Ravitch Procedure for Pectus Excavatum

Updated: Oct 21, 2016
  • Author: Marybeth Browne, MD; Chief Editor: Dale K Mueller, MD  more...
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Overview

Background

The Ravitch procedure was developed for the surgical treatment of congenital chest wall deformities, including pectus excavatum and pectus carinatum. These congenital abnormalities are thought to result from abnormal overgrowth of the rib cartilage adjacent to the sternum, displacing the sternum (1) anteriorly, resulting in pectus carinatum; (2) posteriorly, resulting in pectus excavatum; or (3) a combination of anterior and posterior displacement, resulting in an asymmetric deformity. [1]

Pectus excavatum may be noted at birth and may become more pronounced when the child experiences rapid skeletal growth during adolescence. The exact mechanism underlying abnormal cartilage growth in pectus deformities is unknown. Familial inheritance patterns are present in 37% of cases. [2] Most of the remaining cases are idiopathic. [3]

Pectus deformities are also known to be associated with connective tissue diseases, including Marfan syndrome and Ehlers-Danlos syndrome, and can be associated with other skeletal abnormalities, including scoliosis. [4]

The goal of the Ravitch procedure is to remove abnormal rib cartilage while preserving the perichondrium, allowing regrowth of rib cartilage to the sternum in a more anatomic fashion. [5] Other key elements in the operation include performing a sternal osteotomy to allow redirection of the sternum and stabilization of the sternum with a metal bar, when necessary. Safe performance of concomitant cardiac surgery, if necessary, appears to be possible. [6]

The Nuss procedure is a minimally invasive alternative to the Ravitch procedure for the treatment of pectus deformities. It involves only internal bracing without resection of the abnormal cartilage. A study of the procedural preferences of 135 patients with pectus excavatum found that 62.2% preferred the modified Ravitch procedure and 37.8% the Nuss procedure; it thus appears desirable for surgeons to be experienced with both. [7]

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Indications

Indications for surgical correction of congenital chest wall deformities include cosmetic, psychosocial, and physiologic reasons. Palpitations, exertional dyspnea, fatigue, and chest pain are commonly reported symptoms attributed to pectus deformities. [8]

Many patients have reported exercise intolerance and increasing limitations in physical activity, which they attribute to their chest deformity. Some patients with pectus excavatum have been shown to have a dynamic restrictive pulmonary process. [9] That said, controversy over the association of pectus deformities with cardiopulmonary compromise still exists.

Pectus deformities are often associated with body image issues, especially for patients in their teenaged years, and these issues can predispose patients to psychological distress. Surgical repair of pectus deformities has been shown to improve both physical limitations and psychosocial well-being in children. [10, 11] Improved physical ability after repair may be more a psychological response than a physiologic change.

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Contraindications

Contraindications to the Ravitch procedure are patient-specific and related to operative risk.

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Technical Considerations

Procedural planning

Sternal stabilization bars of all sizes should be available in the operating room prior to incision. A chest tube should be available in case of iatrogenic pneumothorax during the dissection and may be placed at the conclusion of the case.

A type and crossmatch should be performed in order to have crossmatched blood available in the operating room before incision. Otherwise, no specific laboratory tests are needed preoperatively or postoperatively unless otherwise dictated by the patient’s specific clinical situation.

Complication prevention

One of the most common complications after the Ravitch procedure is seroma formation. For this reason, a drain can be left under the subcutaneous flaps to allow egress of fluid, which may otherwise accumulate. Antibiotics to cover skin flora should be given within one hour of incision.

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Outcomes

Intraoperative iatrogenic pneumothorax occurs in up to 3% of cases and is managed with tube thoracostomy at the conclusion of the operation. In the immediate postoperative period, the most common complication is seroma formation. [1, 3] For this reason, a drain may be left under the skin flaps at the end of the operation and is removed before patient discharge. The Ravitch procedure is associated with less postoperative pain than the Nuss procedure is. [6, 12]

Long-term patient satisfaction with cosmetic outcome is generally very good. [1, 3]

Rarely, complications that warrant operative revision result from displacement of the sternum or gross infection that necessitates incision and drainage. [3] Recurrence has been reported in 3-10% of patients. [1, 2, 13, 14, 15, 16]  The Nuss procedure can be performed for recurrent pectus excavatum, regardless of the technique used for the initial repair; however, the Ravitch procedure is still a useful approach for severe recurrences involving sternocostal junction abnormalities and cartilage regrowth under the sternum. [17, 18]

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