Surgery chapters
Chest wall disorders and diaphragm: pectus deformities, chest wall infections, diaphragmatic hernia and eventration
Pectus excavatum and carinatum and their operations, other chest wall problems including infections and thoracic outlet, congenital diaphragmatic hernia (Bochdalek and Morgagni), traumatic rupture of the diaphragm, and eventration versus paralysis.
- Pectus excavatum (sunken sternum) is the commonest chest wall deformity; it is mainly a cosmetic problem, corrected by the Nuss (bar behind the sternum) or Ravitch (cartilage resection) operation; pectus carinatum (pigeon chest) is treated, if at all, near the end of growth.
- Bochdalek hernias are posterolateral and left-sided in newborns, and kill through pulmonary hypoplasia; Morgagni hernias are anterior, usually right, and often found in adults.
- Traumatic rupture is usually left-sided after blunt trauma and easily missed; eventration is a thin, fibrous but intact diaphragm that rises, and symptomatic cases are treated by plication.
On this page
Overview
The chest wall (sternum, ribs, cartilages, muscles) and the diaphragm make breathing possible. Their surgical problems are:
- Shape deformities – pectus excavatum and carinatum, mostly cosmetic.
- Infections and tumours of the chest wall.
- Holes in the diaphragm – congenital (Bochdalek, Morgagni) or traumatic – that let abdominal organs into the chest.
- A weak or high diaphragm – eventration or phrenic nerve paralysis.
Part 1: Chest wall disorders
Pectus excavatum (funnel chest)
What it is: the sternum and lower costal cartilages are sunk inwards, giving a dish-shaped hollow on one or both sides. It is the commonest chest wall deformity and is commoner in boys.
Associations: Marfan syndrome, Noonan syndrome and other connective tissue disorders.
Features:
- Usually noticed in childhood and becomes more obvious in the adolescent growth spurt.
- Mainly embarrassment about appearance; most have no breathing problem. Some complain of reduced exercise tolerance or palpitations.
- Chest X-ray: the heart is pushed to the left; CT shows the depth of the depression.
Treatment (for appearance or symptoms):
| Operation | What is done |
|---|---|
| Nuss procedure (minimally invasive) | A curved metal bar is passed behind the sternum (thoracoscopic guidance) and flipped to push it forward; the bar is removed after a period once the chest has remodelled |
| Ravitch procedure (open) | Resection of the deformed costal cartilages and mobilisation (osteotomy) of the sternum, which is then held in its new position |
Bailey & Love stresses that pectus excavatum is essentially a cosmetic problem – it is not a cause of significant respiratory disease. Do not choose "respiratory failure" as its usual complication.
Pectus carinatum (pigeon chest)
What it is: the sternum protrudes forward above the level of the ribs.
- Often appears during the adolescent growth spurt; may follow rickets in some regions (still seen in Pakistan in nutritional rickets).
- Usually asymptomatic; treatment is for appearance only.
- External bracing is often tried first in growing children.
- Surgery mobilises the sternum and costal cartilages so the sternum can be flattened; it is best delayed until the late teens, when chest growth is complete. Explain the risk of an imperfect result.
| Feature | Pectus excavatum | Pectus carinatum |
|---|---|---|
| Sternum | Depressed (funnel) | Protruding (pigeon) |
| Frequency | Commoner | Less common |
| Main problem | Cosmetic | Cosmetic |
| Surgery | Nuss or Ravitch | Sternal mobilisation/flattening in late teens; bracing in growing child |
The Nuss operation is the minimally invasive repair: a retrosternal bar pushes the sternum forward and is removed later. The Ravitch operation is the open repair with costal cartilage resection.
"Excavatum = Excavated (dug in); Carinatum = keel of a ship (sticks out)."
Other congenital chest wall problems
- Poland syndrome: absence of the sternal head of pectoralis major (often with hand anomalies such as syndactyly and breast hypoplasia); commoner in males. The chest looks hyperlucent on that side on X-ray.
- Cervical rib / thoracic outlet syndrome: an extra rib or fibrous band from C7 to the first rib compresses the lower trunk of the brachial plexus (T1) – wasting of small hand muscles and T1 sensory loss – and the subclavian artery (post-stenotic dilatation, thrombus, emboli to the hand).
- Bifid rib and similar anomalies are usually incidental X-ray findings.
