1. “Open” pectus excavation repair. A
“Open” pectus excavation repair. A. A transverse incision is placed below and well within the nipple lines at the site of the future inframammary crease. The pectoralis major muscle is elevated from the sternum along with portions of the pectoralis minor and serratus anterior bundles. B. The correct plane of dissection of the pectoral muscle flap is defined by passing an empty knife handle directly anterior to a costal cartilage after the medial aspect of the muscle is elevated with electrocautery. The knife handle is then replaced with a right-angled retractor, which is pulled anteriorly. The process is then repeated anterior to an adjoining costal cartilage. Anterior distraction of the muscles during the dissection facilitates identification of the avascular areolar plane and avoids entry into the intercostal muscle bundles. C. Subperichondrial resection of the costal cartilages is achieved by incising the perichondrium anteriorly. It is then dissected away from the costal cartilages in the bloodless plane between the perichondrium and the costal cartilage. Cutting back the perichondrium 90° in each direction at its junction with the sternum (inset) facilitates visualization of the back wall of the costal cartilage. D. The cartilages are divided at the junction of the sternum with a knife with a Welch perichondrial elevator held posteriorly to elevate the cartilage and protect the mediastinum (inset). The divided cartilage can then be held with an Allis clamp, elevated, and divided laterally, preserving the costochondral junction with a segment of costal cartilage. E. A sternal osteotomy is created above the level of the last deformed cartilage and the posterior angulation of the sternum, generally the third cartilage but occasionally the second. Two transverse sternal osteotomies are created through the anterior cortex with a Hall air drill 2 to 4 mm apart. F. The base of the sternum and the rectus muscle flap are elevated with 2 towel clips, and the xiphoid is divided from the sternum with electrocautery. This procedure allows entry into the retrosternal space. This step is not necessary when a retrosternal strut is used. Preservation of the attachment of the perichondrial sheaths and xiphoid avoids an unsightly depression that can occur below the sternum. G. With the nonstrut method the osteotomy is closed with several heavy, nonabsorbable sutures as the sternum is elevated by the assistant. H. Correction of the abnormal position of the sternum is achieved by the creation of a wedge-shaped osteotomy that is then closed, bringing the sternum anteriorly into an overcorrected position. I. The use of both retrosternal struts and Rehbein struts (David Scott Company, Framingham, MA). The Rehbein struts are inserted into the marrow cavity (inset) of the third or fourth rib and are then joined to each other medially to create a metal arch anterior to the sternum. The sternum is sewn to the arch to secure it in its new forward position. The retrosternal strut (V. Mueller, Baxter Operating Room Division, McGraw Park, IL) is placed behind the sternum and is secured to the rib ends laterally to prevent migration. J. Anterior depiction of the retrosternal struts. The perichondrial sheath to either the third or fourth rib is divided from its junction with the sternum, and the retrosternal space is bluntly dissected to allow passage of the strut behind the sternum. It is secured with 2 pericostal sutures laterally to prevent migration. Division of the perichondrial sheath immediately adjacent to the sternum avoids injury to the internal mammary vessels, which are more lateral. K. The pectoral muscle flaps are secured to the midline of the sternum, advancing the flaps to obtain coverage of the entire sternum. The rectus muscle flap is then joined to the pectoral muscle flaps. (A–H and K reproduced with permission from Shamberger RC, Welch KJ. J Pediatr Surg 1988;23:615–622. I and J reproduced with permission from Shamberger RC. In: Shields TW, ed. General Thoracic Surgery. 4th ed. Baltimore: Williams & Wilkins; 1994:538.)
Source: Pectus Excavatum, Operative Pediatric Surgery
Citation: Ziegler MM, Azizkhan RG, Allmen D, Weber TR. Operative Pediatric Surgery; 2014 Available at: Accessed: October 07, 2017
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