Received: 4 March 2021 Revised: 9 May 2022 Accepted: 25 May 2022

DOI: 10.1111/vsu.13843

CASE REPORT

A novel video-assisted thoracoscopic approach for pectus

excavatum surgical treatment in a dog

Diego Bobis Villagrà DVM, MSc, PhD, PGDip SAS, PGCert VEaMIS, MRCVS |
Tim M. Charlesworth MA, VetMB, CertSAS, DSAS (Soft Tissue), FRCVS

Eastcott Referrals, Edison Park,

Swindon, UK Abstract
Objective: To describe a novel, video-assisted thoracoscopic surgery (VATS)
Correspondence
approach used to treat pectus excavatum (PE) in a dog.
Tim M. Charlesworth, Eastcott Referrals,
Edison Park, Dorcan Way, Swindon SN3 Animals: A 5 month-old, 5.1 kg, intact, female, Cockapoo.
3FR, UK. Study design: Case report.
Email: tim.charlesworth@eastcottvets.
Methods: Clinical, imaging and surgical records of a dog with severe PE who
co.uk
underwent VATS-assisted sternal cast placement were reviewed and reported.
Treatment involved introduction of a mild pneumothorax and use of VATS,
allowing direct visualization and therefore safe passage of circumsternal
sutures as they were placed to reduce the risk of vascular/cardiac or pulmo-
nary penetration and intraoperative complication in this patient.
Results: Treatment involved introduction of a mild pneumothorax and use of
VATS, allowing direct visualization and therefore safe passage of circumsternal
sutures as they were placed to reduce the risk of vascular/cardiac or pulmo-
nary penetration and intraoperative complications in this patient. The patient
recovered well and had an excellent long-term outcome with significantly
improved vertebral index and frontosagittal index.
Conclusion: This modified technique resulted in an excellent outcome and
minimized the risk of intraoperative complications during the surgical proce-
dure in a dog.
Clinical significance: This novel VATS approach for PE correction may pro-
vide a useful technique to help reduce intraoperative risk during PE correction
in dogs.

1 | INTRODUCTION species.1,4–13 The most commonly described area affected

is the caudal portion of the sternum,1,6–8,10–12 but PE is
Pectus excavatum (PE) is one of the most commonly also described affecting the rostral portion.1,5 In dogs, no
reported congenital skeletal deformities and the most gender or breed predispositions are described although
well known skeletal deformity affecting the thoracic wall. brachycephalic breeds are over-represented.1,14,15
PE, also known as funnel chest or sunken chest, is distin- The cause and development of PE is uncertain. Multi-
guished by dorsal deviation of the sternum and costal ple theories have been described but involvement of more
cartilages.1–4 This deformity has been well described in than one animal within the same litter suggests a genetic
both human and veterinary medicine being reported in component.1,5,7–9,11 Other potential causes include dia-
dogs, cats, cows, sheep as well as in nondomesticated phragmatic defects (muscular and tendinous), failure

Veterinary Surgery. 2022;1–7. wileyonlinelibrary.com/journal/vsu © 2022 American College of Veterinary Surgeons. 1

