Pectus repair after prior sternotomy: clinical practice review and practice recommendations based on a 2,200-patient database

Abstract

The minimally invasive repair of pectus excavatum (MIRPE) is widely accepted as a method of pectus excavatum (PE) repair. Repair is rarely performed in patients with a history of median sternotomy. A feared complication of this procedure is iatrogenic cardiac injury; the risk of injury in patients with prior sternotomy is especially high due to the development of post-surgical retrosternal adhesions, which obscures the "critical view" during MIRPE. A 14-center review reported the incidence to be as high as 7% after analyzing 75 patients with history of sternotomy who underwent MIRPE. Little literature exists on how to best prepare for MIRPE in patients with prior sternotomy. A review of the literature and a retrospective review of over 2,200 patients who underwent MIRPE at our institution was performed to analyze 9 patients who underwent MIRPE after prior sternotomy. Iatrogenic cardiac injury occurred in 2 patients. Given the infrequency in our experience and the low numbers reported in the literature, statistical conclusions cannot be drawn. However, prudent strategies based on this experience include thoracoscopy, routine sternal elevation, direct sub-xiphoid retrosternal dissection, coordination with cardio-thoracic surgeons, preparation for cardio-pulmonary bypass, and massive transfusion protocol availability to optimize surgical outcomes in patients undergoing MIRPE with a history of sternotomy.

Keywords: Nuss procedure; Pectus excavatum (PE); median sternotomy; minimally invasive repair of pectus excavatum (MIRPE).

Figure 1

Pre-operative axial non-contrasted CT image of a patient who suffered intra-operative cardiac injury during MIRPE, with history of prior sternotomy. The arrow highlights the sternotomy wire. CT, computerized tomography; MIRPE, minimally invasive repair of pectus excavatum.

Figure 2

Pre-operative axial non-contrasted CT image of a patient who suffered intra-operative cardiac injury during MIRPE, with history of prior sternotomy. The arrow highlights the sternotomy wire. CT, computerized tomography; MIRPE, minimally invasive repair of pectus excavatum.