Pectus Excavatum

Pectus Excavatum

Pectus Simple Autogenous Tissue C. OTTO Support ANY EXCELLENT been ARTICLES written on symptomatology, thology of been plicity Whether...

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Pectus Simple

Autogenous

Tissue

C.

OTTO

Support

ANY

EXCELLENT

been

ARTICLES

written

on

symptomatology,

thology

of been

plicity

Whether desirable

question. support edly,

questioned?

tus

abnormality are patients respiratory

many

related to the deformity. with cardiac abnormalities impairment, but their

excavatum is coincidental cause. Observation of patients correction

of

veals

a greater

thoracic

it is impossible function. When patient and

has

has

lived right

deep

after

right thoracoplasty, pectus excavatum

ment

of

who

num.

The

pneumonectomy

has

pectus

and

observation

of young

The

cosmetic

num, and

the flat chest, the protruding

effect

most

of

deformity

workers

of

concern gery, *From of

the

about the

the

safety

the

Department

Maryland

School

the

depressed

that

body

predictable of

of of

and Anatomy,

to

to

correct

by

the

Once been

the held

either

fixation

by

modifications

inter-

which

autogenous

by

It

use,

is ac-

tissue

the has

described may,

its

is the

by

one

is held

securely

in position

of

the

6th

or

4)

that

are

allowed

General perichondral

tal

cartilages,

7th

attached to the is extrapleural. anesthesia

intratracheal

is used tube.

stripping

and

in

most surgeons The sternum,

use

out

been time

PROCEDURE

procedure

bilateral

(Fig.

the

worth.

the years one feature.

normally operation

667

that

elevated, tilages

University

be

OPERATIVE

surgical

throughout adds only

Medicine.

the

is

indicate

one has not yet belief and desire that

prove

THE

The

sim-

would

reliable

procedure to

and

of surthe

have

impossible and modifica-

position

sternum

the

indicate

results

surgery,

older

is de-

to

methods

old

used

external”

proper or described.

about the structural

seems

surgiand

pectus excavatum. been elevated, it has

corrected or

and

shoulders, easily con-

of discussions of this obvious

the

) ‘#{176} and

different described,

it almost methods been

of pec-

(1911

not been described. Some investigators deny that any type of support is necessary for the sternum once it has been elevated? The many different s u rg i cal procedures

ster-

correction

has

elevated

the psychodeformity is troublesome.

the stooped abdomen

A critical review surgical correction

com-

rester-

and

have of

purpose.

many been of

this

tissue for undoubt-

correction

Meyer

(1913) have

of

resolve

complished by the use of various methods and materials.A method of fixationof

suffers

decompensation of the depressed

the surgical

by

that

nal”4 15

function. Opis the 60-year-old

deep

first

modifications

deformity sternum

it is difficult to causes impair-

cardiac correction

accomplish the

excavatum

in

for and

will

tions

excavatum,

adults leads to the belief that logic difficulty caused by the common and can be rather

vinces sirable.

yet

difficulty

cardiopulmonary to this observation

troublesome lieved after

and

A simple, certain

deformity,should

been used, making describe the various

to physiologic a 72-year-old

pectus

without

plete believe

patient

re-

capacity,

years

posed

easily

deformity

to relate this one observes

who yet

the

the and

procedure. procedure,

the

Sauerbruch cal procedures

There and pectus

and not before

operative

operative

The use of autogenous of the elevated sternum,

Since

Many careful studies indicate that only an occasional patient presents a physiologic

after

of the safe

correcting

pa-

necessary or

Elevated*

F.C.C.P.

easy,

etiol-

associated

pectus excavatum.14 is

M.D.,

Sternum

Maryland

HAVE

history,

and

surgical correction has

the

to Keep

BRANTIGAN,

Baltimore,

M ogy,

Excavatum

while

the

and once by the

costal

car-

to remain

sternum. with

During of the

used

The or

with-

the

sub-

deformed

sternum

cosis

OTTO

668

being elevated, a mild positive pressure anesthesia is used in order to prevent pneumothorax, even though a small opening might inadvertently be made in the pleura. At

closureof

is not connected

the

The

incision

is used

end

of the

peritoneal

ity

(Fig.

2).

from just above the sternal to about the mid-point between sternum

and

incision is carried the peritoneum. It

to

adjacent deformed

cartilages are tomic structures

cavity;

the

to the avoids

entering

sected sides

pectoralis free as far

extends.

