectus bar. A single pectus bar provided complete correction of the caved-in sternum and the mediastinum returned to normal position.

Figure 12

Chest radiograph of an adult patient treated for pectus excavatum with placement of two pectus bars. Stabilizers were necessary only on the lower bar.

Figure 13

Illustration of the technique for placement of the “third point of fixation” (or peri-costal sutures) for stabilization of the pectus bar. This is an effective method for minimizing the risk of bar displacement.

Figure 14

Chest radiograph of a patient that experienced superior displacement of the pectus bar with separation of the lateral stabilizers from the bar. This patient required re-operation for correction of this problem.

Figure 15

Skin rash surrounding the right lateral chest wall incision two months after MIRPE. The patient was diagnosed with metal allergy as the cause of the skin reaction. MIRPE, minimally invasive repair of pectus excavatum.

Figure 16

Technique for pectus bar removal. The old incision site is re-opened and the bar is removed by applying traction towards the floor. The bar should not be pulled straight across the chest as this may cause injury to the mediastinum.

Figure 17

Image of a 17-year-old patient with recurrent pectus excavatum post minimally invasive repair initially performed at 6 years of age.

Figure 18

Adult patient with a recurrent pectus excavatum post open modified Ravitch repair performed initially performed at 14 years of age.

Figure 19

A 12-year-old child with pouter pigeon chest, also known as ‘Horns of Steer’ pectus deformity. Note the protrusion in the upper sternum and the caved in lower sternum.