Royal Brompton Hospital Your pectus correction surgery · any surgery. Both the Nuss and Ravitch...

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Your pectuscorrection surgery

Royal Brompton Hospital

Your pectus correction surgery.qxp:Patient Booklet 30/01/2015 09:30 Page 2

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What is pectus anomaly? 3

How many people have pectus anomaly? 3

What causes pectus excavatum / carinatum? 4

What are the effects of pectus anomaly? 4

What treatments are available for pectus anomaly? 5

What surgical treatment is available at Royal Brompton Hospital for pectus anomaly? 5

The Ravitch procedure 5

The Nuss procedure 6

What are the benefits of surgical treatment for pectusanomaly? 8

What are the risks of surgical treatment for pectus anomaly? 8

The operation 9

What pain relief will I receive during my time in hospital? 14

When can I start moving around? 15

When will I be ready to go home? 16

Will I need to continue my physiotherapy once home? 16

Who can I contact if I need further support? 17

Who can I contact for information once I have left hospital? 18

Contents

This leaflet gives you general information about your pectuscorrection surgery. It does not replace the need for personaladvice from a healthcare professional. Please ask us if you haveany questions.


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Your pectus correction surgery

Pectus anomaly is a deformityof the sternum (breastbone).An anomaly is somethingdifferent to what you wouldexpect to find. Pectus anomalyis the most commoncongenital chest walldeformity. Congenital meansthe anomaly is present atbirth.

A pectus anomaly is oftennoticeable at birth but usuallybecomes more apparentduring the period of fastgrowth of the skeleton. Thishappens during earlyadolescence; the time when achild matures into an adult.Once growth is complete theanomaly remains unchanged.

There are two main types ofanomaly:

1. Pectus carinatum (alsoknown as pigeon chest)where the sternum is raised and the chest lookspushed out. Sometimesthere may be a depression(dip) on one side andprotrusion (bulge) on theother, or the anomaly canbe more complex than this.

2. Pectus excavatum (alsoknown as funnel chest orsunken chest) where thesternum is sunken inwardsand the chest looks hollow.

There is a rare third type ofanomaly called pectusarcuatum (curved or arched).There is a ridge high across theupper part of the sternum,with the rest of the chestfalling away to a flatter shape.

What is pectus anomaly?

Pectus anomalies are found in about four out of every 1,000people. It is more common in males than females.

How many people have pectus anomaly?


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Many people with pectusanomaly are content with theshape of their chest and donot wish to have surgery tocorrect this. However, somepeople experience physicalproblems, such as:

• Reduced stamina (energyand strength); a lot ofeffort is needed to doexercise

• Chest pain

• Frequent respiratoryinfections

Sometimes, there may bepsychological effects, such asnegative body self-image andlow self-confidence. The mostcommon concern for thosewith pectus anomaly is beingseen without their chestcovered.

What are the effects of pectus anomaly?

Pectus anomalies are thoughtto be caused by irregulargrowth of the cartilages (astrong, elastic material)between the breast bone andthe ribs before a child is born.The growth can sometimes beexcessive. As the cartilagesgrow longer, the sternum iseither pushed inwards(excavatum) or outwards(carinatum).

Certain conditions can belinked with pectus anomaly,such as:

• Scoliosis – where the spinecurves and becomesdeformed

• Marfan’s syndrome – aninherited condition of theconnective tissue (amaterial that helps tosupport and connect organsin the body)

• Poland’s syndrome – a rareinherited condition wherethe chest muscles on oneside of the body areunderdeveloped or do notdevelop at all

What causes pectus excavatum / carinatum?


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Many people with pectusanomaly decide to investigatewhat treatment is available tothem. Non-surgical supportincludes counselling,physiotherapy, postureimprovement, siliconeimplants, and vacuum bell

therapy. We do not offer anyof these treatments at ourhospital, but you can readmore about them by visitingwww.pectus.org. We do,however, offer the option ofsurgical treatment.

What treatments are available for pectusanomaly?

