Perioperative management - Pectus excavatum correction

• Patient's desire
  • Particularly during adolescence, there is an impairment of self-esteem, leading to significant psychological stress.
• Haller index > 3.25
• Limitation of physical endurance
  • Here, the limitation of cardiac pump function is particularly relevant, while lung restriction often plays a minor role.
• Chest and/or back pain
  • Chest deformity or resulting misalignments of the spine, such as scoliosis or kyphosis, can promote pain.
• Rare: cardiopulmonary symptoms such as arrhythmias and/or frequent respiratory infections

• absolute contraindication: 
  • Inability to undergo anesthesia
  • Allergy to the metal used
  •  
• relative contraindication:
  • Promising conservative therapy attempt in mild cases.
  • In some cases, another surgical method may be recommended, especially in adult patients due to ossified cartilage and/or significant asymmetry or severity of pectus excavatum.

• MRI of the thorax (Reduction of radiation exposure compared to computed tomography with the same diagnostic value regarding pectus excavatum)
• Allergy test for the metal used in the bar
  • Note: Even a negative allergy test does not exclude an allergic reaction after the surgery.
• Echocardiography
• if applicable, pulmonary function test and spiroergometry
• if applicable, psychological assessment

• Shaving if necessary
• Single-shot antibiotic Cefuroxime 1.5g
• Epidural catheter or paravertebral block as per patient's request

Since this is a highly elective procedure, in addition to the general surgical risks such as thrombosis, embolism, allergy, infection, bleeding, and wound healing disorder, the sometimes rare but serious complications must also be discussed in detail:

• prolonged, severe pain after surgery
• pneumothorax
• dislocation of the metal bar with possible need for re-operation
• allergies to the metal, possibly necessitating explantation
• injury to the internal thoracic vessels with subsequent bleeding
• sternum fracture
• injury to the lung parenchyma
• injury to the heart, for example, perforation with potentially fatal outcome

Double-lumen intubation anesthesia.

Standard supine position, the right arm can be bent at the elbow and suspended above the head, the left arm is abducted. Finally, ensure to pad pressure-sensitive areas and place the head on a gel ring.

The surgeon stands on the right side, with the assistant and surgical nurse on the left side of the patient.

Instruments for Pectus Excavatum Correction:

• Standard VATS Tray
• Additional Special Instruments:
  •      Tunneling Tool (Sword)
  •      Modeling Pliers
  •      Bending Iron

• postoperative analgesia

Recommended are local pain management techniques such as the epidural catheter or paravertebral block. Additionally, analgesia according to the WHO step scheme with non-opioid analgesics (e.g., metamizole) and, if necessary, in combination with a low-dose opioid (e.g., tilidine) is advisable.

• medical follow-up treatment

X-ray control after extubation on the operating table

Perioperative antibiotic therapy with cefazolin (100mg/kg body weight in 3 doses) for 48 hours.

Before discharge, chest X-ray a.p. and lateral in standing position. Follow-up approximately 1.5 to 2 weeks after discharge for clinical check-up and 6 weeks postoperatively for clinical and radiological check-up (chest X-ray a.p. and lateral in standing position).

• thrombosis prophylaxis

Standard thrombosis prophylaxis for 14 days with low molecular weight heparin subcutaneously, taking into account comorbidities, renal function, and laboratory control to exclude HIT.

• physical therapy

Respiratory therapy with "Triflow" hourly, mobilization from the 1st postoperative day, deep breathing exercises and secretion mobilization, as well as specific physiotherapy instruction.           

For 6 weeks postoperatively, no sports, no cycling, maximum load of 2kg in front of the body and 5kg over the shoulders, sleeping on the back, avoiding rotational movements in the upper body. After the completion of the 6th postoperative week, no load restrictions with avoidance of contact sports until the removal of the pectus bars after 3 years.

• dietary progression

Regular diet

• bowel regulation

Accompanying opioid analgesia

• work/school incapacity

Considering the activity and patient situation, approximately 14 days