Step 1
Surgical Anatomy
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Pectus excavatum, or funnel chest, is the most common of all congenital chest wall deformities. It is defined as the posterior depression of the inferior portion of the sternum with posterior curving of the attached ribs at the affected levels. The defect may or may not be symmetric, but most eccentric defects have more severe depression of the right side of the sternum.
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Pectus excavatum affects 1 in 400 children and is three to five times more prevalent in boys than in girls. Associations with connective tissue disorders, particularly Marfan syndrome, have been demonstrated. Combined pectus excavatum with pectus carinatum defects are also possible.
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As with all chest wall deformities, pectus excavatum can have many effects on the patient, both physiologic and psychosocial. Physiologic impairments resulting from pectus excavatum include decreased exercise tolerance, mitral valve prolapse, decreased stroke volume, and restrictive-type pulmonary dysfunction. The major psychosocial effects are due to poor self-image and low self-esteem in adolescence as a result of the noticeable deformity of the anterior chest wall.
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Understanding the abnormal relationship of the chest wall structures is vital to planning the repair. Pectus excavatum is a congenital malformation of the anterior thorax characterized by a prominent depression of the body of the sternum, usually involving the lower one half to two thirds. Usually ribs 1 to 3 are spared, as is the manubrium, with most deformities involving the fourth through seventh ribs and their respective costal cartilages. Usually the deepest point of depression is just above junction with the xiphoid. The Nuss procedure corrects the anomaly by realigning the sternum in situ without resection of the costal cartilage. A personalized titanium bar is fashioned in the operating room to hold the sternum in correction for 2 years so that remodeling can take place. When the bar is removed, the chest wall has remodeled and stays in its new alignment.
Step 2
Preoperative Considerations
1
Preoperative Workup
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Assess severity of defect
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Imaging
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Chest radiograph: anteroposterior (AP), lateral
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Computed tomography (CT) ( Fig. 22-1 ) chest measurement of Haller index (should be >3.5) ( Fig. 22-2 )
Figure 22-1
Figure 22-2
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Transverse diameter of chest wall, AP diameter
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Studies
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Echocardiogram
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Pulmonary function tests
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Exercise tolerance testing
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Labs: Complete blood cell count, bone morphogenetic protein, prothrombin time, partial thromboplastin time
Step 3
Operative Steps
1
Anesthesia
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Supplemental thoracic epidural for postoperative pain control
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Deep venous thrombosis prophylaxis for older patients
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Good intravenous (IV) access with two large-bore peripheral IVs
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Antibiotic prophylaxis
2
Positioning and Prepping
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The patient is placed supine on the operating room table with both arms abducted on arm boards so that the axillae are able to be prepped in the field.
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Foley catheter, nasogastric tube (NGT) remove at end of case
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Prep of choice should include bilateral chest to level of bed laterally to include both axillae, superiorly to chin and inferiorly to umbilicus ( Fig. 22-3 ).
Figure 22-3
3
Landmarks and Measurements
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Mark the deepest portion of the deformity. If the deepest location is at the xiphoid, then use the base of the sternum as the level of incisions and bar placement.
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Mark the intercostal spaces laterally that correspond to this level, and draw planned transverse lateral incisions from anterior to midaxillary lines bilaterally (~2.5 cm long).
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Mark the location where the bar should enter the thoracic cavity bilaterally at the point of maximal excursion of the defect anteriorally (mark with X ) ( Fig. 22-4 ).
