ABSTRACT
Pectus excavatum is the most common chest wall deformity referred for surgical correction. As a congenital lesion, it is a highly visible anomaly and is easily diagnosed. Its anatomic severity can be readily assessed by visual measurement. Repair is undertaken to alleviate symptoms of pain, cardiac or respiratory compromise, as well as to diminish significant psychosocial consequences to a child or adolescent. Was to study results of renewing the standard surgical approach to the pectus repair based on the technique described by Ravitch. Several technical modifications in the operative procedure and perioperative management strategy were added. Two post-operative pain management techniques were used following the Ravitch repair of pectus excavatum: continuous intravenous opioid analgesia, and thoracic epidural analgesia using opioid and local anesthetic combination. This study included 15 patients [nine females 60% and six males 40%], their ages ranged from 8-13 years old with a mean of 10.6 +/- 2.7 subjected to pectus excavatum repair in the cardio-thoracic surgery department between 2001 and 2006. A limited transverse submamary skin incision with generous subcutaneous flap over the muscle fascia. Three to four sets of costal cartilages were removed to get optimal remodeling. The xiphoid process was detached from the sternum. An anterior wedge osteotomy was done using the redo sternal saw leaving the posterior table intact. Final stabilization was done using Kirshner wires mounted on drill, passing transversely under the lower segment of the sternum. Asymmetry can be easily dealt with by adjusting the angle of the osteotomy. Thoracic epidural catheter was routinely placed preoperatively by the anesthesiologist at the most appropriate level between T3 and T8, after induction of general anesthesia. No operative mortality or significant infra-operative morbidities were reported. Blood loss was minimal. Two children developed ileus. One patient had a wound infection that required incision and drainage. Seromas developed after discharge in two patients. All patients had extubated before leaving the operating room and were sent to the thoracic surgery ward after leaving the recovery room. Both regimens provided effective analgesia. A low morbidity with excellent short- and long-term results combined with a high level of patient satisfaction were achieved and should be the standard against which the Nuss procedure is compared. Indwelling epidural catheters placed at the time of surgery lead to smooth postoperative course. This strategy has greatly reduced the amount of narcotics required and allowed for more rapid mobilization