ravitch procedure

Ravitch Procedure for Fixing Pectus Excavatum

Pectus Excavatum Over the Years

From ancient times up until today, people are suffering from pectus excavatum.

We are constantly searching for more information and more better ways to solve the problem with the sunken chest.

The first time pectus excavatum was described was in 1594, by Bauhinus. He had a patient with short breath problems.

After that, in 1820, Coulson recognized and described a genetic predisposition to this kind of deformity.

There were families with three generations that had pectus excavatum problems.

Numerous other cases appeared in the 19th century, but methods to solve them were limited.

As time passed, various methods are invented and discovered.

There is a surgical and non-surgical treatment available to handle the condition of individuals with a sunken chest deformity.

Treatment options are different depending on the type of pectus deformity and the stage of the deformity.

Non-surgical options include posture improvement exercises, bracing and psychical care.

Where surgical intervention does take place, there are two types of surgery.

KEY POINT:

Pectus excavatum affected the population centuries ago. In the 20th century, Ravitch and Nuss invented procedures that could surgically correct the deformity.

Nuss Procedure Shortly Explained

In 1998 Doctor Nuss and co-workers submitted a new minimally invasive technique for correction of concave chest.

Today it is known as the Nuss procedure.

It involves placing one or two steel bars under the breastbone.

The purpose of this is to elevate the sternum, by using the ribs as pressure countering correction of the abnormal shape of the chest.

Each bar, curved to fit the patient's chest, is implanted through small openings in the chest. 

The bar is left in place for a few years and then is removed in a one-day operational procedure.

The method is created for prepubertal children and the optimal recommended age for rehabilitation was between 12 and 16 years old.

When it comes to choosing between the Nuss and Ravitch procedures, the scar you’ll get after the operation is critically important.

You will live with this scar till the rest of your life.

The Nuss procedure gives an improvement of the deformity without a scar on the front part of the chest.

The Ravitch method offers proven results over a long period, however it will leave a small anterior scar.

Both methods are universally trusted among the pediatric surgical community. They are constantly modified to become safer and more effective for the patients.

KEY POINT:

The Nuss procedure is a minimally invasive procedure that uses steel bars to elevate the indented sternum.

What's the Difference Between Nuss and Ravitch

nuss vs ravitch comparison

There's no big difference between these two surgeries.

That is why they are still the most used surgical procedures out of them all.

The best possible evidence arrives from a systematic review.

39 studies, including 807 adults and 2716 pediatric examples, focused on the comparison of the Ravitch and Nuss surgical treatments.

The summary showed that complication rates varied.

Nuss and Ravitch procedures were generally safe for both pediatric and adult patients.

No fatalities during the time period of a patient’s surgical procedure were reported.

A UK research published in 2019 revealed the re-operation rate in adult patients was the highest for plastic implant methods at 18.8%, followed by Nuss 5.3% and Ravitch 3.3%.

But there was no dramatic difference in these rates in children. 

KEY POINT:

Both Ravitch and Nuss procedures are effective in correcting pectus excavatum. There aren't any significant differences between the two.

History of the Ravitch Procedure

ravitch procedure history

At the beginning of the 20th century, there has been great progress in the area of anesthesia.

That led to the development of breast surgery.

Among the first operative procedures for fixing pectus excavatum was the removal of deformed rib cartilage, especially the second and third ribs on the right.

This type of surgery was done by Meyer in 1911.

However, this procedure did not result in clinical improvement in the deformity.

Two years later, in 1913, Sauerbruch, a pioneer of thoracic surgery, developed a special negative pressure cabin for chest surgeries, with a more aggressive strategy in the treatment of pectus excavatum.

As a result of his hard work, for the first time in the treatment of pectus excavatum deformity, there were significant clinical improvement in patients.

The operative procedure involved cutting out a portion of the anterior wall of the chest, which included rib cartilages from the fifth to ninth ribs on the left, as well as part of the sternum.

Postoperatively, cardiac pulsations were evident because the bone defect was covered only with a set of muscles.

The patient who had severe dyspnea and pulsations earlier in the surgery, now can continue to work and live normal, without any clinical problems.

The teachings of this procedure were later popularized by Mark Ravitch.

In 1939, Lincoln Brown published his experience with pectus excavatum patients, with special reference to etiology. 

He thought the deformity was caused by a serious mechanical backward pull of the anterior wall of the chest, by the short diaphragmatic ligaments.

Guided by these views, he invented two surgical procedures as a treatment of pectus excavatum. 

The first procedure was performed in young children. 