There are two surgicaltreatments for pectus anomaly:

1. The Ravitch procedure /modified Ravitchprocedure

Rib cartilages allow your ribsto move when you breathe.They are found between therib and the sternum. In theRavitch procedure, an incision(cut) is made from one side ofthe chest to the other. Thecartilages are cut away oneach side and the sternum isflattened.

In pectus excavatum (sunkensternum), one or more struts(metal bars) may then be

inserted to help the sternumkeep its shape. No bars arenecessary in pectus carinatum(raised sternum) correction.

In the modified (slightlydifferent) Ravitch procedurean incision is made eitherlengthwise (up and down) oracross the chest. This allowsthe cartilages to be removedand the sternum can bemoved either forward orbackwards, to correct thepectus. The sternum is thenfixed firmly in the correctposition with one or morestruts (metal bars), or a meshsupport structure. Thisprocedure is used for complexpectus anomalies.

What surgical treatment is available at RoyalBrompton Hospital for pectus anomaly?


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Tubes to drain the wound areplaced temporarily on eachside of the chest to remove anyfluid from around the area ofyour operation. The wound isclosed using dissolvablestitches. Struts are permanent,but may be removed ifproblems develop in thefuture, such as pain. The meshsupport stays in placepermanently.

What are the advantagesof the Ravitch procedure?• It is a tried and tested

method of correction forpectus anomaly. Researchshows that 97 per cent ofpatients (97 out of every 100)stated they are happy withthe post-operative results.

• Once the procedure hasbeen performed, it isextremely unlikely that theanomaly will re-occur.

• It can also be used tocorrect complex pectusanomalies.

What are thedisadvantages of theRavitch procedure?• A large scar from the cut,

although this normally fadesover time to a thin line.

• The procedure is a moreextensive operation thanthe Nuss technique(explained below).Although unusual, theneed for a bloodtransfusion is more likelythan if a Nuss procedurewas performed.

2. Nuss procedure(minimally invasiverepair of pectusexcavatum – MIRPE)

The Nuss procedure, alsoknown as the MIRPE, is aminimally invasive technique.Invasive means a techniquewhere the body is entered bya cut.

A curved steel bar is placedunder the sternum throughsmall cuts on either side of thechest wall. This pushes thesternum forward. The bar isfixed firmly to the chest wallwith a metal wire. The cuts areclosed with dissolvablestitches.

Wound drains are placedtemporarily on either side ofthe chest to remove any fluidfrom around the area of youroperation. This procedure canonly be used for pectusexcavatum, and not all


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patients will be suitable forthe operation.

This technique was initiallyused for children andadolescents, but has now beenused in adults for more than10 years. In children, the bar isremoved after two years oncepermanent reshaping hastaken place. In adults, the baris removed after three to fiveyears.

What are the advantagesof the Nuss procedure?• It is a minimally invasive

operation – only three tofive small cuts are needed(a cut on each side of thechest, one cut below the tipof the sternum, and two orthree small wound draincuts), so scarring is minimal.

• There is no need for cuttingor removal of cartilage.

• There is generally littleblood loss during theprocedure. It is rare for apatient having thisoperation to need a bloodtransfusion.

• It is generally a quickeroperation than the Ravitchprocedure.

• At Royal Brompton Hospital85 per cent of patients whohad a Nuss procedurethought that their decisionto have this operation wasthe right one.

What are thedisadvantages of the Nussprocedure?• The procedure can

sometimes be more difficultto carry out in adults thanin children.

• It is possible that theanomaly will re-occur oncethe bar is removed.

• Rarely, when positioningthe bar it is possible tocause an injury to theheart. Your surgeon will usevarious techniques toreduce this risk, and willdiscuss this with you beforethe procedure.


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Surgery will improve the shapeof your chest and this mayimprove your self-confidenceand self-esteem. Some peoplewho have had the operationreport that they also feelphysically better following theprocedure.

