Ravitch Procedure for Pectus Excavatum Technique

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

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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.

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