He expected that this procedure could prevent the complete evolution of this deformity in adulthood. 

The second procedure was designed for older children, adolescents, and adults.

Mark Ravitch, in the 1950s, made the greatest contribution in building a surgical method of permanently repairing pectus excavatum.

His method involved:

  • An osteotomy (cutting a malformed bone) on the sternum and ribs
  • Rib cartilage sternum elevation
  • stabilization of orthopedic material in the wanted position

Due to its good results, this surgical method was becoming extremely popular, despite its complexity and its many complications. 

KEY POINT:

The Ravitch procedure was invented in 1950 by Mark Ravitch. At that time, it was the best surgery to repair the hollow chest deformity.

Ravitch Surgical Procedure Step-by-Step

Operational treatment of chest deformities is done primarily because of medical reasons. 

Repairing the deformity will help you with the following:

  • Mental health
  • Posture improvement
  • Cardiac and pneumonic functioning recovery

Surgical treatment is rarely used in children under 8 years old. 

It is important to use the time between your appointment for surgery and the procedure itself to improve your overall level of fitness. 

If you smoke, you need to stop.

Smoking is bad for your heart and lungs and may cause risks of developing chest infections during your operation.

This would mean that your stay in the hospital could be much longer than usual.

Before Surgery

Right before the operation, there isn't any special preparation needed, only good health care. 

Your doctor will choose your treatment.

After that, you need to do cardiology evaluation, as well as pulmonary function tests which are very helpful.

You will be asked to work on your good health condition in the weeks leading up to surgery.

Before the operation, you may need to avoid specific foods, drinks and certain medications.

The idea behind Ravitch's operating procedure is based on the belief that the deformity is caused by more intensive growth of the rib cartilage, compared to the growth of the sternum itself. 

During Surgery

The surgical procedure consists three main elements of correction:

  • Resection (cutting) parts off the rib cartilage
  • Oblique resection
  • Sternal fixation

The surgery begins with a central longitudinal or oblique inframammary cut (better cosmetic results are achieved in women).

Then, mobilization takes place in pectoral muscles, parallel to the costochondral union and exposures of the rib cartilage.

Often it is done from the third to the seventh, and sometimes the second rib cartilage is included.

Any rib cartilage that enters the deformity is resected, and partially or completely removed with a try to preserve the perichondrium.

The section towards the sternum appears with special care because of the risk of injury.

It is essential to preserve rib growth at least 1-1.5 cm of rib cartilage. 

By performing this part of the procedure, the xiphoid is separated from the sternum.

After that, the sternum is placed according to the point of needed correction.

Fixation of the corrected sternum is achieved by the retrosternal placement of Kirschner wire or a metal bar.  

Then, an extra fixation for the corresponding ribs is done.

Next is a reconstruction of the chest muscles and their join up in the midline. Next is the repair of the surgery scars by layers. 

Postoperative Results

Ravitch's method of surgical treatment, as well as Nuss's minimally invasive procedure, gives excellent results in deformity corrections.

This is approved by thousands of satisfied patients. 

However, this technique is characterized by a longer surgery time and an excessive amount of blood loss.

Also, Ravitch is characterized by a lower intensity of postoperative pain, in comparison to the Nuss procedure. Recovery is quicker, as is the return to daily activities.

The period for removal of fixation and stabilization material is shorter, compared to the Nuss method.

Overall, for the last 70 years, the usual surgical approach to the pectus excavatum repair has been with the techniques described by Ravitch.

The basic systems include subperichondrial removal of the offending costal cartilage, remodeling of the sternum, and stabilization.

The Ravitch procedure offers safeness for the patients and doctors as well.

KEY POINT:

For the Ravitch procedure to be fully successful, surgeons divide it in three parts. Surgery preparation, surgery and after-surgical care.

The Modified Ravitch Procedure

This procedure requires elevation of the sternum and surrounding area, removal of abnormal cartilages, and fixation of the sternum in a more natural position with a metal bar.

This metal bar stays in place in your chest for at least a year.

After this reshaping period, it is removed with another procedure.

While this procedure has a good history of correcting the condition, it requires a cut (and scar) on the front of the chest.

The modified Ravitch operation includes creating a horizontal cut from one side of the chest to the other.

Drains are injected on each side of the chest to remove any fluid from the operation. The injury is closed using dissolvable stitches.

A strut is injected to settle the chest in place permanently but may be removed if it causes pain or other problems.

This operation might take several hours and requires postoperative hospitalization for pain control.

Physical activity is seriously restricted for several months as the costal cartilages slowly grow back together.