The

rectus

is dissected free rectus sheath costal

major

margin.

muscle

on

only

muscular

constant

found

in

cerns both

the sides.

5th mal.

costal On one

side

cartilage as found the rectus

stops

short

the

costal

rectus Rarely

at

muscle both

the 7th costal cartilage. freed from the xiphoid

FIGURE

where the its highest

devision

laterally

line,

back,

for

the

purpose

of smoothness

final freed

contour. first, but

leave

it normally

dis-

attached

to

exact

side

attached

the

number

is

front

to

of the

cartilage necessary

to the

is to

sternum.

is next freed in the it is allowed to remain

sternum.

and 3rd

4th,

5th,

from

The 7th costal it is absolutely

6th costal cartilage mannerand

The same

In

sequence, the

costal

depends

cartilages upon

the

(the extent

of

posterior from the

freed in a subperichonand these deformed cartilages An identical procedure is car-

deformity

ried

the

con-

on either one or extend up to the in the normuscle often which

The diaphragm process and

1

laterally reaches

oblique

The

of

pleural

the deformity) dral fashion, are excised.

development

margin,

rib

is is the

out

on

are

opposite

side.

and 7th costal cartilages allowed to retain their to the vorably

sternum placed

sternum

are allowed on

that either

used hold the sternum

to remain

both

FIGURE

Both

the

6th

bilaterally normal attachment

in order one on

sternum can be in position after Two

of

the costal

free

the

an

on both deformity either

divided or

chest

of anasurface.

stripped

anteriorly.

cav-

are

cartilage

are (avoiding

on

pleural

wall chest

cartilages tissue

made

and the

from the ribs. The is dissected free The

the

exposed and freed on their anterior

level

umbilicus.

muscles

from the chest laterally as the

stage,

It

sternum entering

the

At this deformed

dethe

is avoided. The

costal margin. sternum and

costal

A mid-line

lower

the

operative wound a drain The costal If a drain it should is be used, perichondral constant negative pressure cavity) and

used. with

suction. extends formity

Diseases

C. BRANTIGAN

sides

2

the most side of

are fathe

to the sternum is elevated. attached in

to the case

one

is

broken

Volume November,

off

52,

No. 1967

5

inadvertently.

cartilages use

These

also

for

act

traction

Traction

it easier and the posterior sternum either bone

costal

safer surface

to

by

wedge

osteum.

stainless mere On

sternum. makes

steel

and sutures of

occasions,

the

of then

an accessory osteotomy direction in the distal end

sternum

or an oblique

to bring about rarely necessary

the

osteotomy

is selected

on

in order It is pro-

made,

remaining

The

costal

costal cartilages

are

used

placed

in the

Rsctus Muscl.s Advapc.d -

N left).

FIGURE

It

is

5). Once

the

cartilages

D.tach.d

(upper

sides.

(Fig. 4 and

been

t.ctus

3

both

adjacent

of the intact rib or costa! cartilage

The sternum

FIGURE

nec-

accomcartilage,

attached to the sternum is fixed to the selected rib or costal cartilage on its respective side by two stainless steel wire sutures.

in the of the

cess.

the

is stripped of periosteum or perichondnium. The selected costal cartilage on both sides

pen-

a straight sternum. to resect the xiphoid

7th,

or

surface

it is necessary

to make opposite

6th

and

or osteotomies suitable costa!

the selection has

fixed,

strong

osteotomy the most

or costal cartilage

the

through

elevated

the sternum

essary plished,

selected by its ability to lie in an intercostal space along the side of an undissected rib

from

osteotomy

suturing some

to

free the tissue of the sternum.

is accomplished

or

the cartilages

669

With

costal

structures

elevating

these

necessary

attached

as excellent in

on

The

EXCAVATUM

PECTUS

4 (upper

right).

FIGURE

5

(lower).

are to

resected.

anchor

intercostal

the space

6 o

OTTO

order

in

to avoid

on the cles

a visible

anterior

are

chest

approximated

It is often

muscles cartilage. the

as

line.

sutured and

The

pleural

the

and

the

in

pairment

tion

most is

and

mid-

skin

No

are

drain

is

entered, of the

manner).

surgical pneumothorax.

