Ravitch Procedure for Pectus Excavatum 

Updated: Oct 30, 2020
Author: Marybeth Browne, MD; Chief Editor: Dale K Mueller, MD 

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) both anteriorly and posteriorly, resulting in an asymmetric deformity.[1, 2]

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.[3] Most of the remaining cases are idiopathic.[4]

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.[5]

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.[6] 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.[7]

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.[8]

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.[9]

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.[10] 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.[11, 12] Improved physical ability after repair may be more a psychological response than a physiologic change.

Contraindications

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

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.

Typing and crossmatching 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 1 hour of incision.

Outcomes

Intraoperative iatrogenic pneumothorax occurs in as many as 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.[2, 4] 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.[7, 13]  However, a meta-analysis of 19 studies (N = 1731) found that the postoperative length of stay was similar for the two procedures and that the Nuss procedure (n = 989) was associated with shorter operating times and less blood loss than the Ravitch procedure (n = 742).[14]

Long-term patient satisfaction with cosmetic outcome is generally very good.[2, 4]

Rarely, complications that warrant operative revision result from displacement of the sternum or gross infection that necessitates incision and drainage.[4] Recurrence has been reported in 3-10% of patients.[2, 3, 15, 16, 17, 18]  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.[19, 20]

Instances of fracture of the titanium bars used in a modified Ravitch procedure have been reported.[21]

Toci et al assessed outcomes in 290 adults undergoing Ravitch (n = 53) or Nuss procedures (n = 237) for pectus excavatum to determine whether postoperative complications and recurrence differed significantly between primary and redo operations.[22]  There were no significant differences in postoperative complications or recurrence rates between Nuss and Ravitch repairs overall, between redo Nuss repairs (n = 53) and Ravitch repairs (n = 26), between primary and redo Nuss repairs, or between primary and redo Ravitch repairs; however, there were significant differences between all Nuss and all Ravitch repairs with respect to age, length of stay, follow-up, bars inserted, and estimated blood loss.

 

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-inflammatory drugs (NSAIDs), 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.

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.[23]  A Haller 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.[24]

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.

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, though a titanium bar has also been used.[21] Allogenic bone graft has been reported as a strut alternative to the metal bar.[25]

Chest tubes should be available should iatrogenic pneumothorax inadvertently occur.

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.

Monitoring & Follow-up

Patients can be discharged 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.

 

Technique

Open Repair of Pectus Excavatum

The chest and upper abdomen should be prepared and draped with the patient in the supine position.

The dissection starts with a transverse incision at approximately the inframammary line from the midclavicular line of the right chest to the midclavicular line of the left chest, usually along the inframammary line. A horizontal incision may also be used.

The subcutaneous soft tissues are dissected with an electrocautery until the pectoralis fascia is identified. The pectoralis fascia is incised and subpectoral flaps elevated with an electrocautery, elevating the pectoralis muscles off of the anterior chest wall.

This dissection is continued cephalad until the upper level of the cartilage is identified, which corresponds to the highest level of abnormal cartilage, most commonly at the second or third rib. Once this superior pocket is created, the rectus abdominis is dissected free from the sternum and mobilized sufficiently to expose the deformed cartilage laterally. Once this dissection is completed, the abnormal cartilages are removed.

An anterior longitudinal split is made in the perichondrium with an electrocautery, extending from the bony rib to the sternum. The cartilage is removed from within the perichondrium by using Freer and Haight elevators, with care taken to preserve the perichondrium.

After the deformed cartilage is removed from the rib to the sternum, the xiphoid process is identified and elevated. A subxiphoid space is created, and the sternum is dissected from the underlying tissues with electrocautery or blunt finger dissection. The intercostal bundles are then disconnected from the sternum and may be ligated or preserved.

The sternum is elevated and an anterior transverse wedge osteotomy performed at the sternal-manubrial junction. The sternum is then fractured and elevated to a normal position. Sternal wires can aid in maintaining this position.

With the abnormal cartilages removed and the osteotomy performed, an appropriately sized bar is selected. The sternum is elevated anteriorly, and the bar is placed behind the sternum and sutured or tied to the bilateral rib heads with absorbable suture (eg, polydioxanone or polyglyconate). A wire can also be used.

If the intercostal bundles were preserved, they now may be sutured to the back of the sternum. The perichondrial sheaths are then reapproximated, if necessary, to the sternum with absorbable suture.

At this point, chest evaluation should reveal flat pericostal cartilage with good sternal reduction of the excavatum defect.

The rectus muscles are reconstructed in the midline with absorbable suture and are then sutured to the sternum with the xiphoid placed beneath the rectus. Preserved intercostal bundles are secured to the posterior aspect of the rectus. If the bundles are redundant, then they may be reefed by using 1-0 polydioxanone suture to shorten the distance from the rib to the sternum and to ensure that the cartilages grow in straight and flat.

A drain can be tunneled out subcutaneously through the midline of the lower chest, which is placed in the wound bed overlying the area from which the pericostal cartilage was resected. The pectoralis muscles are reapproximated to each other and secured to the sternum. The pectoralis muscles are secured to the anterior abdominal wall muscles. The subcutaneous tissues are closed in layers, and a sterile dressing is placed.

A small study (N = 12) by Baccarani found that modification of the Ravitch procedure to include bilateral mobilization and midline transposition of the pectoralis muscle flap improved postoperative morphologic outcomes and reduced long-term complications (eg, wound dehiscence, skin thinning, and hardware exposure).[26]  

In a retrospective cohort study of 44 patients undergoing a modified Ravitch procedure for pectus excavatum, de Loos et al evaluated locking compression plates (LCPs; n = 26) against mesh and wires (n = 18) for fixation of the sternal osteotomy.[27]  They noted a lower incidence of symptomatic nonunion after fixation of the sternum with LCPs, though the difference did not reach statistical significance.

Postoperative Care

Patients are admitted to the hospital postoperatively with analgesic administration.

If a thoracic epidural was not placed preoperatively, patient-controlled analgesia (PCA) with a narcotic should be used to control what can be severe postoperative pain. Intravenous nonsteroidal anti-inflammatory drugs (NSAIDs) can be used around the clock to aid in achieving pain control; patients may be switched to oral NSAIDs once they resume their diet. Muscle relaxants (eg, diazepam) are also commonly used as adjuvants for analgesia. A pain pump for installation of local anesthetic may also be considered.

The Foley catheter (if placed) is removed when the patient is ambulating well, ideally on postoperative day 1.

Subcutaneous drains are removed when output is less than 20 mL over 24 hours, prior to discharge from the hospital.