However, it is important toknow that there is noevidence to suggest thatpectus correction surgery willimprove heart or lungfunction.

Please remember that we arenot able to tell you by howmuch we will be able toimprove the shape of yourchest with surgery. Yoursurgeon will discuss the aimsof your operation with you.

Many people feel more positiveabout themselves following thecorrective procedure. However,some continue to need, andreceive, counselling and othersupport for poor self-esteem orconcerns over body image.

What are the benefits of surgical treatment forpectus anomaly?

Complications can occur withany surgery. Both the Nuss andRavitch procedures have goodsafety records.

For pectus anomaly correctionsurgery, the specific risksinclude:

• Bleeding: rare for Nussprocedure; unlikely forRavitch procedure

• Wound infection: rarecomplication

• Pleural effusion (collectionof fluid around one or bothlungs): rare complication

• Pneumothorax (air leakfrom either lung): rarecomplication

• Keloid scarring (the scarbecomes red, thickened anditchy because it has healedtoo quickly): rarecomplication

What are the risks of surgical treatment forpectus anomaly?


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It is important to use the timebefore the procedure toimprove your overall level offitness. This makes sure yourhealth is in the best shape tohelp you recover and avoidcomplications.

If you smoke, it is importantyou try to stop completely, orat least for several weeks,before your treatment.

Smoking is particularly bad foryour lungs and heart. Stoppingsmoking makes youranaesthetic safer. This isbecause chemicals in cigarettesmoke can interfere with somedrugs. It reduces the risk ofbreathing problems, anddeveloping a chest infectionafter your operation, whichwould increase the length ofyour stay in hospital.

The sooner you stop smoking,the more it will reduce yourrisk of complications. There issupport available to help yougive up smoking – you can ask

your GP, pharmacist, or contact:

• SMOKEFREE, the free NHShelpline on 0800 022 4 332– www.nhs.uk/smokefree

• Quit, a stop smokingcharity, on 0800 002 200 –www.quit.org.uk

What will happen when Iam admitted to hospitalfor my operation?You will usually be admitted aday before your operation. Wewill use this time to do tests tocheck your general health, andto make sure that you are wellenough to have surgery.

Tests may include:

• MRSA (methicillin resistantstaphylococcus aureus)swabs: to check whetheryou have MRSA bacteria onyour skin or in your nose.This is a routine test for allpatients admitted to the

• Long term discomfort fromthe sternal bar: unlikelycomplication

• Damage to the heart frombar placement: a very rarecomplication

The operation


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hospital. It is an importanttest that helps to stop thespread of MRSA (sometimesreferred to as a“superbug”).

• Blood tests: to check yourgeneral state of health

• Chest X-ray: to check yourheart and lungs

• CT (computerisedtomography) scan: to lookat the pectus anomaly

• Electrocardiogram (ECG): tocheck the electrical activityof your heart

What do I need to bringwith me to hospital?• All medication that you

take – in their originalpackaging

• Suitable clothing – loosefitting shirts (preferablywith buttons down thefront)

• Comfortable, but supportivefootwear

• Toiletries – we will providetowels and disposable washcloths, so you do not needto bring these with you; justbring your normal toiletries

Please try to avoid bringingvaluable items into hospital. Ifyou do, we have a safe on theward to store valuable items.While you are in theatre, and inthe recovery room, we can lockyour belongings away safely.

Which staff will I seeduring my time inhospital?The nursing team will:• Help you settle into the

ward on the day you arrive.

• Check your general health,measure your height andweight, ask about allergies,and your past surgical andmedical history. They willalso ask you aboutarrangements for goinghome, such as who will becollecting you from hospital.

• Regularly measure yourblood pressure, pulse,oxygen levels andtemperature.

• Check your wound andhelp you with washing andgoing to the toilet, andmobility needs (movingaround).

• Work with your doctors tomanage your pain and helpwith any concerns you mayhave.


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• Talk to you about yourplans for going home, tomake sure that you haveenough support when youreturn home.

