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Operative Procedures

Operative Procedures

Most surgeons use techniques involving stabilisation with a metal frame. Of these techniques, the most versatile (and one for which the most information on long-term results is available worldwide) is an open repair using metal plates for post-operative stability. The fundamentals of this technique were developed in the 1950s by Sulamaa, Wallgren and Paltia in Helsinki, Finland. In recent years it has been improved in the light of extensive experience and scientific studies on selective tension reduction. Chest wall corrective surgery today, as developed further under Hümmer and colleagues, represents a substantially less invasive procedure than open techniques in the past.
In particular, operating times and lengths of hospital stay have been substantially shortened. This has been possible because of a reduction in the size of incisions, to the extent that now minimally invasive techniques leave barely perceptible scars.

→ Minimal Access Open Repair of Pectus Excavatum (MAORPE)
→ Minimally invasive techniques
→ Historical techniques
→ Cosmetic corrections

 

 

Minimal Access Open Repair of Pectus Excavatum (MAORPE)

The malformed section of chest wall is mobilised via a small (5-10 cm, 2-4 in) incision. This can be made longitudinally (in boys), or transversely at the breast fold. A notch is cut in all malformed ribs at the rim of the deformity, they are either separated from the sternum or shortened as appropriate, and then after raising or sinking them to the correct position they are sewed together under minimal tension. The reconstruction is stabilised with a thin elastic metal frame made from stainless steel or titanium.
The frame is anchored to the sternum and is supported at the sides by stable parts of the ribcage. In children with a soft sternum it is possible to do without the division of the ribs. Supplementary correction of the ribcage can be made via tiny stab incisions.
With the help of tension measurements (tensiometry) it is possible to measure the forces that are acting. The metal frame is brought in from the side and anchored to the sternum under direct vision via a small (about 2-4 cm, 0.8-1.6 in) incision in the middle of the ribcage. Stabilisation at the sides is not necessary, because of the fixation to the sternum. Minimally invasive supplementary correction of projecting ribs can be achieved via a 1-2 cm (0.4-0.8 in) skin incision. The metal frame is routinely removed after one to two years, on an outpatient or day-case basis.
In powerfully-built men, two frames may be needed for stabilisation. A strong absorbable suture gives extra stability. These measures enhance the robustness of the repair and allow early discharge from hospital, typically after 6-10 days. Since 1954 over 6,000 major corrective chest wall operations have been carried out. Operations last between 40 and 70 minutes.
The metal frame used for stabilisation is taken out via a small side incision after about one year, in a procedure which can be arranged on a day-case basis.

Figures:
Operation results:

Adult male, after correction of symmetrical funnel chest

Young woman, after correction of symmetrical funnel chest

Young man, after correction of pigeon chest

 

 

Minimally invasive techniques

This term refers to the principle by which large incisions and wound surfaces are avoided, using special techniques and instruments.
Operation after Nuss (Minimally Invasive Repair of Pectus Excavatum, MIRPE):
In this technique an attempt is made to pull out the indrawn chest wall into the correct plane without freeing it at the outer aspects or dividing the ribs. As a result in older patients considerable force may be necessary. For access, two incisions are made in the sides of the chest wall, through which a strong bowed metal plate is slid behind the sternum. The elevation of the chest wall is achieved by twisting of the plate. A thoracoscope can be used to obtain a better inside view of the ribcage and avoid injury to adjacent structures. The metal plate must be anchored at the sides by supplementary plates, in order to prevent shifting of the metalwork and early relapse. Because of the strong tension, the plate needs to remain in place for three to four years.
MIRPE has become an accepted and widely used method for symmetrical, mild deformities but is unsuitable for most of the more complex deformities.

 

 

Historical techniques

External distraction methods (from 1950)

These methods, such as the basket method (Körbchenmethode), are no longer used because of danger of infection.

 

Cartilage cutting method (from 1950)

In this method the malformed costal cartilage is first removed, then trimmed and finally returned to the chest. This method was soon abandoned and is no longer used today.

 

Grafts

For example the method of Wada (Tokyo, Japan): sternum and attached stumps of costal cartilage are excised and reattached backwards, so as to reverse the funnel shape and create a curved chest wall. To avoid compromising perfusion, reconnection of blood vessels was recommended. The method has good results, but is extensive and associated with high risks.
Implant-free techniques, in particular the method of Ravitch (1949-65)
Subperichondral extensive cartilage resection, support of the sternum on the stumps of resected ribs, gathering of the perichondrium with sutures. The method is still used, particularly in the United States of America, but has been modified by new developments:

  • Sweet 1946: fixation with sutures
  • Brunner 1954: T-osteotomy, raising of the sternum
  • Robicsek 1974: tension banding of the xiphisternum and ribs
  • Hecker from 1977 onwards, Welch 1980, Mataizeau 1984, Laquet 1985 and many other further modifications, mostly based on the Ravitch method.
  • the later period of the Ravitch repair was characterised by the insertion of a stabilising metal bar similar to the above mentioned.

Unlike the Ravitch tradition in America, the European developments of open correction of chest wall deformities were based on techniques in which cartilage was dissected more sparingly and slender steel plates were used to stabilise the chest wall, with good results. These methods were refined by Hegemann and Hümmer over the following decades.

Other surgical techniques were widely used at that time but involved larger incisions and scars, extensive metalwork, and often unsatisfactory outcomes. In the long term, it became evident that operations early in childhood and with extensive cartilage resection often resulted in thoracic dystrophy.
Therefore the Ravitch technique and its modifications are not widely practised any more.
It is still used in older individuals, where the sternum has calcified, when the deformity is asymmetrical, or when the less invasive Nuss procedure (MIRPE) has proven unsuccessful.

 

Rehbein Method

Mobilisation of the chest wall is carried out in a similar way to the original Erlangen method of Hegemann. Stabilisation is achieved using several separate pairs of metal straps. Removal of the metalwork is relatively awkward.

 

 

Cosmetic corrections

These avoid raising the indrawn portion of chest wall, and so do not correct the narrowing of the ribcage. The uneven chest wall is smoothed out using:

  • Plastic implants, e.g. silicone implants
  • Grafts of muscle or fatty tissue
  • Revision of previous procedures, such as smoothing out of bony projections, or excision of scars followed by resuturing and/or gluing of the skin.

Implants are to be avoided in children, and rarely have a role in men. In women with soft tissue problems, chest wall corrective surgery can be combined with the insertion of implants for breast augmentation.

 

 

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