The Ravitch Procedure - Surgical Technique and Clinical Outcomes

Introduction

The Ravitch procedure is named after Dr. Mark. M. Ravitch discovered and implemented this technique in 1949. It is a surgical technique commonly used to treat severe chest wall deformities. This procedure has evolved over the years and remains a cornerstone in the surgical management of conditions such as pectus excavatum (inward growth of ribs and breast bone) and pectus carinatum (outward growth of ribs and breast bone). The article further discusses a detailed understanding of the Ravitch Procedure, including its indications, surgical technique, outcomes, and potential complications.

What Are the Indications for Ravitch Procedure?

The following are the indications of the Ravitch procedure:

Individuals with Chest Wall Deformity: In patients with severe forms of chest wall deformities, the Ravich procedure is indicated to alleviate symptoms such as

1. Chest pain.

2. Shortness of breath.

3. Exercise intolerance.

4. Psychological issues related to body image.

5. Patients with cosmetic concerns.

Pectus Excavatum - In individuals with inward growth of the ribs and breast bone (sternum) with depression or dent (concave or cave-shaped bent) on the chest. This condition is also called ‘sunken chest.’

Pectus Carinatum - In individuals with chest wall deformity characterized by outward protrusion of the ribs and sternum, giving a birdlike appearance of the chest. This condition is also called ‘pigeon breast.’

How Is Ravitch Procedure Performed?

The steps used in the Ravitch procedure are:

• Patient Preparation: A detailed medical history of the patient is recorded by the surgeon, along with medicinal and past surgical history. A pre-operative (before operation) scan such as chest X-ray, pulmonary function tests, and computed tomography (CT) scan are ordered by the surgeon to evaluate the size and the extent of the deformity.

• Administration of Anesthesia: The procedure is usually performed under general anesthesia to ensure the patient is pain-free throughout the procedure.

• Surgical Incision: A horizontal or oblique incision or surgical cut is made across the anterior (front) chest wall, typically along the inframammary fold (lower border where the chest meets). The surgeons usually decide on the choice of incision based on the location and extent of the deformity. The sternum is exposed by carefully dissecting and retracting the surrounding tissues.

• Cartilage Resection: The deformed cartilage or breast bone is resected (cut or excised) or reshaped to correct the contour of the chest wall. The costal cartilage is usually excised during the procedure.

• Stabilization: Stainless steel or titanium struts or bars are placed to support the corrected chest wall position. In a few cases, multiple bars are placed to stabilize the sternum in the new position. A small drain (tubular structure) is placed for the removal of excess fluid from the surgical site.

• Surgical Closure: The surgical site incision is closed with black silk sutures (stitches) or staples.

• Postoperative Care: Close monitoring in a surgical intensive care unit (ICU) immediately after the procedure, followed by a tailored recovery plan, including pain management and respiratory therapy. The recovery period after the surgery varies from four to six weeks.

What Are the Preventive Measures to Be Followed After the Surgery?

After the Ravitch surgery, patients are advised to follow the following instructions:

• Patients should avoid driving.

• Strenuous exercises such as running and going to the gym should be avoided by the patient.

• Heavy weightlifting should be avoided. Children should avoid heavy backpacks.

• It is advised not to engage in sports like football, baseball, etc, as it can result in chest injury.

• All routine activities, such as exercises, driving, etc, should be resumed six months after the surgery.

What Are the Clinical Outcomes of the Ravitch Procedure?

The Ravitch procedure has demonstrated favorable outcomes in appropriately selected patients. Benefits may include:

• Improved Chest Wall Appearance: Correction of the deformity leads to a more aesthetically pleasing chest contour. Most patients with cosmetic concerns are satisfied with the surgical results.

• Symptomatic Relief: Many patients experience relief from symptoms such as chest pain, exercise intolerance, and breathing difficulties.

• Enhanced Quality of Life: Correction of the chest wall deformity can alleviate psychological distress and improve self-esteem and body image, thereby improving the patient's quality of life.

What Are the Complications Associated With the Ravitch Procedure?

Although the Ravitch Procedure is generally safe, potential complications may include:

1. Surgical Site Infection: Risk of wound infection at the surgical site necessitating antibiotic treatment or prophylaxis.

2. Hematoma: Blood collection at the surgical site may occur during or after the surgical procedure.

3. Seroma: Accumulating fluid (pus) in the surgical site can result in infection. It is often managed conservatively but may require surgical drainage of the pus.

4. Damage to the Underlying Vital Structures: Damage to the underlying structures such as nerves and vessels, heart, and lungs may occur during the surgery.

5. Stabilization Implant-related Complications: Displacement of titanium stents or bars and failure of the stabilizing might indicate the necessity of revision surgery. The risk of displacement of titanium bars is observed in around two percent of cases.

6. Chest Wall Deformities or Asymmetry: In some cases, minor asymmetry or recurrence of the chest deformity may occur.

7. Instability of the Sternum: It may develop when cartilage removal during the surgical process is overly aggressive, leading to discomfort, persistent or intermittent clicking sensations, and potentially pain over time. Addressing such issues may involve the use of pain relief medication, limitations on specific activities exacerbating the abnormal movement, or, in some cases, additional surgery aimed at stabilizing the sternum.

8. Pain: Long-standing pain may occur after the surgical procedure. Patients are usually prescribed painkillers after the procedure.

9. Pulmonary Edema: Fluid accumulation in the lungs may occur in a few cases, resulting in collapsed lungs.

10. Pericarditis: Inflammation of the heart's lining may occur in a few cases due to the accumulation of fluid in the heart's outer lining.

Conclusion

The Ravitch procedure remains a valuable surgical option for patients with severe chest wall deformities, offering the potential for significant improvement in both physical and psychological well-being. However, careful patient selection and meticulous surgical technique are essential to optimize outcomes and minimize complications. Continued research and advancements in surgical techniques will further refine the management of these complex conditions, ensuring the best possible outcomes for patients undergoing the Ravitch procedure.