1. Pectus excavatum and pectus carinatum are the most common anterior chest wall deformities, with pectus excavatum occurring more frequently. 2. The Ravitch procedure and Nuss procedure are two common surgical techniques used to repair pectus excavatum, with Ravitch being an open resection and Nuss being minimally invasive. 3. Chest wall tumors can be either benign or malignant, with malignant tumors like fibrous histiocytoma and chondrosarcoma requiring wide resection for treatment.

1. Dr Dhanesh

2. CHEST WALL DEFORMITIES
 Pectus excavatum
 Pectus carinatum
 Poland syndrome
 Rare lesions:
Thoracic ectopia cordis
Jeune asphyxiating thoracic dystrophy

3. PECTUS EXCAVATUM
 Most common anterior chest wall deformity
(1 in 300 to 400 live births)
 Positive family history (37%-47%)
 4:1 M:F ratio
 Progression is expected during growth spurts
 Tall, poor posture
 Due to excessive misdirected growth of lower costal
cartilages

4. PRESENTATION
 Clinical spectrum
 Posterior angulation of the body of the sternum
 Posterior angulation of the costal cartilages that
meet the sternum
 In severe cases posterior angulation of the most
anterior portion of the osseous ribs
 Depression may be asymmetric
(carinatum/excavatum deformities)

5. PRESENTATION
 Many are asymptomatic
 Precordial pain
 Pain after sustained exercise
 Palpitation (mitral valve prolapse)
 Systolic ejection murmur is frequently identified
 Shortness of breath
 Decreased exercise tolerance

7. Associated Abnormalities
Scoliosis
Kyphosis
Myopathy
Poland syndrome
Marfan syndrome
Prune belly syndrome
Neurofibromatosis
Cerebral palsy
Tuberous sclerosis

8. PECTUS EXCAVATUM
 Work-up
 CT of the chest
 Pulmonary Function Tests
 Echocardiogram

9. PULMONARY FUNCTION
 The forced vital capacity and FEV1 is lower than
normal
 Exercise tolerance is improved after surgery

10. CARDIAC FUNCTION
 Anterior indentation of right ventricle is present.
 Elevated right heart pressure.
 In pectus excavatum, increased cardiac output on
exertion is due to increased heart rate rather than
stroke volume.
 Echo reveals mitral valve prolapse, which can
subside after surgery.

11. INDICATIONS FOR SURGERY
 Progressive symptoms
 Restrictive disease, decreased work production or
oxygen uptake as demonstrated by PFT’s
 Ct scan showing cardiac compression or
displacement
 Pulmonary atelectasis
 Mitral valve prolapse, bundle branch block
 Recurrent pectus excavatum after repair

12. TIMING
 Can be performed in younger children with severe
exercise tolerance
 Best deferred until after the pubertal growth spur

13. RAVITCH PROCEDURE

14. RAVITCH PROCEDURE
 Transverse skin incision
 Mobilization and retraction of pectoralis and rectus
abdominis muscles
 Excision of deformed cartilages leaving the
perichondrium intact
 Fracture of the sternum (wedge osteotomy)
 Metal strut for stabilization

17. NUSS PROCEDURE

18. Ravitch vs Nuss
1. Open resection minimally invasive
2.Reoccurrence rate
less more
3. Postoperative complication
(hemo/pneumothorax)
less more
4.Surgery duration
more less
no difference in hospital stay and time of ambulation
in both procedures.

19. COMPLICATIONS
Early:
 Pneumothorax
 Hemothorax
 Wound infection
 Pneumonia
 Pericarditis
 Pleural effussion
Late:
 Bar infection
 Bar displacement
 Recurrence
 Repairs performed in children <4years result in impaired growth of
the ribs resulting in a band-like narrowing of the chest the chest

20. POST-OPERATIVE PERIOD
 5-7 days in the hospital
 Seroma discharge from surgical site
 Prolonged duration of Blake drains
 Avoid contact sports for 3 months
 Not to sleep prone

21. PECTUS CARINATUM

22. PECTUS CARINATUM
 Less frequent than pectus excavatum (1 per 1500 live
births)
 M:F 3:1
 No known cause
 Mild deformity at birth worsens as the child grows
 Positive family history in 26%
 History of scoliosis in 15%

23. PECTUS CARINATUM
Presentation:
 Symmetric or asymmetric protrusion of the sternum
 Associated lateral depression of the ribs
 Pain in the area
 Some patients experience exercise limitation
 Rotation of the sternum is often seen

24.  1. Chondrogladiolar (90%)
(1) It is most common pectus
carinatum .
(2) It consists of anterior protrusion of the
body of sternum and lower costal
cartilages.
 2. Mixed with excavatum and carinatum (9%)
It consists carinatum on one side and
excavatum on another side.

25.  3. Chondromanubrial (1%)
(1) It is the most uncommon pectus carinatum.
(2) It consists protrusion of manubrium,
2nd and 3rd costal cartilages with
relative depression of the body and
sternum.

