Chest wall repair surgery

When is chest wall reconstruction / repair surgery performed?

The chest wall reconstruction is performed mainly in two groups of patients:

• who have had an infection of the chest wall after heart surgery
• in patients suffering from congenital chest wall deformities (pectus excavatum and pectus carinatum).

Chest reconstruction should performed by an experienced thoracic surgeon, as this is a a complex operation. We cooperate with leading Israeli cardiothoracic surgeons, heads of departments and research institutes in Israel.

Our cardiac surgeons perform the chest wall repair operation under the highest medical standards in the Assuta hospital.

Reconstruction / repair of chest wall deformities – pectus excavatum

Pectus excavatum is a congenital deformity with depression of the sternum. This defect creates the appearance of a nest or fossa in the chest. Usually it is only a cosmetic problem without dangerous symptoms for life. But sometimes deformation worsens the functions of the cardiovascular and respiratory systems, and can also cause pain in the back and chest. Female and men with a hollow chest problem can experience negative psychological consequences, especially adolescents.

There are several types of operations for pectus excavatum treatment with surgery on the sternum or ribs, or improving the aesthetic appearance without bone tissue surgery, for example:

• • Bone replacement: truncation of the deformed bones of the ribs, sternum and their proper positioning. There are two pectus excavatum repair procedures that are used: the older Ravitch technique, when  sternum is detached and fixed into a more correct position with mesh supports metal strut, and modern Nuss repair with titanium bar.

Our surgeons perform new minimally invasive Nuss operation for pectus excavatum. Using an expansion device, doctor threads a titanium curved bar through two small incision under the armpit to raise the depressed sternum into a normal position. Using this way our experienced surgeons safely eliminate a cosmetic defect and expand the chest.

• Without surgery on bone tissue: a silicone insert is implanted under the sternum to expand the chest.

Correction and treatment of congenital chest wall deformities – pectus excavatum and pectus carinatum – is easier to perform at an early age, because the bones are softer and better suited to shape physiologically form of sternum.

The advantages of leading Israeli surgeons lies in many years of experience and personal approach to diseases and conditions, where the main priority is to achieve the full recovery of the patient with a minimum risk.

Treatment of infection after open heart surgery

About 1–5% of patients after open heart surgery have various complications because of wound infection. Signs and infection symptoms are local inflammation and fever, swelling, soreness, discharge from the wound, body weakness. Symptoms may appear from a few days to several months after surgery.

The inflammation causes in these patients are not fully understood. The main reasons are:

• lack of blood supply to the node during coronary artery bypass grafting
• mechanical tissue impact
• the use of metal structures which are perceived as foreign material by the body
• bacteria in a surgical wound.

Surgical wound infections are divided according to severity. Mild cases are associated with an infection of the upper soft tissues such as the skin and subcutaneous fat. In more problematic cases, the contact between metal areas of surgical hardware and the sternum tissue are affected. In the most difficult conditions, an infection of the bone tissue occurs – osteomyelitis. Contagion of a surgical wound can even endanger a patient’s life if it spreads to the chest area and around the heart – mediastinitis.

Due to the cases complexity, before making a decision about treatment, our cardiothoracic surgeons carefully evaluate the severity of the infection, the degree of bone damage and the general condition of the patient. The assessment includes:

• patient’s clinical condition
• wound appearance
• blood tests
• chest x-ray and computed tomography (CT) results.

There is a major problem in such conditions that usually it is not possible to eradicate a bacterial infection with antibiotics alone.

In mild cases when there is no suspicion for a sternum infection and the operation has been performed recently, conservative treatment is prescribed. In this way the wound is treated with antibacterial medication, simultaneously with the intravenous antibiotics. Therefore, it is possible to take action against several infections in the operation area, until the wound is completely closed.

Wound closing can be done in several ways:

• Vacuum reduction in a few days
• Direct suturing of the open wound edge
• Implantation of a skin graft

In more complex cases, when a bacterial contagion of the sternum also occurs, the modern therapeutic approach is using to prevent the bone and implants contamination. After bone resection, healthy tissue with good blood supply and effective postoperative antibiotic therapy restore the chest wall.

How to prepare for chest reconstruction surgery

Before the operation, the consultation of the leading cardiac surgeon is necessary. Blood tests should be performed, including CBC, chemical panel SMA, electrolytes, liver function and blood coagulation. In addition, an ECG and computed tomography (CT) scan of the chest should be performed to assess more accurately the clinical picture for our surgeon.

Consultation / approval of additional doctors is required in case of various chronic diseases – such as:

• cardiologist if you have a heart condition
• neurologist if you had a brain disease
• pulmonologist if you have a respiratory or severe lung disease, etc.

We coordinate consultations with leading Israeli doctors of the necessary specialty.

One week before surgery, you should stop taking anticoagulants (such as Aspirin or Coumadin). Our doctor will consult you about the necessity of these medications.

On the day of the operation, a full fast is observed 8 hours before procedure. You should also avoid chewing gum and smoking. Before entering the operating room, it is necessary to remove dentures, jewelry and personal clothing.

How is chest reconstruction surgery performed in Israel?

A reconstruction surgery of the chest wall is performed under general anesthesia, so the patient falls asleep and does not remember anything. Closer to the start of the operation, the you will be given infusion treatment, due to which the anesthetist will administer sedatives to help you reduce anxiety and put you in a deep sleep.

At the first stage of the operation, soft tissues are prepared. If there are signs of bone infection (according to a visual examination of our surgeon and preoperative tests (ECG, CT, etc.)), a more complex operation is required. It includes the removal of the stainless steel strut used to fix the bones after previous surgery, as well as complete or partial resection of the infected bone.

The chest wall can be repaired during the same operation, but in some cases, when the infection is extensive, the reconstruction will be provided later and only when the acute phase has passed.

In cases where the initial skin stitching cannot be provided due to contaminated tissue, chest wall reconstruction is performed by removing the skin and muscle layers from other chest areas or abdominal wall and transferring them to the ​​the defected area. Sometimes deep layers require a more complex transplantation, such as an additional incision an omentum from abdominal region. Israeli surgeons perform minimally invasive operations using the most modern equipment, which ensures quick patient recovery.

At the end of the surgery, usually a drainage is left to drain excess fluid in the chest area. This fluid can worsen the fusion of the sternum skin and muscle fibers. A surgery can take from one hour to six hours, depending on the problem severity.

Risks and complications of chest wall reconstruction

This type of operation involves risks and complications, as with any other invasive surgery. Our surgeon will give you explanation during the appointment.

After the chest surgery

At the end of the operation, you will be taken to the postoperative ward for approximately two hours to ensure a slow and safe recovery. Then medical staff will transfer you to the inpatient department. Depending on your condition, the medical staff will assist when you is moving in a bed or chair, including special meals. After a few days, the chest drainage is removed.

After the operation, our surgeon will prescribe an intravenous antibiotic. The type and duration of treatment depends on the severity and infection type. It can take about 6 weeks in case of bone contagion.

The hospitalization duration after surgery depends on the patient’s condition and usually takes one to two weeks.