Treatments include surgical treatment and non-surgical support, such as counselling, physiotherapy, posture improvement, implants and vacuum bell therapy. 

We do not offer any of the non-surgical treatments at the Trust, but you can read more about them at www.pectus.org. 

There are two surgical treatments for pectus anomaly available at Royal Brompton Hospital. 

Ravitch procedure/modified Ravitch procedure

Rib cartilages allow your ribs to move when you breathe, and are found between the rib and the sternum. In the Ravitch procedure, an incision (cut) is made from one side of the chest to the other. The cartilages are cut away on each side and the sternum is flattened.

In pectus excavatum (sunken sternum), one or more struts (metal bars) may then be inserted to help the sternum keep its shape. No bars are necessary in pectus carinatum (raised sternum) correction.

In the modified Ravitch procedure, an incision is made either up and down or across the chest. This allows the cartilages to be removed and the sternum can be moved either forward or backwards to correct the pectus. The sternum is then fixed firmly in the correct position with one or more struts (metal bars) or a mesh support structure.

This procedure is used for complex pectus anomalies.

Tubes to drain the wound are placed temporarily on each side of the chest to remove any fluid from around the area of your operation. The wound is closed using dissolvable stitches. Struts are permanent but may be removed if problems develop in the future. The mesh support stays in place permanently.

What are the advantages of the Ravitch procedure?

• It is a tried and tested method of correction for pectus anomaly. Research shows that 97 per cent of patients stated they are happy with the post-operative results 
• Once the procedure has been performed, it is extremely unlikely that the anomaly will re-occur 
• It can also be used to correct complex pectus anomalies 

What are the disadvantages of the Ravitch procedure?

• A large scar from the cut, although this normally fades over time to a thin line 
• The procedure is a more extensive operation than the Nuss technique (explained below). Although unusual, the need for a blood transfusion is more likely than if a Nuss procedure was performed 

The Nuss procedure (minimally invasive repair of pectus excavatum – MIRPE)

The Nuss procedure, also known as the MIRPE, is a minimally invasive technique. A curved steel bar is placed under the sternum through small cuts on either side of the chest wall, which pushes the sternum forward. The bar is fixed firmly to the chest wall with a metal wire. The cuts are closed with dissolvable stitches. 

Wound drains are placed temporarily on either side of the chest to remove any fluid from around the area of your operation. This procedure can only be used for pectus excavatum, and not all patients will be suitable for the operation.

This technique was initially used for children and adolescents, but has now been used in adults for more than ten years. In children, the bar is removed after two years once permanent reshaping has taken place. In adults, the bar is removed after three to five years.

What are the advantages of the Nuss procedure?

• It is a minimally invasive operation – only three to five small cuts are needed (a cut on each side of the chest, one cut below the tip of the sternum, and two or three small wound drain cuts), so scarring is minimal 
• There is no need for cutting or removal of cartilage 
• There is generally little blood loss during the procedure. It is rare for a patient having this operation to need a blood transfusion 
• It is generally a quicker operation than the Ravitch procedure 
• At Royal Brompton Hospital, 85 per cent of patients who had a Nuss procedure thought that their decision to have this operation was the right one 

What are the disadvantages of the Nuss procedure?

• The procedure can sometimes be more difficult to carry out in adults than in children 
• It is possible that the anomaly will re-occur once the bar is removed 
• Rarely, when positioning the bar it is possible to cause an injury to the heart. Your surgeon will use various techniques to reduce this risk, and will discuss this with you before the procedure 

What are the benefits of surgical treatment for pectus anomaly?

Surgery will improve the shape of your chest and this may improve your self-confidence and self-esteem. Some people who have had the operation say that they also feel physically better following the procedure. However, it is important to know that there is no evidence to suggest that pectus correction surgery will improve heart or lung function.

It is important to remember that it is not possible for us to say to what extent we will be able to improve the shape of your chest with surgery. Your surgeon will discuss this with you. Although many people will feel more positive about themselves following the corrective procedure, many continue to need, and receive, counselling and other support for poor self-esteem or concerns over body image.

What are the risks of surgical treatment for pectus anomaly?