Infective chest wall disease
| Condition | Key points |
|---|---|
| Tuberculosis of ribs, sternum or chest wall | Cold abscess: painless, fluctuant swelling without heat or redness; may track and form sinuses. Diagnose by aspiration/biopsy (AFB, Xpert, culture, histology). Treat with anti-TB drugs, with drainage or debridement of the abscess and dead bone if needed. Common in Pakistan |
| Pyogenic osteomyelitis/chondritis of ribs or costal cartilages | Often after surgery, trauma or empyema; costal cartilage infection is hard to clear because cartilage has a poor blood supply, so excision of infected cartilage is often needed |
| Empyema necessitans | Pleural pus bursts through the chest wall to form a subcutaneous abscess (classically TB or actinomycosis). Drain the empyema and treat the cause |
| Actinomycosis | Chronic chest wall mass with multiple discharging sinuses and sulphur granules; long course of penicillin |
| Sternal wound infection / mediastinitis after sternotomy | Deep infection in about 0.5–2% after cardiac surgery; risk higher in diabetics, obese and dialysis patients and with bilateral mammary grafts. Signs: fever, wound discharge, unstable (clicking) sternum. Needs debridement, antibiotics, rewiring or muscle flap closure; high mortality |
| Rib/chest wall abscess from subphrenic or spinal infection | Treat the source and drain |
Tietze syndrome (costochondritis) causes tender, painful costosternal junctions but is not infective. It is benign, self-limiting and treated with NSAIDs and reassurance.
Chest wall tumours
Can arise from bone, cartilage or soft tissue; also secondary deposits and direct invasion from lung or breast cancer. They are treated as at other sites; wide excision may need chest wall reconstruction (mesh, muscle flaps) in a specialist unit.
Part 2: The diaphragm
The diaphragm is a dome of muscle with a central tendon, supplied by the phrenic nerve (C3, 4, 5). Its problems are holes (hernias) and weakness or elevation (paralysis, eventration).
Sites of diaphragmatic hernia
| Hernia | Site | Notes |
|---|---|---|
| Bochdalek | Posterolateral, through the pleuroperitoneal canal | Commonest congenital type; usually left; presents in newborns |
| Morgagni | Anterior, retrosternal, between sternal and costal origins | Usually right; often adults, often incidental; commonly contains transverse colon or omentum |
| Oesophageal hiatus | Hiatus | Commonest diaphragmatic hernia overall (see the oesophagus chapter) |
| Traumatic | Anywhere, mostly left dome | After blunt or penetrating trauma |
"Bochdalek – Back and Left, in Babies. Morgagni – front (Middle/anterior), on the right, in grown-ups."
Congenital diaphragmatic hernia (CDH)
Cause: failure of the pleuroperitoneal membrane to close (Bochdalek), usually on the left. Bowel, stomach, spleen and sometimes liver enter the chest while the lung is developing.
Pathophysiology: compression causes pulmonary hypoplasia (on both sides, worse on the hernia side) and pulmonary hypertension. These – not the hole itself – determine survival.
Presentation:
- Often detected on antenatal ultrasound.
- Respiratory distress and cyanosis soon after birth.
- Scaphoid (empty) abdomen, barrel chest, bowel sounds in the chest, apex beat and heart sounds displaced to the right.
- Chest X-ray: bowel loops in the left chest, mediastinum pushed to the right, nasogastric tube tip in the chest.
Management:
- Immediate intubation; avoid bag-and-mask ventilation (it fills the bowel in the chest with gas).
- Nasogastric tube on suction to decompress the bowel.
- Gentle ventilation, treat pulmonary hypertension; ECMO in specialist centres if needed.
- Repair only after stabilisation – CDH is a physiological emergency, not a surgical emergency. Repair is through the abdomen (or thoracoscopically), by primary closure or a patch.
Outcome: despite intensive support, up to about 30% die from respiratory failure. Small defects may present later in childhood with chest infections or bowel symptoms.
The main cause of death in CDH is pulmonary hypoplasia with pulmonary hypertension, so early surgery does not improve survival – stabilise first.
Morgagni hernia
- Anterior defect behind the sternum, usually right-sided.
- Often asymptomatic and found on chest X-ray as a mass at the right cardiophrenic angle (may show gas-filled colon); may cause epigastric discomfort or obstruction.
- Repair (laparoscopic or open, abdominal or thoracic route) with primary suture or mesh, because of the risk of obstruction or strangulation.
Traumatic diaphragmatic rupture
Mechanism:
- Blunt: a sudden compressive force on the abdomen and pelvis raises intra-abdominal pressure and bursts the diaphragm, producing a large tear. Usually left-sided – the liver protects the right.
- Penetrating: any wound of the lower chest (below the 5th intercostal space, the "junctional zone" where the diaphragm moves between about the 4th and 8th spaces) may cross the diaphragm. Treat these as both chest and abdominal injuries.
Blunt diaphragmatic rupture is usually left-sided and is often missed at first; it may present months or years later with strangulated stomach or colon in the chest.
Diagnosis: easily missed; most are clinically silent at first and the signs come from injured nearby organs.
- Chest X-ray: raised or ill-defined hemidiaphragm, bowel or stomach gas in the chest, nasogastric tube coiled above the diaphragm.
- CT helps but can miss small tears.
