Simplified Open Repair of Pectus Deformities

The main cause of pectus deformities is thought to be abnormal elongation and/or distorsion of the rib cartilages. In this video, a simplified open repair of both pectus excavatum and protruding deformities is described, based on the subperichondrial resection of the abnormal cartilages. The procedure is performed through a limited transversal or submammary incision in female patients (mean 13-cm long in adult patients). The chondrosternal wall is exposed by minimal detachment of the pectoralis major muscles, then the rectus abdominis sparing the posterior part of the sheath. In the standard form, the subperichondrial resection is complete from the 3rd to the 6th rib cartilages, and limited to the upper extremity of the 7th. An optional transverse osteotomy across the anterior table of the upper sternum is performed when the cartilage resection is not sufficient to ensure a complete mobilization of the lower sternum in the proper position. (In this video the sternum osteotomy was not performed.) In the case of pectus excavatum, chest wall stability is ensured by a straight metallic strut (Wurtz bar, Medicalex, Bagneux, France), placed anterior to the ribs laterally and secured to the base of the sternum with an absorbable suture. The extremities of the 7th rib cartilages are stitched to the base of the sternum, or to the xyphoid process, which is never resected. A "ruffling" suture of perichondrial sheaths is performed using an absorbable running suture, restoring tension to the adjacent intercostal spaces (Fig. 1). In the case of diastasis, the pectoralis major muscles are sutured along the midline. After reinsertion of the middle part of rectus abdominis to the lower edge of the sternum, the pectoralis major and rectus abdominis muscles are approximated, by suturing their respective sheaths. Two suction drains are placed between cartilage and muscle repair, and both subcutaneous tissue and skin are closed with interrupted and intradermal suture, respectively. In the case of pectus excavatum repair, the straight metallic strut is easily removed under local anesthesia on an outpatient basis, six months after the initial procedure.

This therapeutic approach in accordance with the pathogenesis can be applied to different forms of pectus deformities, with low morbidity and no mortality [1]. It corrects the cardiopulmonary disorders associated with pectus excavatum [2, 3]. Last, it can be performed concomitantly to cardiopulmonary bypass surgery [4].

References

1. Wurtz A, Rousse N, Benhamed L, Conti M, Hysi I, Pinçon C, Neviere R. Simplified open repair for anterior chest wall deformities. Analysis of results in 205 patients. Orthop Traumatol Surg Res 2012;98:319-26
2. Neviere R, Montaigne D, Benhamed L, Catto M, Edme JL, Matran R, Wurtz A. Cardiopulmonary response following surgical repair of pectus excavatum in adult patients. Eur J Cardiothorac Surg 2011;40: e77-82
3. Neviere R, Benhamed L, Duva Pentiah A, Wurtz A. Pectus excavatum repair improves respiratory pump efficacy and cardiovascular function at exercise. J Thorac Cardiovasc Surg 2013;145:605-6
4. Rousse N, Juthier F, Prat A, Wurtz A. Staged repair of pectus excavatum during an aortic valve-sparing operation. J Thorac Cardiovasc Surg 2011;141:e28-30