What is the recommended surgical technique for correcting pectus excavatum?

Ravitch Surgical Technique for Pectus Excavatum Correction

Primary Recommendation

The Ravitch procedure remains a valid and widely-chosen open surgical technique for pectus excavatum correction, involving cartilage resection and sternal osteotomy with or without strut placement, though the minimally invasive Nuss procedure has become increasingly popular as an alternative approach. 1, 2

Technical Components of the Ravitch Procedure

The classical Ravitch technique involves the following key steps:

• Cartilage resection: Removal of deformed costal cartilages (typically 3rd through 7th ribs bilaterally) with preservation of the perichondrium 1, 3
• Sternal osteotomy: Transverse wedge osteotomy of the sternum to allow anterior repositioning 3
• Strut placement: Optional placement of a supportive bar (either temporary or permanent) to maintain sternal position 3
• Perichondrial preservation: Maintaining the perichondrial sheaths allows cartilage regeneration 1

Modified Ravitch Approach

Recent adaptations have refined the technique:

• Combined procedures: The modified Ravitch can be safely performed simultaneously with complex cardiac surgery (valve-preserving aortic root replacement, mitral valve repair) in patients with connective tissue disorders 3
• Multidisciplinary approach: Requires coordination between thoracic and cardiac surgical teams when combined with cardiac procedures 3
• Operative times: Mean total operative time of 400 minutes when combined with cardiac surgery, with cardiopulmonary bypass time of 168 minutes 3

Patient Selection Considerations

When patients are given a choice between surgical approaches:

• Patient preference: 60.9% of patients choose Ravitch over Nuss (15.2%) or Leonard (23.9%) procedures when offered all options 2
• Age considerations: The Ravitch procedure is traditionally preferred for older adolescents and adults, while the Nuss technique is typically reserved for patients under age 15 1, 4
• Severity assessment: Haller index (CT measurement of chest width divided by anteroposterior distance) helps quantify severity, with mean index of 7.3 in surgical candidates 3
• Specific indications: Asymmetrical deformities, recurrent pectus after failed Nuss procedure, and patients with connective tissue disorders (Marfan syndrome) may benefit from Ravitch approach 1, 3

Perioperative Outcomes

Hospital Course

• Length of stay: Mean 2.2 days for isolated Ravitch procedure 2, extending to 9.1 days when combined with cardiac surgery 3
• Pain management: 50% of patients require epidural analgesia or patient-controlled analgesia pumps 2
• Blood loss: Minimal in isolated procedures 4
• ICU stay: Mean 82 hours when combined with cardiac surgery 3

Complications

• Overall complication rate: 14.3% for Ravitch procedure 2
• Wound infections: No deep or superficial sternal wound infections reported in recent series 3
• Respiratory complications: No prolonged ventilation or reintubation for respiratory failure in recent series 3
• Bleeding: No reoperations for bleeding or tamponade in recent series 3

Critical Long-Term Considerations and Pitfalls

Late Complications

• Catastrophic events: Life-threatening cardiac tamponade and cardiogenic shock can occur up to 19 years postoperatively due to broken metal sternal wires injuring the ascending aorta 5
• Hardware failure: Metal wire breakage represents a serious delayed complication requiring salvage cardiac surgery 5
• Long-term surveillance: Patients require indefinite follow-up given the potential for very late adverse cardiovascular events 5

Comparative Outcomes

• Cost: Mean charges of $27,414 for Ravitch versus $43,749 for Nuss procedure 2
• Complication rates: Lower than Nuss procedure (14.3% vs 35.7%) 2
• Analgesic requirements: Lower than Nuss (50% vs 100% requiring epidural/PCA) 2

Alternative: Minimally Invasive Nuss Procedure

For comparison, the Nuss technique offers:

• Mechanism: Retrosternal metallic bar placement through lateral incisions under thoracoscopic guidance, raising the sternum without cartilage resection 1, 4
• Age preference: Best suited for symmetrical pectus excavatum in 7-14 year-old children 1
• Bar removal: Hardware removed after 1-2 years once permanent remolding occurs 1, 4
• Complications: Higher overall rate (35.7%) with bar displacement being most common 2, 4
• Hospital stay: Longer (3.9 days) with higher analgesic needs (100% requiring epidural/PCA) 2

Key Caveats

• Hardware-related risks: Both permanent and temporary metal implants carry risk of migration, breakage, and cardiovascular injury even decades after implantation 5
• Recurrence: Failed Nuss procedures may require conversion to Ravitch approach 3
• Cosmetic indications: Most repairs (76% in one series) are performed for purely cosmetic reasons rather than cardiorespiratory compromise 1