Wiki Ravitch vs Nuss Pectus Excavatum Repair

Caldwell, ID
Best answers
Hello, I was curious if anyone has had experience with coding pectus excavatum repairs? I am currently working with a surgeon who states she did a modified Ravitch procedure combined with a Nuss procedure. I am going back and forth on the coding between 21740 and 21743. Any help would be greatly appreciated. Below is the operative report.
The patient received general anesthesia. He was carefully positioned supine
with his arms out on arm boards and padded. The entire chest wall was
sterilely prepped and draped, and an Ioban drape was placed. The patient had
a marked carinatum of the upper sternum and an excavatum of the lower
sternum. The plan was to elevate the lower sternum, and it was understood
that this might not be possible with just placement of the bar and a possible
correction of some of the carinatum was also planned. A small incision was
made on each side of the chest at the anterior axillary line. A tunnel was
created to the appropriate rib space, which was just above the end of the
sternum. On the right side, a 5 mm port was placed into the chest cavity,
and a second 5 mm port was placed just above the diaphragm. The original 5
mm port was removed. A small tunneler was then used to pass across the
sternum, and it was planned to likely place an 11-inch bar at this site and
the bar was chosen and bent with a slight convex contour. When the tunneler
was placed, there was minimal elevation of the lower sternum and the sternum
appeared to be quite stiff. It was felt that placing the bar would not
accomplish elevation of the lower portion of the sternum and would just make
the carinatum worse. Therefore, an incision was made in the midline on the
sternum for approximately 6 cm. The sternum itself was identified, and the
pectoral muscles were carefully dissected free from the attachments of the
cartilage. The two most proximal cartilages, which were ribs 3 and 4, on
each side were felt to cause a significant elevation of the sternum, and on
each side the perichondrial sheath was opened and approximately a 2 cm
distance of cartilage was excised up to the joint with the sternum. This
again was done for ribs 3 and 4 on both sides of the chest. This definitely
allowed for some flattening of the sternum but still did not allow for lift
of the lower sternum. Therefore, it was felt that it would be necessary to
transect the sternum. The plan to do this was more superior to the bar so
that the bar could then lift the lower portion of the sternum. The
thoracoscope was placed inside the chest so that the sternum and heart could
be visualized. The sternal saw was used then to transect the sternum
completely. This did not enter the pleural cavity as this was done under
direct vision. As planned, this did allow for marked elevation of the lower
portion of the sternum. An X-plate from the SternaLock set was chosen, and
for one of the screw holes on each side, a drill was used to drill a hole
through the sternum, again under direct vision inside in the chest so that
FiberWire could be placed through a hole on each side of the cut in the
sternum to better stabilize the plate. The 14 mm screws were chosen for the
other remaining holes on the plate, and the plate was then screwed into the
sternum on each side of the break in the sternum. There was now about a 3 mm
gap, and bone putty was used to fill this gap and around the plate. This
elevated the sternum very nicely. There was still a carinatum in the upper
portion of the sternum, but this was felt to be so high that it was not
possible to fix. A small amount of the sternum was rongeured down using the
pineapple bur drill, making it slightly less pronounced. The tunneler was
then removed, and again using the camera, the 11-inch bar was placed into the
chest and flipped over. This had an excellent fit. The sites where the
cartilages were excised were closed with 4-0 PDS in the perichondrial sheath,
and #2 FiberWire was used to stabilize the cartilage back to the sternum.
The xiphoid was also pulling the end of the sternum down, and thus, the
attachments to the xiphoid were excised, and the xiphoid was excised, again
allowing improvement of elevating the sternum. The rectus muscles were then
closed with #2 FiberWire over the space where the xiphoid had been. The
midline incision was then closed with 3-0 PDS, 4-0 Monocryl and 5-0 Monocryl
subcuticular sutures. Attention was turned back inside the chest where the
camera was placed into the left chest and the bar was secured with #5
FiberWire around two separate ribs. This was also done on the right side of
the chest. There was some oozing from the sternum, and therefore, it was
felt important to place a chest tube, which was placed in the port where the
camera was. After the port was removed, a 16-French chest tube was placed.
The incisions were then closed with 2-0 PDS, 4-0 Monocryl and 5-0 Monocryl
subcuticular sutures. Steri-Strips and sterile dressings were applied.
Bilateral On-Q pumps were applied and placed, and the patient tolerated the
procedure well.
I found descriptions of both out on the web:

Nuss Procedure for Chest Wall Defects
The Nuss procedure is a minimally invasive technique to correct pectus excavatum. Your child may be a candidate if he or she experiences symptoms including:
• Shortness of breath
• Inability to exercise
• Chest pain

During the procedure, we will:
1. Administer general anesthesia. Children’s National is the only facility in the region to guarantee 24/7 access to a pediatric anesthesiologist. Learn more about anesthesia at Children’s National.
2. Make two incisions on the sides of the chest.
3. Insert one or more curved steel bars under the sternum (the breastbone).
4. Make a separate incision to insert a thoracoscope, a thin tube with a small camera, which allows us to visualize the operating area.
5. Attach the steel bars to the ribs on either side.
6. Close the incisions.
You cannot see the bars from the outside. They stay in place for approximately two to three years, and then your child returns for a removal procedure. Long-term results for children who undergo the procedure are excellent and most do not experience a recurrence of the condition.

Ravitch Procedure for Chest Wall Defects
The Ravitch procedure treats pectus excavatum and pectus carinatum. It is a more invasive surgery. However, there are times when we may determine it is more appropriate for your child and will offer a better outcome.

During a Ravitch procedure, we will:
1. Make a horizontal incision from one side of the chest to the other.
2. Cut away some of the rib cartilage on each side of the ribs
3. Flatten the sternum.
4. Insert one or more bars (in some cases) to help the sternum keep its new shape. These bars stay in the chest for varying lengths of time.
5. Insert drains on each side of the chest to remove fluid from the surgical site.
6. Close the incisions.

The Ravitch procedure has excellent long-term results. Most patients do not experience a recurrence of the chest wall defect.

I would choose 21740 since she cut the breast bone. The Nuss is a minimally invasive procedure and per your note this most definitely was not minimally invasive!