Anatomical Study of the Thorax for the Safe Performance of the Nuss Procedure for Pectus Excavatum

Abstract

Background: To perform a minimally invasive repair for pectus excavatum safely, accurate knowledge of the anatomy of the retrosternal region is crucial. This study was carried out to provide more information on this region. Methods: 1. Using 32 human cadavers, the vascular structure in the retrosternal region was studied. 2. The pleura, transverse thoracic ligament, pericardium, and diaphragm were taken from 10 fresh cadavers, and their thicknesses and breaking strengths were measured. Results: Thick vessels connecting the internal mammary vessels and anterosuperior phrenic vessels were present in a certain number of cadavers. This presence of a vascular communication was observed in 44 % of left thoracic cavities and 12.5 % of right thoracic cavities. The breaking strengths of the pericardium and diaphragm were found to be nearly ten times greater than that of the pleura. Conclusions: Care should be taken not to injure vessels connecting the internal mammary vessels and anterosuperior phrenic vessels when performing retrosternal undermining of the xiphoid region. Since the pericardium is much thicker than the pleura, injury of the pericardium can be avoided by careful undermining.

Key words

thoracic surgery - anatomy - pleura - pectus excavatum

References

• 1 Suita S, Taguchi T, Masumoto K, Kubota M, Kamimura T. Funnel chest: treatment strategy and follow-up.  Pediatr Surg Int. 2001;  17 344-350
• 2 Antonoff M B, Erickson A E, Hess D J, Acton R D, Saltzman D A. When patients choose: comparison of Nuss, Ravitch, and Leonard procedures for primary repair of pectus excavatum.  J Pediatr Surg. 2009;  44 1113-1119
• 3 Davis J T, Weinstein S. Repair of the pectus deformity: results of the Ravitch approach in the current era.  Ann Thorac Surg. 2004;  78 421-426
• 4 Ravitch M M. The operative treatment of pectus excavatum.  J Pediatr. 1956;  48 465-472
• 5 Choi J B, Rim T G. Oblique wedge osteotomy for correction of asymmetric pectus excavatum in young children.  Ann Thorac Surg. 1994;  57 235-236
• 6 Bentz M L, Futrell J W. Improved chest wall fixation for correction of pectus excavatum.  Br J Plast Surg. 1992;  45 367-370
• 7 Nuss D, Kelly Jr R E, Croitoru D P, Katz M E. A 10-year review of a minimally invasive technique for the correction of pectus excavatum.  J Pediatr Surg. 1998;  33 545-552
• 8 Pilegaard H K, Licht P B. Routine use of minimally invasive surgery for pectus excavatum in adults.  Ann Thorac Surg. 2008;  86 952-956
• 9 Park H J, Lee S Y, Lee C S, Youm W, Lee K R. The Nuss procedure for pectus excavatum: evolution of techniques and early results on 322 patients.  Ann Thorac Surg. 2004;  77 289-295
• 10 Kim D H, Hwang J J, Lee M K, Lee D Y, Paik H C. Analysis of the Nuss procedure for pectus excavatum in different age groups.  Ann Thorac Surg. 2005;  80 1073-1077
• 11 Castellani C, Schalamon J, Saxena A K, Höellwarth M E. Early complications of the Nuss procedure for pectus excavatum: a prospective study.  Pediatr Surg Int. 2008;  24 659-666
• 12 Belcher E, Arora S, Samancilar O, Goldstraw P. Reducing cardiac injury during minimally invasive repair of pectus excavatum.  Eur J Cardiothorac Surg. 2008;  33 931-933
• 13 Park H J, Lee S Y, Lee C S. Complications associated with the Nuss procedure: analysis of risk factors and suggested measures for prevention of complications.  J Pediatr Surg. 2004;  39 391-395
• 14 Weber P G, Huemmer H P, Reingruber B. Forces to be overcome in correction of pectus excavatum.  J Thorac Cardiovasc Surg. 2006;  132 1369-1373
• 15 Imai R, Matsumura H, Tanaka K, Uchida R, Watanabe K. Comparison of Doppler sonography and multidetector-row computed tomography in the imaging findings of the deep inferior epigastric perforator artery.  Ann Plast Surg. 2008;  61 94-98
• 16 Chang H, Heo C, Jeong J, Baek R, Minn K, Yoon C. Unilateral buttock reconstruction using contralateral inferior gluteal artery perforator flap with the aid of multi-detector CT.  J Plast Reconstr Aesthet Surg. 2008;  61 1534-1538