KEY POINT:

During the Modified Ravitch procedure, the malformed cartilage is cut and the breastbone is elevated using a metal support system.

Ravitch Procedure Cost

According to this study, the cost per patient for Ravtch procedure surgery is at around $4,000 based on current pricing. 

Further costs related to the initial appointment, pre-admission checks and follow-up arrangements are expected to be around $800.

This sums to an estimated total cost of the Ravitch procedure in the United States of £4,800 per patient.

What You Need to Know About This Procedure

The Ravitch procedure is used to correct a severe case of pectus excavatum.

It's usually used for patients from 13 to 22 years old. 

  • A cut is made across the chest.
  • The bone cartilage is reshaped.
  • Bars are placed to keep the sternum in its new position.
  • Bars are removed in about 6–12 months.
  • One or more drains are placed under the skin to drain fluid from the surgery site.
  • A chest tube may be placed to prevent the lung from collapsing.
  • The cut is closed.

Few months after the surgery, the cartilage grows and keeps the chest in the new position.

5 Types of Anesthesia for Ravitch Surgery

There are few types of anesthesia to prevent terrible pain during the surgery.

The Nuss procedure pain during the surgery can’t be compared with the brutal pain of open repair techniques such as Ravitch procedure.

However, there was no difference in the pain scores of adults and children after surgery.

1. Thoracic Epidural Anesthesia (TEA)

This is used for abdominal, vascular and cardiothoracic surgeries.

The purpose of the thoracic block is not to block harmful afferent stimuli from the operation, but to allow a bilateral selective thoracic sympathectomy.

Terms of pain relief enable patients to cough, inhale deeply and drink.

Prepare offers postoperative outcomes such as improved respiratory capacity, reduction in ileus and proteid saving.

TEA is supplied for at least 3 days.

Epidural analgesia after repair of pectus excavatum consistently showed valid pain control with TEA.

But, the thoracic epidural can be critical to insert mainly in adults and is associated with a failure rate of about 30%.

So, you need to know that this strategy is not without potential complications.

Your doctor must know everything about your condition before you use this anesthesia.

2. Paravertebral Block (PBV)

This is commonly done in thoracic surgery as a supplement to anesthesia after surgery.

PBV means a local injection of anesthesia in a space immediately tipped to where the spinal nerves begin from the intervertebral opening.

This procedure is being used more for intra-operative and postoperative analgesia.

But also as a single anesthetic technique for bringing out different procedures. This procedure is popular mainly because of the ease of the technique and fewer complications.

With the Paravertebral block, there is a potential risk of local anesthetic toxicity.

The increase of epinephrine to the local anesthetic extract may prevent the absorption of local anesthetic from the space and decrease the risk of local anesthetic toxicity.

3. Intercostal Nerve Blocks

This is an injection of medication that helps you with pain relief in the chest area caused by an infection or a surgery.

Intercostal nerves are under every rib. When these nerves get irritated or inflamed, it can cause pain.

And with these blocks, nerves are prevented, and the risk of pain is small.

4. Other Chest Wall Blocks

Pecs I block

Local anesthesia is injected into the plane between the pectoralis main muscle and the pectoralis minor muscle.

If the anesthetic is too deposited above the serratus anterior muscle at the third rib the method is described as the Pecs II block.

Serratus nerve block

This involves an ultrasound-guided shot of local anesthetic external or deep under the serratus anterior.

Those new blocks techniques have the potential of being important supplements in chest wall surgeries and promise to be a great option for cases with contraindications of techniques such as epidural or PVB.

KEY POINT:

Five types of anesthesia can be used so the patient won't feel any pain during, and after the Ravitch prcoedure.

How Does the Patient Receive the Anesthesia?

When your doctor chooses any of these anesthesia for you, the first one is a medication to relax you.

The doctor uses antiseptic to prepare the area of skin near your ribs and then inserts a thin needle beneath the rib and injects an anesthetic.

He/she uses an X-ray guidance to insert a second needle and inject a steroid pain remedy.

Normally it takes less than 30 minutes, and after that, you can go home the same day.

Depending on the pain level, relief can come immediately after the injection or may take a few hours later. 

But, there is longer-term relief anesthesia, which begins to work in two to three days.

How long the pain relief lasts is different for each patient. For some, the relief can last several months.

If the treatment works for you, you can have periodic injections to stay pain-free.

The risk of complications is very low.

However, there could be bruising or soreness at the injection site.

Serious complications, including infection, collapsed lung, nerve damage and bleeding, are uncommon.

Don't do any harsh movements for 24 hours after your anesthesia wears off.

