Minimally Invasive Repair of Pectus Carinatum

Pus carinatum is a chest wall anomaly that can be corrected by a number of surgical and non-surgical techniques. Minimally invasive repair of pectus carinatum, also known as the Abramson or reverse Nus procedure, is an innovative technique that can correct the pectus without cartilage resection. The operations depicted in this video were carried out on 2 16-year-old boys who had onset of pectus carinatum at adolescence. Their correction pressures were between 6 and 7 pounds per square inch, indicating moderate stiffness of the chest wall. They and their families were well informed of. All options and chose to proceed with the minimally invasive repair. In addition to the Zimmer Biome pectus tray containing tunnelers and bars, the special equipment used in this procedure includes 4 hole stabilizers, bendable rib protectors, and the pioneer sternal cable system. The procedure is performed under general anesthesia with an epidural catheter for intraoperative and postoperative analgesia. Prophylactic antibiotics are given, and a Foley catheter is inserted and kept for 24 hours. The patient is marked as shown. A vertical line is drawn in the midline of the chest from sternal notch to xiphoid. The distance between the two mid-axillary lines at the highest point of the carinatum is measured after correction of the carinatum, and a bar of equal length is chosen. The bar is placed on the chest and its borders drawn. The end of the bar on each side should correspond to the intercostal space between the two ribs where the stabilizers will be anchored, here shown on the patient's right side. The markings on the left side are shown here, and the incision is again centered between the two ribs which have been labeled. The incision is taken through skin, subcutaneous tissue. And all muscle layers down to the ribs, which are cleared of all muscle attachments for a distance of approximately 3 centimeters. After rib dissection, the bar is again placed on the chest wall to confirm correct positioning. A 1 inch periosteal incision is made in the rib, and the periosteum separated from the underlying bone anteriorly and posteriorly. The subperiosteal dissection of both ribs on the right side is complete. A right angle clamp is placed in the subperiosteal space under the rib. A narrow measuring tape is brought under the rib to measure the space. A rib protector of similar size is bent to the shape of the rib, and a cable is threaded through its holes. The cable is grasped, and the cable and protector are passed under the rib within the subperiosteal space. Here we can see that the process has been completed for the lower rib where the cable and rib protector are already in place. A small piece of dental wire is used to label the rib protector to facilitate removal from behind the rib in 2 to 3 years. The two rib protectors and cables on one side of the dissection are now in position. The two ends of each cable are then threaded through the two holes on each side of the stabilizer. The stabilizer with all cables threaded is then positioned in the pocket previously created. A tunnel is then created between the muscles and the bony chest wall using a long curved clamp and finger dissection from both sides meeting at the midpoint. It's completed with the least curved pectus tunneler. A 2 silk is tied to the pectus bar which has been bent in preparation for bringing it across the tunnel. The ends of the bar are inserted into a stabilizer on each side. Sterner wire is placed around a notch in the bar just distal to the stabilizer to lock the bar and stabilizer in position. The cables are adjusted so that each limb is of equal length. The pioneer cable system is assembled for deployment. The cable ends are threaded through the crimps at the tip. They are then fed through the instrument and tightened. With pressure on the chest to achieve a corrected position, the crimps are locked on the anterior surface of the stabilizer. The same process is performed twice on each side, and once completed, the bar will be tightly anchored to 4 ribs, 2 on each side. The rib protectors prevent the cables from cutting through the ribs. Excellent correction has been achieved. The incision is closed in layers to obtain adequate covering of the hardware. The postoperative chest x-rays of both patients are shown here. Here we see the results one year after repair. Excellent correction was achieved and maintained. Notice that in addition to correction of the pectus, lateral chest wall expansion has occurred.