The surgical team• Members of the surgical

team (either a doctor or aspecialist nurse) will visityou on the day you areadmitted to hospital andask you about yourprevious medical andsurgical experiences.

The information you givethe doctor may seemsimilar to the history yougave to your nurse.However, each team usesyour history in a differentway so they can give youcare related to theirparticular role.

• A member of the team willexplain the operation to youand explain potential risks.Once we have explainedthe procedure we will askyou to sign a consent form.This document records thatwe have explained theprocedure, and its risks, toyou, and that youunderstand and consent(agree) to go ahead withthe operation. If you have

any questions or worries,please ask. We want you tofully understand theprocedure you are having.

• The anaesthetist is part ofthe surgical team, but willvisit you separately todiscuss the anaesthetic andyour pain relief after theoperation. The anaesthetistwill let you know when youneed to stop eating anddrinking fluids inpreparation for surgery. Ingeneral, you need to stopeating food six hoursbefore your surgery andstop drinking clear fluidstwo hours before yoursurgery. Do not worry – youwill be given clearinstructions about this.

The physiotherapists• A physiotherapist will see

you during your time inhospital.

• They will explain theimportance of post-operative physiotherapy –including breathingexercises, posturecorrection and regularexercise. Exercise willimprove how well yourlungs work and improvethe speed of your recovery.


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What will happen on theday of the operation?You will be asked to have ashower with an antibacterialbody wash, which will beprovided for you, and changeinto a clean hospital gown(please do not wearunderwear).

There is no need to shave yourchest hair before the procedure.

You will be asked to put onsome anti-thrombus stockings,also known as TEDs. Duringand after your operation, youwill be less mobile thannormal. TEDs improve thecirculation of blood in yourlegs and help to prevent bloodclots.

If you have been prescribed apremedication (premed), thenurse caring for you will givethis to you one or two hoursbefore the operation. Themedication will make you feelsleepy and possiblylightheaded, so you should notget out of bed unless there isa member of staff with you. Ifyou need to go to the toilet,after your premed, please letthe nursing staff know, andthey will help you.

When it is time for youroperation, a porter and anurse will take you, on your

bed, to the operating theatre.A member of the theatre staffwill check your details withyou and the nurse, and moveyou into the anaesthetic room.We will clip a pulse andoxygen monitor to your fingerand put a cannula (smallplastic tube) into a vein inyour arm. The anaesthetist willgive you some medicationsthrough the cannula that willsend you to sleep.

Can my family and friendsstay with me before theoperation?Your family and friends arewelcome to stay with you untilyou go into the operatingtheatre. If they wish, they canstay on the ward while youhave your operation – our staffwill be happy to keep themupdated on your progress.

What happens after theoperation?Immediately after theoperation we will take you tothe recovery unit (recovery) towake up. A nurse will be withyou at all times. You may feelquite drowsy from theanaesthetic.

• We will monitor your heartrate, blood pressure andoxygen levels.


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• You may have a catheter(thin plastic tube) to drainthe urine from yourbladder.

• You will have a cannula(thin plastic needle) in avein in your arm. Fluids andpain-relieving medicationare given through thecannula.

• You will have wound drainsin place. These remove anyfluid gathering around thearea of your operation.

Can my friends and familyvisit me in recovery?There is a restricted visitingtime in recovery. Staff willadvise your visitors when theycan visit. If you are going tobe in the recovery room for afew hours, visiting is generallyallowed in the evening onlywhen there are less patients.The number of visitors perpatient is limited to only oneor two people at a time.

When will I move out ofrecovery?Once you are awake we willmove you to the highdependency unit (HDU). Mostpatients stay in HDU for thenight following theiroperation and move back to

the ward the following day.When you are in HDU, we willcontinue to monitor youclosely. At some point duringthe evening following youroperation, a nurse will helpyou get out of bed. Your nursewill help you to start movingaround. You will practisewalking on the spot and sit inyour chair for a while. This willhelp to prevent any post-operative complications, suchas a chest infection or DVT(deep vein thrombosis – bloodclot).