Complications can occur with any surgery. Both the Nuss and Ravitch procedures have good safety records. 

For pectus anomaly correction surgery, the specific risks include: 

• Bleeding: rare for Nuss procedure and unlikely for Ravitch procedure
• Wound infection: rare
• Collection of fluid around one or both lungs (pleural effusion): rare
• Air leak from either lung (pneumothorax): rare
• Quick healing of the surgical wound, which results in the scar being red, thickened and itchy (Keloid scarring): are
• Long-term discomfort from the sternal bar: unlikely
• Damage to the heart from bar placement: very rare

Preparing for your operation

It is important to use the time between your referral for surgery and the procedure itself to improve your overall level of fitness. This makes sure your health is in the best shape to help you recover and avoid complications.

If you smoke, it is important you stop. Smoking is particularly bad for your lungs and heart. Stopping smoking makes your anaesthetic safer because chemicals in cigarette smoke can interfere with some drugs. Quitting will also reduce the risk of breathing problems and chest infections, which would increase the length of your hospital stay. 

There is online support from the NHS available to help you quit smoking: NHS smokefree website. You can also ask your GP, pharmacist, or phone Quitline on 0800 002 200 or the NHS Smoking Helpline on 0800 169 0 169.

What will happen when I am admitted to hospital for my operation?

You will usually be admitted a day before your operation. We will use this time to carry out tests to check your general health and to make sure that you are well enough to have surgery.

Tests may include:

• Blood tests: to check your general state of health
• Chest X-ray: to check your heart and lungs
• CT (computerised tomography) scan: to get a detailed view of the  anomaly
• Electrocardiogram (ECG): to check the electrical activity of your heart
• MRSA swabs: to check whether you have MRSA bacteria on your skin or in your nose. This is a routine test for all patients admitted to the hospital and is an important test to stop the spread of MRSA (sometimes referred to as a “superbugs”)

The day of the operation

Six hours before the operation we will ask you to stop eating. You will be allowed to drink clear fluids up to two hours before surgery. We will ask you to have a shower with an antibacterial wash and to change into a hospital gown (please do not wear underwear). We will not need to shave your chest prior to the procedure.

We will also ask you to put on some anti-thrombus stockings, also known as TEDs. During and after your operation, you will be less mobile so the stockings improve the circulation of blood in your legs and help to prevent blood clots.

If you have been prescribed a pre-medication, the nurse caring for you will give this to you one or two hours before the operation. The medication will make you feel sleepy and so you should not get out of bed unless there is a member of staff around – you may feel lightheaded.

When it is time for your operation a porter and a nurse will wheel you, on your bed, into the operating theatres. A member of the theatre staff will take your details and we will then move you into the anaesthetic room. We will clip a heart and pulse monitor to your finger and put a small plastic tube into a vein in your arm. The anaesthetist will give you some drugs via this tube which will send you to sleep.

Can my family and friends stay with me before the operation?

Your family and friends are welcome to stay with you until you go into theatre. If they want to, they can stay on the ward while you have your operation – our staff will be happy to keep them updated on your progress.

After pectus anomaly surgery

Immediately after the operation we will take you to the recovery unit. A nurse will be with you at all times. You will be awake but you may feel quite drowsy from the anaesthetic.

• We will monitor your heart rate, blood pressure and oxygen levels
• You may have a catheter (small tube) to drain urine from your bladder
• You will have a cannula (thin plastic needle) in a vein in your arm. You will be given pain-relieving medication and fluids through this
• You will have wound drains to remove any fluid gathering around the area of your operation

Pain relief

Please be assured that we will do everything we can to control your pain during your time in hospital.

There are several pain relief methods we can use such as:

• Epidural: a catheter (small, fine, plastic tube) is placed in your back, close to your spine in an area called the epidural space. This is inserted in the anaesthetic room before surgery. This gives continuous pain relief in the form of a local anaesthetic and painkillers 
• Patient-controlled analgesia (PCA): a PCA pump is a device that is designed to give you a preset (fixed) amount of pain-relieving medicine when you press the button. There is no risk of addiction or overdose 
• Oral painkillers: we will give you pain relief in tablet or liquid form regularly

We have specialist pain management nurses. They will check your treatment plan to help find the best pain relief methods for you. A nurse will regularly check your pain following your surgery. If you experience pain during your time in hospital, please tell us immediately and we will take steps to control it.

