The operation I perform is a modification of the sub-perichondrial excision operation popularised by Ravitch. The sternum is radically mobilised and only an absorbable PDS suture is left to support it.

The operation steps are the same for an excavatum or carinatum defect with only the final osteotomies being different. Even for unilateral deformities I usually find it necessary to perform bilateral dissections in order to make the two sides equal. There are exceptions to this where leaving the normal side intact acts as a good scaffold for the reconstructed side.

Anaesthesia, position and preparation

General anaesthesia with muscle relaxation is used. Single lumen endotracheal intubation is used, there being no indication for single lung ventilation. Intravenous access and both invasive and non invasive blood pressure monitoring should be in place. Blood group and save should be obtained but cross match should not be required. Some anaesthetists favour epidural analgesia placed prior to surgery. Because of the difficulty anaesthetising to the level of the second costal cartilage, others prefer PCAS and systemic analgesia.

The patient is placed supine. A small sandbag may be placed between the scapulae.

The skin is prepared from the chin to below the umbilicus. Draping should leave the sternal notch, nipples and umbilicus exposed to allow planning of the incision and extent of the repair.

Special instrument sets are available for chest wall reconstruction, particularly for paediatric use. As with most procedures I try to keep to standard instruments.