Abstract
In this chapter, pectus excavatum is discussed with regard to diagnosis, surgical indications, evaluation of severity and surgical approaches. The author reviews the anesthesia implications for the minimally invasive thoracoscopic approach (currently the standard technique) as well as a multimodal approach to pain management including regional and medical management options.
A 16-year-old female with a history of pectus excavatum (CT: Haller index 3.5) without cardio-pulmonary dysfunction presents for cosmetic repair of her pectus deformity. She and her parents are most concerned about postoperative pain control.
What Is Pectus Excavatum?
Pectus excavatum is a congenital deformity consisting of abnormal sternum development that leads to a characteristic caved-in appearance of the anterior chest. The severity of the disease varies greatly from a simple cosmetic deformity to one with significant cardiopulmonary compromise. In addition to the physiologic effects, the deformity itself can cause significant psychosocial and emotional disturbances, particularly during adolescence. Pectus excavatum occurs in roughly 1:300–1,000 live births, with a 4:1 male predominance. Often there is progression of the deformity during puberty.
What Are the Indications for Surgical Correction of Pectus Excavatum?
The indications for surgical repair must include at least two of the following:
Presence of symptoms most commonly including: shortness of breath with exercise, lack of endurance, and chest pain.
Physical exam shows that there is a moderate to severe pectus excavatum deformity which may be symmetric or asymmetric.
The chest wall imaging shows severe pectus excavatum deformity defined as a Haller index > 3.2 or correction index >10%.
The chest imaging shows cardiac and/or pulmonary compression or displacement.
Pulmonary function studies demonstrating a restrictive or obstructive pattern.
Cardiology evaluation elucidates cardiac compression or displacement, rhythm disturbance, and/or mitral valve prolapse.
Significant body image and/or psychosocial impairment.
What Is the Haller Index?
The Haller index is a measure of severity of compression. It is calculated using dimensions from an axial CT by: transverse diameter of the chest from the inside of the ribcage and the anteroposterior diameter from the inside of the sternum to the vertebral body (at the shortest distance) (Figure 48.1). A normal Haller index is <2.5.
Describe the Surgical Repair of Pectus Excavatum?
The modified Ravitch and Nuss procedures represent the two most widely used procedures for pectus repair. The older Ravitch procedure requires significant exposure of the sternum and resection of abnormal cartilage followed by placement of a metal strut that is later removed. This procedure has nearly been abandoned with the creation of the less invasive Nuss procedure, which provides a minimally invasive alternative that does not require osteotomy or cartilage removal.
The Nuss procedure involves two small incisions, one on each side of the lateral chest wall. A thoracoscope is inserted and the chest is insufflated using CO2 allowing for an introducer to be tunneled under the sternum by direct vision. The bar is pulled through under vision to avoid injury to the heart using umbilical tape as a guide. The bar ends are curved appropriately followed by a 180° rotation of the bar. The bar ends are affixed to the chest wall to avoid dislodgement (Figure 48.2). The created pneumothorax is evacuated by placing chest tubes with the distal ends under water followed by application of intrathoracic positive pressure to remove all air bubbles.