When will I move back tothe ward?The surgical team will visit youin HDU in the morningfollowing your operation todiscuss your progress with youand to plan your transfer to theward with the nursing team.

If you have wound drains inplace, we will check theamount of fluid collecting inthem each morning. Oncethere is only a small amount offluid draining out each day,and your chest X-ray showsthat your lungs are back tonormal, we will remove thedrains. Please remember thatit may take several days beforethe drains are ready to beremoved.


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Please be reassured that wewill do everything we can tocontrol your pain during yourtime in hospital. There areseveral pain relief methods wecan use such as:

• Epidural: A catheter (small,fine, plastic tube) is placedin your back, close to yourspine in an area called theepidural space. This isinserted in the anaestheticroom before surgery. Thisgives continuous pain reliefin the form of a localanaesthetic and painkillers.

• Patient-controlled analgesia(PCA): A PCA pump is adevice that is designed togive you a preset (fixed)amount of pain-relievingmedicine when you pressthe button. There is no riskof addiction or overdose.

• Oral painkillers: we will giveyou pain relief in tablet orliquid form regularly.

We have specialist painmanagement nurses. They willcheck your treatment plan tohelp find the best pain reliefmethods for you. A nurse willregularly check your painfollowing your surgery. Duringyour time in hospital, if youexperience pain, please tell usimmediately and we will takesteps to control it.

Managing your pain well willallow you to increase yourmobility (moving around) andability to do physiotherapyexercises. Getting up andmoving around early willimprove your lung functionand reduce the risk of a chestinfection developing aftersurgery.

What pain relief will I receive during my time inhospital?

Can my friends and familyvisit me on the ward?Your friends and family arewelcome to visit you on theward. Visiting times are 10amto 8pm. We have a rest periodfor patients from 1pm to 2pm,following their lunch. If you

wish to see your visitors in theward dayroom during thistime, please discuss this withthe nurse in charge.

If your relatives have to travela distance, it may be possibleto arrange visiting outside ofthe usual hours.


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You will be encouraged tomove about with assistance assoon as possible, at first withhelp of your nurse andphysiotherapist. Physiotherapywill be an important part ofyour recovery, both on theward and when you go home.It is important to get out ofbed as soon as possible.

The physiotherapists or yournurse will show you how to situp without risk of injury. Wewill encourage you to walkaround the ward as much asyou can. The nursing and thephysiotherapy team will be

there to help you. When youare ready, your physiotherapistwill encourage you to progressto climbing stairs with theirassistance.

We will offer you postureadvice as needed, and alsoteach you:

• Breathing exercises

• A supported coughtechnique to assist theremoval of sputum (mucus)

• Shoulder exercises

When can I start moving around?

We will discuss the date to gohome with you. Before youleave, we will make sure that:

• Wound drains have beenremoved.

• Your bowel function isreturning to normal.

• Your pain is well controlledwith pain medications.

• You have a discharge letterfrom the surgical team.

• You have arrangedtransport to get you homesafely.

• You have support fromfriends or family once youare home. You will notneed 24-hour nursing carebut you will need someoneto help you with cleaningand any heavy tasks.

• When you are going homewe will give you a letter foryour practice nurse, if

When will I be ready to go home?


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necessary. Some patients gohome with stitches that donot dissolve. These need tobe removed by yourpractice nurse.

• You have a follow-upappointment booked withthe surgical team.

It is very important tocontinue exercising when youreturn home.

If you have any questions orqueries, you can contact thephysiotherapist. Call thehospital switchboard on 0207352 8121, and ask for bleep7301.

For the first month followingsurgery, you should not:

• Bend from the waist – youmust only bend from thehips

• Twist your body

• Sit in a slumped position

• Push up and forward usingyour arms

• Lie on your side

• Lift any heavy objects

For two months followingsurgery, you should not:

• Lift any heavy objects

For three months followingsurgery, you should not:

• Drive

You will need to discuss whenyou can return to driving withyour surgeon and yourinsurance company.