The

opening termination

an inadvertent pleura. At the it is dangerous one connected

will is of

can

actually

the

suck

air

postoperative into

the

cavity

through the drain, and thus cause a positive pressure pneumothorax to develop. Drainage is unnecessary. Meticulous care should be given to asepsis and tion of postoperative infection. Advancement been

of

described

past.40 ’ upper inent

It

aids

muscle the body

the

of costal in

of the cartilages 1962.

The

the

cosmetic

many

the

reduction

bulge usual

which deformity that

is an

important

in

the

of

the

of the

patient

patient

has

results.

are

but

age,

deformed freed in a

used

to fix the

of correcting

the

deformity

has

position. RESU

La

deformidad

por

lo

tos

pero

d#{225}lugar

si,

en

que

La

edad

de dos

practicada

pectus

no

a

grado

psicol#{243}gicos.

cosmhicos,

dedor

MEN

denominada

general

mente.

Es

ser a

tern#{243}n es

elevado los

se

proceder

subpericondrial.

le

f#{225}cil y

menor,

esto

y por

los

es

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de

aire-

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ser es-

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por

el

quithrgico

el

aut#{243}genos

la

correcci#{243}n Una vez en

a efec-

quir irgica-

fin

costales

seguro,

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o

tratada

fija

cartilagos

fisiopa-

mayor

este

a#{241}os,pero la cualquier edad.

a

excavatus

trastornos

por

debe

mejor

mediante

que

para

se

sen-

utilizan

sola-

sostener

el

estern#{243}n

“en

entonnoir”

ne

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ou

posici#{243}n elevada.

factor in

has

La

deformation

cause

fonctionnel plus

Ii

in

a nor-

y

moms

a donc un but

was had been and

use used

an

exused with

elle

lieu de esth#{233}tique Le

traitement

est

facile est

oix et

de

fixer il a

sure,

qui

d#{233}crite par

le

reference

For reprints, please Madison, Baltimore

moment

soit

a

l’auteur.

dans coup

Ia

sftr Ic

position simple,

la

n’utilise

appear Dr.

ce peut

cartilages

operation

Elle

will

Les

il

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soutenir

write: 21201.

mails

l’age. ont

sternum

corrige

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pour

ans

#{233}t#{233} Clev#{233}.Une

list

d’une psychologiques.

cette diformitC #{233}viterles probl#{234}mes

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supprimer et pour

d#{233}form#{233}es qui

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est

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psychologiques.

des

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mais

ou

utilis#{233}es pour

by

du

habituellement

dans

of

sternum

excellent

manner

certain

mente

is a promof pectus

of the sternum

operation complications

of

been described using only autogenous tissue for support of the sternum in the elevated

en

has

advancement

elevated

two

in a normal position once the has been elevated to a normal posisimple, easy, safe operative proce-

Describimos

elimina-

muscle

by

cellent result. The 12 times without cosmetic

for

a

prob-

RESUMI

rectus

used

subperichondral sternum sternum tion. A

cillo,

position. Fixation

first

the

It seems

rectus

holding mal

in

abdominal part of the

excavatum. the

and

be repaired

at

problemas

period

pleural

patient

tol#{243}gicos

to use a drain to negative pres-

sure suction. If an ordinary drain is used and there is an unknown small opening in the pleura, the body struggle and the resof

of psychologic

can be done at any age. The costal cartilages that have been

dure

complica-

even made

effort

cause

years

the

anesthesia pneumothorax

piratory

im-

does

about

in

use of slight positive pressure prevent the occurrence of

the operation, other than

it

the

dangerous

though in the

but

degree

It should

excavatum or functional

muscles

usual

unrecognized

or lesser

lems.

DISCUSSION

The

pectus

disease

ordinarily,

greater

recti

of

organic

and/or relief of It is best to treat

mid-line.

the

no

prevention problems.

pleura were to be do a tube drainage

cavity

causes

effect and for the psychologic

tissue

in the

used. (If one should

mid-line

deformity

3rd or 4th costal is closed by suturing

subcutaneous

approximated

SUMMARY

The

mus-

to suture

the

major

Diseases of the chest

BRANTIGAN

bulge

rectus

as high as poscostal cartilage

possible

high as The wound

pectoralis

The

in the

the rectus muscles sible to the sternum beds.

or palpable

wall.

C.

diformit#{233} que

in

Brantigan,

the

des dans

sternum

reprints. 104

West