Managing your pain well will allow you to increase your mobility (moving around) and ability to do physiotherapy exercises. Getting up and moving around early will improve your lung function and reduce the risk of a chest infection developing after surgery.

Can my friends and family visit me in recovery?

There is a restricted visiting time in recovery and staff will advise your visitors when they can visit. If you are going to be in the recovery room for a few hours, visiting is generally allowed in the evening only when there are fewer patients. The number of visitors per patient is limited to only one or two people at a time.

When will I move out of recovery?

Once you are awake we will move you to the high dependency unit (HDU). Most patients stay in HDU for the night after their operation and move back to the ward the following day. When you are in HDU, we will continue to monitor you closely.

At some point during the evening following your operation, a nurse will help you to get out of bed and help you to start moving around. This will help to prevent any post-operative complications, such as a chest infection or blood clot / DVT (deep vein thrombosis).

When will I move back to the ward?

The surgical team will visit you in HDU on the morning following your operation to discuss your progress with you and plan your transfer to the ward. If you have wound drains in place we will check the amount of fluid collecting in them each morning. Once there is only a small amount of fluid draining out each day, and once a chest X-ray shows your lungs are back to normal, we will remove the drains. Please remember that it may take several days before they are ready to be removed.

Can my friends and family visit me on the ward?

Your friends and family are welcome to visit you on the ward. Visiting times are 10am to 8pm. We have a strict rest period for patients from 1pm to 2pm but if you wish to see your visitors in the ward dayroom during this time, please discuss this with the nurse in charge.

When can I start moving around?

You will be encouraged to move about with assistance as soon as possible, at first with help of your nurse and physiotherapist. Physiotherapy

will be an important part of your recovery, both on the ward and when you go home. It is important to get out of bed as soon as possible.

The physiotherapists or your nurse will show you how to sit up without risk of injury. We will encourage you to walk around the ward as much as you can. The nursing and the physiotherapy team will be there to help you. When you are ready, your physiotherapist will encourage you to progress to climbing stairs with their assistance.

We will offer you posture advice as needed, and also teach you:

• Breathing exercises
• A supported cough technique to assist the removal of sputum (mucus)
• Shoulder exercises

Going home after surgery

When will I be ready to go home?

We will discuss your discharge date with you. Before you leave us, we will make sure that:

• Any wound drains have been removed
• Your pain is well controlled with medications 
• Your bowel function is returning to normal
• You have a discharge letter from the surgical team
• You have transport arranged to get you home safely
• You will have support from friends and family once you are home – you will not need 24-hour nursing care but you will need help with cleaning and any heavy tasks
• When you are going home you have a letter for the practice nurse, if necessary. Some patients have stitches that do not dissolve, which will need to be removed 
• You have a follow-up appointment booked with the surgical team

Will I need to continue my physiotherapy once home?

It is very important to continue exercising once you leave hospital and go home. 

You can always contact the physiotherapist if you have any questions about the exercises you need to do following discharge. Call the hospital switchboard on 020 7352 8121 and ask for bleep 7301.

For the first month following surgery you should not:

• Bend from the waist – you must only bend from the hips
• Twist your body
• Sit in a slumped position
• Push up and forward using your arms
• Lie on your side
• Lift any heavy objects

For two months following surgery you should not lift any heavy objects.

For three months following surgery you should not drive. You will need to discuss when you can return to driving with your surgeon and your insurance company. Some people find that wearing a seat belt after their surgery is uncomfortable. It is important to remember that you must, by law, wear a seatbelt – there are no medical conditions that allow anyone to not follow the law. If you find a seat belt too uncomfortable to wear, please use a lap belt if available at the mid-rear seat in your car.

Exercise and sport

Your doctor will let you know how long it will take for you to get back to normal. Walking for exercise will help your recovery, but speak with your surgeon about taking part in activities such as contact sports, weightlifting, golf and tennis.

You should avoid swimming until your wound is well-healed – please get advice from your practice nurse.