Some people find thatwearing a seat belt after theirsurgery is uncomfortable. It isimportant to remember thatyou must, by law, wear aseatbelt – there are no medicalconditions that allow anyoneto not follow the law. If youfind a seat belt toouncomfortable to wear, please

Will I need to continue my physiotherapy athome?


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use a lap belt if available atthe mid-rear seat in your car.

Exercise and sportYour doctor will let you knowhow long it will take for youto get back to normal.Walking for exercise will helpyour recovery, but speak with

your surgeon about takingpart in activities such ascontact sports, weightlifting,golf and tennis.

You should avoid swimminguntil your wound is well-healed – please get advicefrom your practice nurse.

Social services supportindividuals and families duringtimes of difficulty. We cancontact your local authority,and other agencies, to ensureyour needs, and those of yourcarer(s), are met.

Members of the multifaithchaplaincy team are committedto supporting you during your

stay in hospital. If you wouldlike to speak to someone fromthe chaplaincy team, yournurse can arrange this.

If you need any furtherinformation, or would like usto refer you to anotheragency, please ask a memberof the medical or nursingteams.

Who can I contact if I need further support?

References

Krasopoulos G and Goldstraw P. (2011) Minimally invasiverepair of pectus excavatum deformity. European Journal ofCardiothoracic Surgery 39:149-158

Krasopoulos G; Dusmet M; Ladas G; Goldstraw P. (2006) Nussprocedure improves the quality of life in young male adultswith pectus excavatum deformity. European Journal ofCardiothoracic Surgery. 29:1-5


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You can always phone the ward if you have questions orqueries or need advice. The contact numbers are listed below.

Useful contacts

Royal Brompton Hospital switchboard 020 7352 8121

Advanced nurse practitioner 020 7352 8121, andask for bleep 7071

Princess Alexandra Ward 020 7351 8596

Sir Reginald Wilson Ward 020 7351 8483

Physiotherapist 020 7352 8121, andask for bleep 7301

Patient advice and liaison service (PALS) 020 7349 7715

Medicines helpline 020 7351 8910

Smokefree National Helpline 0300 123 1044

Useful websites

UK pectus excavatum and pectus carinatum informationA British site giving information on pectus anomalies, theircauses and possible treatments. The site has been put togetherby staff at Royal Brompton & Harefield NHS Foundation Trust.www.pectus.org

Who can I contact for information once I haveleft hospital?


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About the Nuss procedureWebsite of the Children’s Hospital of the King’s Daughters,where Donald Nuss developed and continues to perform theNuss procedure.www.chkd.org

National Institute for Clinical Health and Excellence (NICE)information on the Nuss procedureThis site contains a useful briefing paper on the Nuss procedure,written for members of the public and those considering havingthe surgery.

www.nice.org.uk/IPG310publicinfo

About pectus anomaly correctionWebsite of the University of Minnesota Department of Surgery.A north American website, which offers support andinformation on the Nuss procedure. www.pectus.com

National Marfan Foundation (NMF)The site of the American National Marfan Foundation, whichoffers support to those affected by Marfan syndrome(commonly associated with pectus anomaly).

www.marfan.org

For information and advice on giving up smokingwww.nhs.uk/smokefree

If you have concerns about any aspect of the service you havereceived in hospital and feel unable to talk to those peopleresponsible for your care, call PALS on 020 7349 7715 or [email protected]. This is a confidential service.


Royal Brompton HospitalSydney StreetLondonSW3 6NPtel: 020 7352 8121textphone: (18001) 020 7352 8121

Harefield HospitalHill End RoadHarefieldMiddlesexUB9 6JHtel: 01895 823 737textphone: (18001) 01895 823 737

Website: www.rbht.nhs.uk

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© Royal Brompton & Harefield NHS Foundation Trust February 2015


Royal Brompton Hospital Your pectus correction surgery · any surgery. Both the Nuss and Ravitch...

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