Scarci Marco, Bertolaccini Luca, Panagiotopoulos Nikolaos, Bedetti Benedetta
Department of Thoracic Surgery, Papworth Hospital, Cambridge, UK.
Thoracic Surgery Unit, Sacro Cuore-Don Calabria Research Hospital, Negrar-Verona, Italy.
J Vis Surg. 2016 Mar 14;2:50. doi: 10.21037/jovs.2016.02.15. eCollection 2016.
Pectus carinatum is a chest deformity characterized by a protrusion of the sternum and ribs (usually 3-7 ribs). The treatment of these patients varies in relation to age. In younger patients we prefer to use a custom-made brace, surgery is the elective treatment for older patients. The minimally-invasive technique (Abramson procedure) is used rarely and for mild defects, whereas open surgery is still preferred by many surgeons to repair major deformities. In our institution we use a modified Ravitch approach trough a vertical incision, which is performed on top of the most prominent part of the defect. The first step is the mobilisation of the pectoralis muscle to allow the exposure of the skeletal structure of the sternum and of the deformed costal cartilages. The second step is to perform multiple parasternal rib cartilage resections to shorten the overabundant length that causes the deformity, avoiding damaging the perichondrium. The third step consists of a wedge osteotomy at the level of the most prominent point of the sternum. The last step is the remodelling and the stabilization of the chest wall. The sternum stabilization is obtained through the placement of one titanium bar and with the filling of the space created at the osteotomy line with fragments of cartilages or with demineralized bone tissue. The perichondrial sheats of the ribs are sutured to the sternum with absorbable sutures. The postoperative pain management should be a priority in order to avoid further complications. In our institution we use a patient-controlled analgesia (PCA) with morphine on the day of the surgery. On the first postoperative day we remove the PCA and start an oral therapy with the combination of opioids and non-steroidal anti-inflammatory drugs. Early mobilisation is also a milestone in the postoperative management of these patients.
鸡胸是一种胸部畸形，其特征为胸骨和肋骨（通常为第3至7肋）突出。这些患者的治疗方法因年龄而异。对于较年轻的患者，我们更倾向于使用定制的支具，而手术是老年患者的首选治疗方法。微创技术（ Abramson手术）很少使用，仅用于轻度缺陷，而许多外科医生仍更喜欢采用开放手术来修复严重畸形。在我们机构，我们通过垂直切口采用改良的Ravitch方法，该切口在缺损最突出部分的上方进行。第一步是游离胸肌，以暴露胸骨的骨骼结构和变形的肋软骨。第二步是进行多处胸骨旁肋软骨切除术，以缩短导致畸形的过长部分，同时避免损伤软骨膜。第三步是在胸骨最突出点的水平进行楔形截骨术。最后一步是对胸壁进行重塑和稳定。通过放置一根钛棒，并在截骨线处用软骨碎片或脱矿骨组织填充所形成的空间来实现胸骨稳定。肋骨的软骨膜鞘用可吸收缝线缝合至胸骨。术后疼痛管理应作为首要任务，以避免进一步的并发症。在我们机构，我们在手术当天使用患者自控镇痛（PCA）给予吗啡。术后第一天，我们撤掉PCA，并开始使用阿片类药物和非甾体类抗炎药联合进行口服治疗。早期活动也是这些患者术后管理的一个关键环节。