26. TREATMENT
 Ravitch procedure
 Bracing

27. BRACING

28. Poland’s Syndrome
 It refers congenital absence of the pectoralis major
and minor muscles, ribs, breast abnormality, chest
wall depression and syndactyly or brachydactyly.
 It is present in 1/30000 per live birth.
 The etiology is unknown but vascular pathogenetic
mechanism is suggested.

30.  Treatment : Ravitch procedure
Breast reconstruction with implants and latissimus
dorsi flaps.
 Chest wall reconstruction : autologous reconstruction
with tensor fascia lata, omental flaps.
 Alloplastic –prosthetic implantable materials
Mesh implants- PPKM ,PTFE,PMMA
Bioprosthetic materials : HADM, Alloderm
Xenografts : surgisis, permacol , totopatch

31. Jeune syndrome
 Asphyxiating thoracic dystrophy
 Rare genetic disorder that affects the way a child’s cartilage
and bones develop
 Affects the child's rib cage, pelvis, arms and legs
 Rib cages (thorax) are smaller and narrower than usual. This
can keep the child's lungs from developing fully or expanding
when the child inhales
 Breathe rapid and shallow
 About 60% to 70% of children with this condition die from
respiratory failure as babies or young children
 It occurs when a child inherits from both parents the gene that
causes Jeune syndrome
 Jeune syndrome occurs in about 1 of every 100,000 to
130,000 per live birth

32. Sternal defects
 Thoracic ectopia cordis
 Cervical ectopia cordis
 Thoracoabdominal cordis
 Cleft sternum

33. Thoracic ectopia cordis Sternal cleft

34. CHEST WALL TUMORS
 BENIGN : 1.Osteochondroma
2Chondroma
3.Desmoid
4.Lipoma
5.Fibroma
6.Neurilemoma

35.  Malignant: 1.Fibrous histiocytoma
2.Chondrosarcoma
3.Rhabdomyosarcoma
4.Myeloma
5.Ewing’s sarcoma
6.Liposarcoma
7.Neurofibrosarcoma
8.Osteogenic sarcoma
9.Hemangiosarcoma
10.Leiomyosarcoma
11.Lymphoma

36. Clinical presentation
 Slow enlarging asymptomatic masses.
 Pain usually occurs on overgrowth due to
suppression of side by structures.
 Patient complains of neuritis or musculoskeletal
pain.
 CT/MRI/PET require for exact location, extend and
metastasis.
 Needle biopsy for malignancy.

37. Benign tumors
 Osteochondroma : most common benign
neoplasm with 50% incidence of all benign tumors.
 M:F – 3:1
 Arises from metaphyseal region of rib and presented
as bony protuberance with cartilaginous cap.
 If detected after puberty or in adult should be rsected
surgically.

38.  Chondroma : 15% of all benign neoplasm of rib
cage
 Occur at costochondral junction anteriorly
 Expansile lesion causing thinning of bone cortex
 Gross appearance is as lobulated mass and
microscopically are lobules of hyaline cartilage.
 All chondromas should considered for malignant
change and treated by surgical resection.

39.  Desmoid : mostly occurs in shoulder and chest wall
laterally.(20% of all chest wall tumors.)
 Encapsulation of brachial plexus and vessels of arm-neck
are common , may extend to pleural cavity.
 Can produce paresthesias, hyperesthesia and motor
weakness.
 Gross examination tumor originates in muscle an tissue
planes and microscopy shows monotonous pattern of
spindle shape cells
 Treatment : enucleation of tumor from side by structures
followed by radiotherapy.

40. Malignant tumors
 Fibrous histiocytoma: occurs mostly in adults
between 50 to 70 years.
 M:F- 3:1
 Painless slowly enlarging mass
 Present with fever, leukocytosis with neutropenia or
eosinophilia
 Resistant to chemo and radio therapy
 Should be treated with wide resection

41.  Chondrosarcoma : 30% of all primary chest wall
tumors
 Arising from costochondral arches or sternum.
 Commonly occurs in 3rd or 4th decade of life.
 Due to degeneration of benign cartilaginous tumors.
 Excisional biopsy for definitive diagnosis.
 Treatment : wide resection with 4cm margin of
normal tissue.

42.  Rhambomyosarcoma : 2nd most common
tumor of chest wall neoplasm.
 Frequently occur in children.
 Non tender and painful but shows rapid growth.
 May show secondary changes like hemorrhage and
necrosis
 Treatment : wide resection followed by radiation and
chemotherapy.

43.  Ewing’s sarcoma : 17% of all malignant chest wall
tumors.
 2/3rd cases below 20 years of age.
 Present as enlarging mass associated with fever,
leukocytosis, anemia
 Onion skin appearance of bony surface.
 Diagnosis by incisional or core needle biopsy.
 Treatment systemic chemotherapy with primary site
radiotherapy and resection.

44.  References : 1.Surgery of chest, Sabiston &
Spencer(8th edition)
2.General thoracic surgery, Shields (7th edition)
3.Stabilization of the chest wall: autologous and
alloplastic reconstructions.(Raman Chaos
Mahabir,MD & Charles E. Butler ,MD),Semin Plast
Surg 2011;25:34-34

45. THANK YOU