Take it easy, for better results. After the first 24 hours, you can live normally and you can eat regularly.

KEY POINT:

You will be given the type of anesthesia, depending on the severity of your deformity.

Day of the Operation

  • You shouldn’t eat a few hours before the surgery.
  • When you are ready, you will be connected to a heart and pulse monitor at the anesthetic room.
  • The anesthetist will give you medications to get you to sleep
  • A tube connected to the breathing machine (ventilator) is inserted, to follow your condition
  • Other drips are inserted, one in the big vain in your neck to give you fluids and another in your wrist to monitor your blood pressure
  • The anesthetist is with you during the whole surgery

Support Bar Removal & Recovery

ravitch procedure metal bar

The metal struts that support your chest are removed one year after they are inserted.
A pre-surgical visit is needed. The removal surgery takes about one hour.

With the minimally invasive surgeries like the Nuss procedure, the pectus bars are removed two years after insertion.

It is also an outpatient process that takes about one hour. A visit to the doctor’s office is required just before removal.

Following the Ravitch procedure, you will be hospitalized for 3-5 days.

The therapeutic team will work with the surgical team to make sure that pain is well controlled, so you can recover smoothly.

Multiple ways can control your pain. A team of doctors will come up with a plan based on your recovery.

Originally, pain medications will be used to control your pain.

When you begin to eat, oral pain medications will be used.

Activity Restrictions

In the hospital, you will have activity restrictions that will continue after the removal of bars.

Restrictions are there to protect your chest during the cartilage rehabilitation.

Your doctor or nurse needs to discuss these restrictions with you.

You need to avoid strenuous activity or sports for several months while the cartilage is recovering. 

After being discharged from the hospital, you will follow up in the clinic in 2-4 weeks.

Hospital Stay Care

For kids operated with the Ravitch procedure for pectus excavatum, the bar is removed around six months after the procedure.

Overall, the pectus excavatum surgical repair is a painful procedure.

Length of clinic stay is managed by postoperative pain management.

An epidural catheter, placed in the back, will be used to give you constant pain remedy for several days.

While the epidural is in place, you will have a catheter in the bladder to drain urine and to give oxygen by a small cell under the nose.

In some cases, it may be necessary for doctors to place a small tube in the cut to drain liquid.

The tubes are removed when the drainage finally stops, usually after several days. 

Homecare

If your kid undergoes this type of surgery, every step of the recovery is the same as for adults.

You can help your child recover faster by performing simple activities such as deep breathing, walking and sitting in a chair a few days after the operation.

The clear plastic strips, placed over the cuts, should be removed a few days after surgery.

There will be steri-strips put over the incisions.

The skin surrounding the cut may be red and bruised, and the cut can be slightly puffed.

All of this is normal when it comes to difficult surgeries.

In most operations, the injury is closed with dissolvable stitches.

These stitches are under the skin and don't have to be removed.

A strut is applied in the more critical pectus excavatum patients.

If the volume of anterior separation created by the repair was so high, that additional stabilization during the bone healing period is acceptable.

Struts are easily removed after 6 to 8 months as an outpatient procedure.

In children, these stitches may be removed in about 4 weeks postoperatively.

The best treatment after this is by gently cleaning the area with soap and water.

With time it will start to normal.

When the stitch falls out or fully disappears, the scar will heal.

There is a chance of acquiring signs like worsening redness, swelling pain in the cut area, and illness in 2 weeks after the operation.

If you have any of this call your doctor, do not try to treat this by yourself.

There may be some inflammation in the incisions. When the cut is healed, you will be able to feel a strong elevation under the cut.

This is named a "healing ridge".

It's because the muscles are pieced back together. You’ll usually feel this for several months.

When your treatment in the clinic is done, you can go home and have your home-recovery time.

Do not forget to continue exercising once you leave the hospital. Easy movements like calming yoga postures can help with your condition.

Walking is one of the best things you can do postoperatively for your well-being. Also, breathing exercises will benefit you greatly. 

Your physiotherapist will give you some simple exercises to perform as well.

KEY POINT:

Metal bar support system removal requires an additional outpatient surgery, that also requires general anesthesia. Your physical activities should be constricted in the days following the surgery.

12 Things You Must Know for a Faster Recovery

Before you leave your hospital make sure that you are feeling fine, and you have everything you need for a good recovery.

That means:

  • You are able to move and walk without any constrictions
  • You don't have any uncontrolled or unusual pain
  • Your breathing is fine
  • Your digestion system is normal
  • Drains and liquids are removed

Find someone, no matter if it is a family member or friend that will be with you throughout your recovery process.

