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Journal of Pediatric Surgery (2009) 44, 471–474

Operative technique

Minimally invasive thoracoscopic repair of unilateralpectus carinatumSunghoon Kim, Olajire Idowu⁎

Department of Pediatric Surgery, Children's Hospital and Research Center Oakland, Oakland, CA 94609, USA

Received 29 July 2008; revised 18 September 2008; accepted 21 September 2008

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Key words:Pectus carinatum;Minimally invasive;Thoracoscopy;Pectus excavatum

Abstract Thoracoscopic repair of pectus excavatum as described by Nuss has become a wellestablished method of repair. However, minimally invasive intrathoracic repair of pectus carinatumhas not been reported in literature. We report a case of successful thoracoscopic repair of unilateralpectus carinatum.© 2009 Published by Elsevier Inc.

Pectus carinatum is an infrequent chest wall deformitycompared to pectus excavatum. It has been described as adeformity that has been undertreated [1]. Unlike thethoracoscopic pectus excavatum repair as popularized byNuss [2], minimally invasive surgical repair of pectuscarinatum has not been established. In this report, wedescribe a repair of an asymmetric pectus carinatumwhereby segments of costal cartilages are removed fromwithin the chest using thoracoscopy. The technique inprinciple is similar to the minimal cartilage resectionmethod as proposed by Fonkalsrud [1]. However, ourapproach minimizes surgical scar and morbidity.

1. Case history

The patient is a 12-year-old boy who felt sociallyimpaired and had subjective decreased stamina because of

⁎ Corresponding author. Tel.: +1 510 428 3022.E-mail address: oidowu@mail.cho.org (O. Idowu).

022-3468/$ – see front matter © 2009 Published by Elsevier Inc.oi:10.1016/j.jpedsurg.2008.09.020

pectus carinatum. He had a left asymmetric pectuscarinatum with slight left sternal deviation (Fig. 1). Hisright chest appeared normal. Although the patient had notgone through adolescent growth spurt, he was quitedepressed about his appearance. We discussed the optionto do an open operation after adolescence if the thoraco-scopic repair did not produce satisfactory outcome.

Informed consent to thoracoscopic procedure wasobtained from parents. A double lumen endobronchialtube was used to intubate the right main stem bronchus.The patient was then placed in right-lateral decubitusposition with appropriate paddings. A 30° 5-mm thoraco-scope was used for visualization. A camera port waspositioned along a posterior axillary line few centimetersbelow the level of the nipple. A second incision was madeat the midaxillary line at the level of the nipple to allowpassage of a angled bone rongeur with a long handle(Fig. 2A) or Bovie cautery with extension. It is possible toswitch the scope between these 2 sites for optimalpositioning of the rongeur. After the camera port placement,CO2 was insufflated at 5-mm mercury pressure to depressthe left lung to create operative space. With external

Fig. 1 Preoperative picture of the patient shows pectus carinatumaffecting mainly the left chest.

472 S. Kim, O. Idowu

palpation and percutaneous insertion of a fine intravenousneedle at the sites of maximal deformity, abnormal ribs tobe resected were localized within the chest with a

Fig. 2 A, Positions of the thoracoscope and angled rongeur are shownBovie cautery extender is used to cut through the cartilage. D, Angledsites of chondrotomy.

thoracoscope (Fig. 2B). Bovie cautery extender with benttip was used to score and cut through the cartilages(Fig. 2C). Using an angled bone rongeur, segments ofcartilage and bone measuring about 5 mm were removednear the costosternal junction (Fig. 2D). Anterior periostealsheath was left intact. A second row of similar segmentswas removed from the deformed ribs further away from thefirst 5-mm osteotomies to optimally affect the depression ofthe chest wall. Two rows of cartilage segments wereremoved from ribs 3 to 5. Only one segment was removedfrom rib 2. After the bone resection, sternal rotationappeared minimal. A 14F chest tube was inserted throughthe camera port site to collect drainage. Operative time wasabout 1 hour.

Postoperation, patient used patient-controlled analgesiafor 48 hours. The chest tube was removed postoperativeday 1. Patient was discharged postoperative day 2 with asoft stretchy chest binder designed by our orthotic service(Fig. 3). Patient used the chest binder for 1 year. One and2-year postoperative pictures are shown in Fig. 4A and B,

. B, Thoracoscopic view of the abnormal anterior ribs is shown. C,bone rongeur is used to remove bone segments. Arrows show the

Fig. 3 Chest binder is used to maintain the chest mold afteroperation.

473Unilateral pectus carinatum

respectively. Appearances at 1 and 2 years were aboutsame. Patient satisfaction at the end of 2 years was good.

ig. 4 A, Appearance of the surgical scar and chest 1 year aftere operation is shown. B, Appearance of the chest 2 years after theperation is shown.

2. Discussion

Treatment options for pectus carinatum have includedobservation, compressive orthotic [3], and cartilage andsternal resection with and without struts. The standardsurgical approach has been an open technique wherebyseries of rib resections and sternotomy are performed [1].First minimally invasive technique was reported byKobayashi et al [4] in 1997. This subcutaneous endoscopictechnique involved prolonged operative time and multiplestab incisions. Schaarschmidt et al [5] then reportedendoscopic minimal access pectus carinatum repair usingsubpectoral carbon dioxide insufflation. With subpectoralcarbon dioxide insufflation, the length of operative timeand cosmesis were improved by creating better visualiza-tion of ribs. Both of these methods achieve rib resection bycreating operative space external to the thoracic cavity.

In our method, we performed rib resections from withinthe thoracic cavity with the aid of thoracoscope. Oneadvantage of the thoracoscopy is the excellent view ofthe ribs from within the chest. However, our methodas presented is limited in correcting unilateral pectuscarinatum. It also involves wearing a binder to maintaincompression of the chest. Although the technique ofSchaarschmidt et al [5] is not limited to unilateral pectuscarinatum, a small midsternal incision has to be madefor sternotomy and transternal strut application. The

correction of a bilateral pectus carinatum with minor sternalinvolvement may be possible with this technique usingbilateral thoracoscopy.

It is likely that combination of techniques may benecessary to repair pectus carinatum with optimal cosmesis.Combination of methods such as use of compressionorthotic, extrathoracic rib resection using subpectoral carbon

Ftho

474 S. Kim, O. Idowu

dioxide dissection, and thoracoscopic rib resection may yieldoptimal solution for improved cosmesis and lessen themorbidity of pectus carinatum repair.

References

[1] Fonkalsrud EW, Mendoza J. Open repair of pectus excavatum andcarinatum deformities with minimal cartilage resection. Am J Surg2006;191:779-84.

[2] Nuss D, Kelly Jr RE, Croitoru DP, et al. A 10-year review of aminimally invasive technique for the correction of pectus excavatum.J Pediatr Surg 1998;33:545-52.

[3] Frey AS, Garcia VF, Browun RL, et al. Nonoperative management ofpectus carinatum. J Pediatr Surg 2006;41:40-5.

[4] Kobayashi S, Yoza S, Komuro Y, et al. Correction of pectus excavatumand pectus carinatum assisted by the endoscope. Plast Reconstr Surg1997;99:1037-45.

[5] Schaarschmidt K, Kolberg-Schwerdt A, Lempe M, et al. Newendoscopic minimal access pectus carinatum repair using subpectoralcarbon dioxide. Ann Thorac Surg 2006;81:1099-103.