- Laparoscopy or VATS is the most accurate test; laparoscopy also allows repair and inspection of the abdomen.
Why it matters: the chest is at negative pressure and the abdomen at positive pressure, so organs are drawn up through the defect over time. Late presentation (months or years) with obstruction or strangulation carries a high mortality.
Treatment:
- Repair all diaphragmatic tears.
- Penetrating injuries are repaired through the abdomen (laparotomy/laparoscopy) so hollow organ injuries are not missed.
- If the patient is ventilated after multiple injuries and there is no bleeding or strangulation, the repair may be deferred while more urgent injuries are treated (positive-pressure ventilation keeps viscera down).
- Long-standing hernias (adhesions in the chest) are often repaired through a thoracotomy, by direct suture or mesh.
A left "raised hemidiaphragm" or "loculated pneumothorax" after trauma may actually be stomach in the chest. Passing a nasogastric tube before inserting a chest drain avoids putting a drain into the stomach.
Eventration of the diaphragm
What it is: part or all of the diaphragm muscle is replaced by thin fibrous tissue but stays attached and intact. It rises into the chest.
- Complete eventration is congenital and usually left-sided (marked elevation of the left dome; may cause gastrointestinal symptoms, and is linked with gastric volvulus).
- Partial eventration is usually right-sided, giving an anterior hump on the diaphragm shadow.
- Many are asymptomatic. Symptomatic cases (breathlessness, recurrent infection in infants, gastric volvulus) are treated by plication (folding and suturing the diaphragm down), by thoracotomy, VATS or laparoscopy.
Diaphragmatic paralysis
| Feature | Unilateral paralysis | Bilateral weakness |
|---|---|---|
| Symptoms | Often none | Breathlessness lying flat (orthopnoea), sleep disturbance |
| Signs | Raised hemidiaphragm | Paradoxical inward abdominal movement on inspiration when supine; vital capacity falls markedly lying down |
| Causes | Phrenic nerve injury: surgery (cardiac, neck), lung cancer, trauma, birth injury, herpes zoster, polio, TB | Neuromuscular disease (MND, Guillain–Barré, MS), high cord injury, viral neuritis |
| Treatment | Plication if symptomatic | Night ventilation or diaphragmatic pacing |
Sniff test (ultrasound or fluoroscopy): a sharp sniff makes a paralysed hemidiaphragm move paradoxically upwards while the normal side descends.
Eventration vs paralysis – both cause a high hemidiaphragm. Eventration is a muscle (structural) defect, present from birth, often partial and anterior; paralysis is a nerve problem with paradoxical movement on sniffing. Both are treated by plication when symptomatic.
Expect: pectus excavatum as the commonest chest wall deformity, its link with Marfan and Noonan, its mainly cosmetic nature and the Nuss (retrosternal bar) and Ravitch (cartilage resection) operations; timing of pectus carinatum surgery in the late teens; TB cold abscess, empyema necessitans, actinomycosis and post-sternotomy mediastinitis; Tietze syndrome as a non-infective mimic; Bochdalek (posterolateral, left, newborn) versus Morgagni (anterior, right, adult) hernias; scaphoid abdomen and pulmonary hypoplasia in CDH; intubation without bag-mask ventilation and delayed repair; left-sided blunt rupture, the nasogastric tube sign and repair through the abdomen for penetrating injury; and eventration versus paralysis, the sniff test and plication.
Quick revision
- Pectus excavatum: sunken sternum, commonest, cosmetic; Nuss bar or Ravitch resection.
- Pectus carinatum: protruding sternum; bracing in growing children; surgery in late teens.
- Chest wall TB: cold abscess, sinuses; anti-TB drugs ± drainage.
- Bochdalek: posterolateral, left, newborn, pulmonary hypoplasia; stabilise before repair.
- Morgagni: anterior, right, adult, colon; mesh repair.
- Blunt rupture: left, often missed, NG tube in chest; repair all; penetrating via abdomen.
- Eventration: thin fibrous diaphragm; paralysis: phrenic nerve, paradoxical sniff test; plication for both.
Written by The House Job from standard references (Bailey & Love; Kumar and Clark's Clinical Medicine).
FAQ
Does pectus excavatum affect breathing?
Usually not in any important way; it is mainly a cosmetic concern, and surgery is offered for appearance or for symptoms in a minority.
Why is congenital diaphragmatic hernia not operated on at once?
The danger comes from the small, stiff lungs and pulmonary hypertension rather than the hole, so the baby is stabilised on the ventilator first and the defect is closed once stable.
Why are traumatic diaphragmatic tears more common on the left?
The liver lies under the right dome and absorbs and spreads the force, so the left side gives way more often.
How is eventration different from a hernia?
In eventration the diaphragm is thin and raised but still continuous, so there is no hole; in a hernia the organs pass through a real defect.