Minimally invasive surgical repair of pectus excavatum

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The minimally invasive repair of pectus excavatum has become widely accepted. The number of patients presenting for repair has increased dramatically. There have been many technical improvements over 20 years that have made the procedure much safer and more successful. The complications have been identified and preventative measures instituted. The long-term results have shown a 95% good to excellent outcome, and patient satisfaction studies have shown similar results.

Section snippets

Preoperative considerations

After confirming that the patient's condition is severe enough to fulfill the criteria for surgical correction as outlined by Kelly in this issue of Seminars in Pediatric Surgery, several other factors need to be considered.

Positioning the patient

The standard position is supine with both arms abducted at the shoulders to approximately 70°, taking care to protect the patient from brachial plexus injury. Alternative methods include elevating the torso on a mattress and extending the arms posteriorly.22, 39 This position allows insertion of the thoracoscope superior to the incision site. It has the disadvantage of over-extending the chest during the surgery. Another alternative position is to flex the left shoulder and elbow anteriorly,

Thoracoscopy

Thoracoscopy has become a routine part of the minimally invasive procedure.11, 41, 42 Most surgeons use right-sided thoracoscopy,43 others prefer left-sided thoracoscopy,40, 44 some use bilateral thoracoscopy,45, 46 and some insert the scope and introducer through the same thoracostomy sites.47 In patients with extremely deep depressions, it may be necessary to use bilateral thoracoscopy because the heart is not only compressed, but is also displaced to the left, which impedes visibility from

Skin incision site

During the early days of the procedure, the anterior thoracic incision used for open repairs was also used for the minimally invasive procedure. However, this incision resulted in keloid formation because of tension on the wound, and it was difficult to place the bar ends into the subcutaneous pouch without extending it all the way across the chest. A decision was therefore made to insert the bar through two small lateral thoracic incisions.1 Transverse lateral thoracic incisions have the

Tunneling

The thoracic entry and exit sites should be placed close to the sternum to prevent disruption of the intercostal muscles. Ideally, the tunnel should pass right under the deepest point of the depression. If the deepest point of the deformity is inferior to the body of the sternum, then the patient requires two bars: one under the sternum and one under the deepest point of the depression. The introducer tip should always be kept in view during the tunneling. If the depression is too deep for this

Sternal elevation

When the introducer is in position across the mediastinum, it is lifted in an anterior direction to pull the sternum and anterior chest wall out of their depressed position, thereby correcting the pectus excavatum. Repeating this lifting maneuver several times loosens up the anterior chest wall, prevents the substernal trauma and intercostal muscle injury caused by bar rotation, and minimizes the pressure on the bar, which decreases the risk of bar displacement. The pectus excavatum should be

Bar stabilization

Bar stabilization is essential for a successful outcome. When the minimally invasive technique was first developed, bar stabilization was attempted by creating a muscular pocket.1 This technique resulted in a 15% bar displacement rate. Subsequently, a stabilizer or foot plate was developed and attached to the bar to give it more stability.11 Initially, the stabilizer was only held in position with fascial sutures, but it frequently became detached from the bar and so it was decided to lash the

Number of bars

Initially the procedure was done only on young patients and so only one bar was necessary.1 However, now that the procedure is being used more commonly in postpubertal patients, it has been noted by numerous investigators that two bars give better and more stable results.1, 18, 48 Patients with Marfan syndrome, asymmetric “grand canyon”-type deformities, and wide saucer-shaped deformities also usually require two bars.1, 7, 9, 36 A second bar should be inserted if the repair is suboptimal after

Bar and chest configuration

Many of the patients who have had to have a re-operation have come to us because they were initially undercorrected. It is important to slightly overcorrect the deformity to prevent “buckling” of the anterior chest wall and to decrease the risk of recurrence. The bar should therefore have a semicircular shape with only a 2- to 4-cm flat section in the middle to support the sternum. The thoracostomy entry and exit sites into and out of the chest should be medial to the top of the pectus ridge on

Re-operation

Re-operations on failed previous repairs have been successfully accomplished in 44 previous Nuss repairs, 40 previous Ravitch repairs, and 2 previous Leonard repairs. Thoracoscopy is particularly important in this group of patients as they usually require lysis of adhesions before the tunneling can commence, and that requires an additional port placement.45 A postoperative chest tube is helpful in managing the inevitable lung leak and oozing that follows the lysis of pulmonary adhesions. The

Pain management

Two years ago, we adopted the preemptive pain management protocol used in other specialties. The purpose of this protocol is to prevent the pain cascade from being triggered in the first place, rather than reacting to it after the fact. We also decided to deal with the patients' anxiety in a proactive manner, since fear is well known to decrease the pain threshold. All patients now receive lorazepam on the night before the surgery so that they will arrive at the hospital well rested and less

Early postoperative complications (Figure 1)

Early complications have been markedly reduced by meticulous attention to fitness for surgery, surgical technique, bar stabilization, evacuation of the pneumothorax, incentive spirometry, and prophylactic antibiotics. Many centers have reported marked improvement in their complication rate after the early learning experience.11, 13, 20, 21, 24

The most common “complication” is an insignificant residual pneumothorax secondary to CO2 insufflation at thoracoscopy, which resolves spontaneously. A

Late complications (Figure 2)

Bar displacement has been the biggest late challenge. The initial bar displacement rate was 15%. After the introduction of stabilizers, it dropped to 5%, and with the addition of pericostal sutures placed around the bar and underlying ribs, it dropped to less than 1%.9, 20 Our standard procedure is to place a wired stabilizer on the left and multiple double-stranded “0” PDS pericostal sutures around the bar and underlying ribs on the right. If feasible, we also place pericostal sutures on the

Results

Long-term results in 628 primary repair patients who are more than 1 year post bar removal are excellent in 540 patients (86.0%), good in 65 patients(10.3%), fair in 15 patients (2.4%), and failed in 8 patients (1.3%) (Figure 3).

Similar results have been reported by other centers.5, 6, 7, 8, 24 Long-term results have shown that the bar should remain in situ for 2 to 4 years (Figure 4).

If the bar is removed before 2 years, the recurrence rate increases inversely with the length of time the bar

Bar removal (see Figure 4)

The bar(s) should remain in the chest for 2 to 4 years after pectus repair. Most patients tolerate the bar well for 3 years and are able to participate in competitive sports. There have been a few patients who have kept their bar in situ for 4 or more years without any problems. If a patient grows more than 6 inches(13 cm) after bar insertion and becomes symptomatic with lateral chest pain, then he needs to be evaluated to see whether early bar removal is required.

Bar removal is accomplished

Conclusion

In the 20 years since the first minimally invasive pectus excavatum repair was performed, numerous modifications have made the procedure safer and more successful. As a result there has been a dramatic increase in the number of patients seeking surgical correction. Recent studies have confirmed a reduction in the complication rate after the early learning experience, an improvement in excellent results, and 95% overall patient satisfaction rate.14, 41

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