Chondrotomy and sternotomy combined with the Nuss procedure for severe asymmetric pectus excavatum: how to do it
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HOW TO DO IT
Chondrotomy and sternotomy combined with the Nuss procedure for severe asymmetric pectus excavatum: how to do it Hisako Kuyama1 · Sadashige Uemura2 · Atsushi Yoshida1 Received: 25 June 2020 / Accepted: 9 September 2020 © Springer Nature Singapore Pte Ltd. 2020
Abstract The correction of severe asymmetric pectus excavatum is still challenging, especially for adults with a rigid thorax. For the repair of asymmetric cases, we introduce our surgical techniques added to the Nuss procedure. Chondrotomy of the depressed and deformed costal cartilage to elevate the depressed side was performed in a 42-year-old female patient. The depressed chest wall was directly elevated using pectus bars. Her sternal rotation angle improved from 27° to 15° after bar removal. In a 26-year-old male patient, oblique sternotomy and chondrotomy were performed. The sternal rotation angle improved from 26° to 9° postoperatively. These techniques were effective for correcting severe asymmetric pectus excavatum in adults. Keywords Nuss procedure · Chondrotomy · Sternotomy
Introduction
Methods
Pectus excavatum (PE) is the most frequent deformity of the thorax. PE, which is characterized by a depression of the anterior chest wall, varies in morphology among cases. Asymmetry is one of the most important factors in the morphology of PE, as it greatly affects the cosmetic results after surgical repair. Several authors have pointed out that asymmetry may progress during the time of growth [1, 2]. In addition, asymmetric PE correlates strongly with sternal rotation [1]. The correction of severe asymmetric PE with sternal rotation is still challenging, especially in adults with a rigid chest wall. The surgical techniques that were added to the Nuss procedure to correct sternal rotation are presented here.
The evaluation of thoracic deformity
* Hisako Kuyama [email protected]‑m.ac.jp 1
Department of Pediatric Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki‑City, Okayama 701‑0192, Japan
Nishinomiya Watanabe Cardiovascular Center, 3‑25 Ikeda‑Cho, Nishinomiya‑City, Hyogo 662‑0911, Japan
2
The degree of the defect in patients with pectus excavatum was assessed based on the Haller index (HI) and correction index (CI) on computed tomography (CT) [3]. In addition, the sternal rotate angle in each patient was measured at the level of the lower sternum.
Surgical techniques Chondrotomy Based on preoperative CT, the deformed costal cartilage is selected for chondrotomy. A midline incision, 2- or 3-cm long, is made on the lower anterior chest wall. In female cases, a submammary line incision on the affected side may be preferred. After dissecting the pectoralis major muscle from the ribs, the deformed 4th to 7th costal cartilage is exposed and incised halfway in the acutely angled spots. When the depression extends to the 3rd and 4th costal cartilage, a thoracoscopic incision is made using electric cautery, and partial resection by rongeurs is performed. The Nuss procedure is then performed using an appropriate number of
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