You will need help with your daily activities.

Activities must be limited for the first few months.

  • Do not lie on your side.
  • Do not sit in a slouched-over position.
  • Don't twist from your waist.
  • You shouldn't lift heavy objects.
  • For the first three months, you shouldn’t drive. Discuss with your doctor when you are ready to go back to traveling.
  • If you want to do any harder physical exrecises, contact your doctor.
  • Ask the doctor to tell you special coughing techniques to prevent you from feeling sharp pain in the chest

Tips for Parents

If your kid undergoes the Ravitch procedure, the following are some helpful tips according to the Children's Hospital Colorado, for a speedier recovery time:

  • Your kid will need to take pain pills.
  • Kids must rest after surgery.
  • They need to stay at home until treatment with pain pills isn’t needed.
  • It may take up to 6 months or more for your kid to go back to the normal daily activities.

6 weeks after the surgery, your child should:

  • Take all medicines for pain control.
  • Do all breathing exercises.
  • Be careful with infections.
  • Long walks or gentle exercises.
  • Avoid gym class at school.
  • Not carry a heavy backpacks
  • Ride in the back seat to avoid potential injury

KEY POINT:

If you don't want to cause an injury to your chest, and want the recovery process to be faster, you should follow the surgeon's recommendations. 

Ravitch procedure Risks / Failes / ​Death Rates

The most common complications of this surgical method are:

  • Displacement of bars.
  • Allergic reactions to the implant.
  • Squeezing or cracking of other fixing material.
  • Horner's syndrome.
  • Wound infections
  • Development of sores.
  • Skin changes.
  • Pneumonia.
  • Pleural effusions.

Early complications of Ravitch surgery are usually classified as:

  • Antitoxin in the wound.
  • Infection of the wound.
  • Development of pleural effusion.

Patients with pneumothorax need control to normalize pulmonary function.

Hypertrophic scars inside areas of the anterior chest wall are also considered to be postoperative complications.

However, proper surgical technique, as well as good postoperative scar treatment, reduce the chances this complication.

Most failed surgeries are caused by mispositioned or displaced bars.

Bars that were too long or placed too laterally are the most common problems. The risks for recurrence are also often related to incomplete healing and difficulties:

  • Incomplete removal of involved cartilages.
  • Operation is too extensive.
  • Failure to save perichondrium on excised cartilage.
  • Half-done healing or failed fusion of excised cartilage and sternum.
  • Disease and seroma difficulties.
  • Failure to support repair or too early removal of support.

Few Cases of Fatal Outcomes

A research published in 2018, reported seven cases of significant complications with bar removal with two fatal outcomes.

The overall occurrence of minor and major complications after Ravitch procedure have been reported in the research to be 2–20%.

The true rate of life-threatening complications and mortality is not known.

That’s because we don't know the overall worldwide number of Ravitch procedures performed.

Then, do what is in your power to prevent all of this.

Be faithful in your treatment period, be positive and tolerant of all the things that happen to you.

Mental health and care are the best way to go through tough times. Do research about pectus excavatum all the time.

Read about your problem and know that you are not the only one who went through this.

KEY POINT:

Even though the Ravtich and Modified Ravtich procedure yield great results, there are a few cases of serious complications, of which two resulted in death.

Conclusion

The Ravitch procedure is one of the best corrective surgical treatments for pectus excavatum.

During the surgery, the costal cartilage is removed, and the sternum is divided before inserting a small bar under it to keep it in the an elevated position.

The bar is left implanted until the cartilage grows back, and is finally removed in a simple procedure.

Immediately after the surgery, the cosmetic effects of the surgery will be evident.

The Ravtich procedure will improve the shape of your chest which will help you increase your confidence and self-esteem.

Also, when you are done with your pectus excavatum problem and all the things that come with this deformity, your total health would be much better.

The Ravitch procedure allows great results with low mortality, combined with an improved patient’s wellbeing.

The current data about the procedure will be helpful as an example, as newer techniques for pectus excavatum repair continue to evolve.

But you must know that there is testimony of patients who are still not satisfied with how their chest looks after the surgery.

This might be because the surgery outcome didn’t give them the results they expected.
To prevent all of this, you must work for your health.

Improve your healthy lifestyle daily. Work out, or do any type of sport. Eat good as well.
These easy and simple steps will help you have a good body image for yourself.

The right mindset will help you fight through even bigger problems than pectus excavatum.

Educate yourself about your problem and you will find out many more proven ways to help you deal with the deformity, both mentally and physically.

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