Ravitch Procedure for Pectus Excavatum Periprocedural Care

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

Patient Education and Consent

Patient instructions

Patients are evaluated and treated by a physical therapist before surgical correction of pectus deformities so that they can practice proper posture and alignment, which will help with their recovery.

Elements of informed consent

Risks of the operation are discussed with the patient, including but not limited to bleeding, infection, recurrence, and injury to the adjacent lungs and heart.

It is important to stress that the operation will be painful despite the maximal utilization of analgesia. A 3- to 7-day hospitalization period is required. Patients will be discharged with oral analgesics, including nonsteroidal anti-inflammatories, narcotics, and muscle relaxants.

Physical activity will be limited for several months after surgery, with no participation in heavy contact sports (eg, football) until the stabilization bar is removed. If a metal bar is placed for sternal stabilization, patients and families need to understand that a second operation will be required 6 months to 1 year later for bar removal.

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Preprocedural Planning

Objective studies that can help measure the severity of the pectus deformity include pulmonary function tests, computed tomography (CT) of the chest, and cardiac evaluation with echocardiography.

Pulmonary function tests may reveal either restrictive or obstructive airway disease. If airway disease is found, a pulmonologist may be consulted prior to surgical correction.

Chest CT is performed to determine the Haller index (or pectus index), which is an indicator of the anatomic severity of the pectus excavatum. The Haller index is calculated by dividing the transverse (lateral) diameter of the chest by the narrowest anteroposterior diameter of the chest, measured from the spine to the sternum. [19]  A CT index greater than 3.25 is considered severe and is an indication for surgery. However, a lower index is not necessarily a contraindication for repair. [20]

Cardiac evaluation should be undertaken in patients who are symptomatic or who are suspected of having Marfan syndrome. Echocardiography enables evaluation for cardiac compression, as well as mitral valve prolapse, which is frequently associated with pectus deformities. In patients with Marfan syndrome, echocardiography may be performed to evaluate for aortic root dilation.

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Equipment

Stabilization bars should be available in the operating room. The use of a stainless steel bar is the most common approach for sternal stabilization. Allogenic bone graft has been reported as a strut alternative to the stainless steel bar. [21]

Chest tubes should be available should iatrogenic pneumothorax inadvertently occur.

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Patient Preparation

General endotracheal anesthesia is required. Preoperative placement of an epidural catheter or paravertebral nerve blocks should be considered to aid in control of postoperative pain, which is significant. The patient is positioned supine on the operating room table. An orogastric tube and a Foley bladder catheter may be placed after induction of general anesthesia.

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Monitoring & Follow-up

Patients can be discharged to home when their pain is well controlled with oral pain medications.

Owing to the risk of significant injury, activities that place patients at risk for sternal trauma are restricted. These restrictions may include refraining from contact sports for at least 3 months or until the support bar is removed, if one was placed. In addition, patients should ride in the back seat of the car to prevent possible sternal trauma if the front seat air bag were to deploy.

Patients are seen for their first postoperative visit 2 weeks after surgery. They are reminded to work on their posture. Some groups advocate regular aerobic exercises to prevent collapse of the repair.

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