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Pectus excavatum

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Pectus excavatum repair

Definition

Pectus excavatum repair is surgery to correct pectus excavatum. This is a deformity of the front of the chest wall that causes a sunken breastbone (sternum) and ribs.

Alternative Names

Funnel chest repair; Chest deformity repair; Sunken chest repair; Cobbler’s chest repair; Nuss

Description

There are 2 types of surgery to repair this condition -- open surgery and closed surgery. Both of these are done while the child is in a deep sleep and pain-free from general anesthesia.

Open surgery is more traditional. In this method, the surgeon makes an incision (cut) across the front part of the chest.

• The surgeon removes the deformed cartilage and leaves the rib lining in place. This will allow the cartilage to grow back correctly.
• The surgeon makes a cut in the breastbone and moves it aside. The surgeon may use a rib or a metal strut (support piece) to hold the breastbone in this normal position until it heals. Healing will take 3 to 6 months.
• The surgeon may place a chest tube to drain fluids that build up in the area.
• Metal struts will be removed in 6 months through a small cut in the skin under the arm. This procedure is usually done on an outpatient basis.

The second type of surgery is a closed, less-invasive method. It is used mostly for children. No cartilage or bone is removed.

• The surgeon makes two small incisions, one under each arm. A curved steel bar that has been shaped to fit the child is inserted through the incisions and placed under the sternum (breastbone).
• This bar is guided into position using a small video camera called a thoracoscope. This camera is placed inside the chest and removed after surgery.
• Then the surgeon uses a special instrument to rotate the bar and lift the sternum or breastbone. No bone or cartilage is removed. The bar is left in place for at least 2 years.

Why the Procedure Is Performed

The most common reason for pectus excavatum repair is to improve the appearance of children who feel very self-conscious about the sunken look of their chest wall. Sometimes the deformity is so severe that it affects breathing, especially in adults later in life.

Surgery is usually not done before the age of 6. Best results are seen when the surgery is done before adulthood.

Surgery is usually done on children who are 12 to 16 years old. It can also be done on adults in their early 20s.

Risks

The risks for any anesthesia are:

• Reactions to medicines
• Breathing problems

The risks for any surgery are:

• Bleeding
• Infection
• Scarring

Risks for this surgery are:

• Lung collapse
• Return of the deformity

Before the Procedure

Your child’s surgeon may ask for your child to have:

• A complete medical history and physical exam before the procedure
• Chest measurements and photos of the chest
• An EKG (electrocardiogram) or ECHO (echocardiogram) that shows how the heart is functioning
• Pulmonary function tests (PFTs) to check for any breathing problems
• CT (computed tomography scan) or MRI (magnetic resonance image) of the chest to look at the internal structures below the chest

Always tell your child’s doctor or nurse:

• What drugs your child is taking. Include drugs, herbs, vitamins, or any other supplements you bought without a prescription.
• About any allergies your child may have to medicine, latex, tape, or skin cleaner.

During the days before the surgery:

• About 10 days before surgery, your child may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), warfarin (Coumadin), and any other drugs that make it hard for blood to clot.
• Ask your child’s doctor which drugs your child should still take on the day of surgery.

On the day of the surgery:

• Your child will usually be asked not to drink or eat anything after midnight the night before surgery.
• Give your child any drugs your doctor told you to give with a small sip of water.
• Your child’s doctor or nurse will tell you when to arrive at the hospital.
• The doctor will make sure your child has no signs of illness before surgery. If your child is ill, the surgery may be delayed.

After the Procedure

It is common for children to stay in the hospital for 1 week. How long your child stays will probably depend on their level of discomfort after surgery.

Pain is common after the surgery. For the first few days, your child may receive strong pain medicine through an IV (in the vein) or through a catheter placed in the spine (an epidural). After that, pain is usually managed with medicines taken by mouth.

Your child may have tubes in their chest around the incisions. These drain extra fluid that builds up and help the lungs expand. These tubes will remain in place until they stop draining, usually after a few days.

The day after surgery, your child will be encouraged to sit up, take deep breaths, and get out of bed and walk. These activities will all help healing.

At first, your child will not be able to bend, twist, or roll from side to side. The activities they are allowed to do will slowly be increased.

When your child can walk without help, they are probably ready to go home. Before leaving the hospital, you will receive a prescription for pain medicine for your child, to fill at a pharmacy.

Outlook (Prognosis)

Improvements in appearance are usually good. Improvements in breathing or ability to exercise varies from patient to patient.

References

Tzelepis GE, McCool FD. The Lungs and Chest Wall Disease. In: Mason RJ, Murray JF, Broaddus VC, Nadel JA. Murray & Nadel's Textbook of Respiratory Medicine. 4th ed. Philadelphia, Pa; 2005:chap 83.

Sugarbaker DJ, Lukanich JM. Chest Wall and Pleura. In: Townsend Jr. CM, Beauchamp RD, Evers BM, Mattox KL. Townsend: Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2008:chap 57.

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