Pediatric Chest Wall Defects: Nuss and Ravitch Technique

At Children’s National, we make the complex routine. When your child needs to undergo an advanced procedure to repair a chest wall defect, you want to come to a center that performs a high volume of these surgeries. Our team is:

• Experienced. We have one of the most experienced chest wall defects teams in the region
• Expert. We perform a large number of these procedures every year, translating into a superior level of expertise
• Comprehensive. The team includes specialists from many fields of pediatric medicine, providing the full spectrum of services for your child’s physical and emotional health:
  • Anesthesiology, Sedation, and Perioperative Medicine
  • Cardiology
  • General and Thoracic Surgery
  • Pulmonology
  • Physical and occupational therapists
  • Nurses
  • Social workers

Even though chest wall surgeries may be routine for us, we understand it is not routine for you. We take the time to discuss the procedure with you in detail and answer any questions you may have. Our clinical expertise combined with our warm, compassionate staff is the reason parents choose us for these intricate procedures.

Often, we diagnose chest wall defects when a child is born. Many times, the defect usually does not affect the child’s growth. The symptoms usually worsen as children enter puberty, because their bones begin growing rapidly. Two common chest wall conditions we treat:

• Petus excavatum is a condition affecting the breastbone that gives the chest a sunken appearance. It is the most common chest wall abnormality.
• Pectus carinatum, also called “pigeon chest,” is a less common defect. It causes the breastbone and rib cartilage to protrude outward, giving the chest an appearance similar to that of a pigeon.

There are two surgical options for correcting these defects. Before the surgery, we conduct extensive evaluations and examinations to determine that your child is a candidate for the operation. We will discuss the risks and benefits of each option and choose the procedure that offers your child the best outcome.

Learn more about:

• Nuss procedure
• Ravitch procedure

The Nuss procedure is a minimally invasive technique to correct pectus excavatum. Your child may be a candidate if he or she experiences symptoms including:

• Shortness of breath
• Inability to exercise
• Chest pain

During the procedure, we will:

1. Administer general anesthesia. Children’s National is the only facility in the region to guarantee 24/7 access to a pediatric anesthesiologist. Learn more about anesthesia at Children’s National.
2. Make two incisions on the sides of the chest.
3. Insert one or more curved steel bars under the sternum (the breastbone).
4. Make a separate incision to insert a thoracoscope, a thin tube with a small camera, which allows us to visualize the operating area.
5. Attach the steel bars to the ribs on either side.
6. Close the incisions.

You cannot see the bars from the outside. They stay in place for approximately two to three years, and then your child returns for a removal procedure. Long-term results for children who undergo the procedure are excellent and most do not experience a recurrence of the condition.

The Ravitch procedure treats pectus excavatum and pectus carinatum. It is a more invasive surgery. However, there are times when we may determine it is more appropriate for your child and will offer a better outcome. During a Ravitch procedure, we will:

1. Make a horizontal incision from one side of the chest to the other.
2. Cut away some of the rib cartilage on each side of the ribs
3. Flatten the sternum.
4. Insert one or more bars (in some cases) to help the sternum keep its new shape. These bars stay in the chest for varying lengths of time.
5. Insert drains on each side of the chest to remove fluid from the surgical site.
6. Close the incisions.

The Ravitch procedure has excellent long-term results. Most patients do not experience a recurrence of the chest wall defect.

Even with the more minimally invasive Nuss procedure, recovery from the procedure can be painful. However, our team pays special attention to pain management in children, helping them recover in a warm, reassuring environment. Your child will most likely receive intravenous (IV) pain medication for a few days before switching to oral pain medication. During recovery, we will work with your child on:

• Breathing deeply
• How to move so as not to dislodge the bar
• Education for children and caregivers for post-discharge care and resuming normal activities

Our team will discuss your child’s follow-up appointments. Your child will have regular visits with:

• Our surgeons, who monitor your child’s progress. They will remove the chest bars from the Nuss procedure once the treatment is complete
• Physical therapists who help patients recover completely from surgery