2 BOBIS VILLAGRÀ AND CHARLESWORTH

of osteochondrogenesis, and high intrauterine pres- then passed through the splint material before being
sure.2,3,7,8,13 PE has also been reported as being acquired tied.2–5,7,8,10,11,13–15,20,22,24 This places ventral traction on
secondary to upper airway disease, laryngeal paralysis or the deviated sternebrae and allows correction of the
inspiratory dyspnea.1,10,13,16 In human medicine, the defect as the animal continues to grow. This technique
most accepted theory is based on an imbalance and over- can therefore only be used whilst the animals are not
growth of costochondral cartilages that push the sterneb- skeletally mature and still retain some growth potential.
rae inward.17–19 Safe corridors for placement of the circumsternal sutures
The most common clinical signs of PE relate to car- are not commonly reported but one series looking at
diopulmonary dysfunction due to the compressive effects proximity of vital structures (heart, vena cava) to the
of the displaced sternebrae. These symptoms include dorsal sternebrae reported distances <2 mm in all cases.4
coughing, cyanosis, anorexia, weight loss, exercise intol- Cardiac, pulmonary or significant vascular perforation is
erance, cardiac murmur and respiratory distress/dys- therefore a concern when performing this surgery on
pnea.1–3,5,13,20,21 severely deformed patients.
The severity of PE can be radiographically assessed by The aim of this case report is to report use of video-
calculating the frontosagittal (FSI) and vertebral index assisted thoracoscopic surgery (VATS) to help minimize
(VI).1,2,4,22 VI corresponds to the ratio of the distance risk of iatrogenic injury in a dog with severe PE.
from the center of the dorsal surface of the vertebral body
overlying the deformity to the nearest point of the ster-
num and the dorsoventral diameter of the centrum of the 2 | MATERIALS AND METHODS
same vertebra. FSI is defined as the ratio of the thoracic
width at T10 on a ventrodorsal radiograph and the dis- A 5 month-old, 5.1 kg, entire female Cockapoo was
tance from the center of the ventral surface of T10 and referred for evaluation of suspected PE. At the time of
the nearest point on the sternum.1,4,22,23 Computed consultation, the patient was reported to be able to walk
tomography (CT) provides additional information which for 15 min at a time but recovery seemed prolonged.
can aid planning of the surgical procedure.4 There were no reported episodes of dyspnea or collapse.
Pectus excavatum can be classified as mild (FSI: 2.0; Clinical examination was generally within normal limits
VI: >9), moderate (FSI: 2.0–3.0; VI: 6.0–9.0) and severe other than an obvious dorsal deviation of the caudal ster-
(FSI: >3.0; VI: <6.0).1,4,22,23 The degree of radiographic num and a dextrally displaced cardiac apex beat. Respira-
severity, as judged by the VI and FSI, does not always tory rate and character were within normal limits.
correlate with the severity of the clinical signs
reported.1,4,22,23
Canine cases of PE are most commonly treated by
application of a sternal splint that is anchored to the
sternum by placement of circumsternal sutures that are

F I G U R E 1 Three-dimensional surface reconstruction of the F I G U R E 2 Axial computed tomography (CT) scan image of
thoracic wall showing sternal deviation and rotation due to pectus the chest demonstrating the proximity of the displaced sternum to
excavatum the heart
BOBIS VILLAGRÀ AND CHARLESWORTH 3

Echocardiography was unremarkable other than dis- A 5 mm skin incision was made in the fifth right
placement of the cardiac axis secondary to the PE intercostal space, just dorsal to the costochondral junc-
deformity. tions. Subcutaneous tissue and muscle were bluntly dis-
Thoracic radiography was performed to confirm the sected carefully with Metzembaum scissors and the
diagnosis of PE and once done, a CT scan was then per- pleural cavity itself was punctured using a fine hemostat
formed to further assess the deformity (Figure 1). The forcep. After creation of pneumothorax, a 5 mm plastic
results obtained confirmed a severe degree of PE (VI: 3.8; cannula was introduced with a blunt trocar. A rigid endo-
FSI: 2.8 using CT; VI: 4.5; FSI: 3.8 using radiography). scope 5 mm, 30 oblique, 29 cm, (Karl Storz, Germany)
The sternum was sinistrally and dorsally deviated, result- was inserted and the thoracic cavity evaluated. The thin
ing in the most dorsal sternebra being only 1.3 mm away caudal mediastinum was perforated and fenestrated
from the heart (Figure 2). The caudal ribs and costochon- using the end of the scope. Lung inflation was sufficient
dral junctions flared abnormally laterally before inserting to maintain patient oxygenation but the pneumothorax
dorsally on the caudal sternebrae. was sufficient for this not to impair visualization of the
The patient was premedicated with 0.3 mg/kg IV relevant anatomy. The caudal sternebrae were severely
methadone (Synthadon, Animalcare, UK), plus 5 mcg/kg dorsally displaced consistent with the preoperative imag-
IV medetomidine (Sedator, Dechra, Netherlands). Gen- ing but this worsened further during inspiration. Total
eral anesthesia was induced with 2 mg/kg IV alfaxalone distance from the caudal sternebrae to the displaced
(Alfaxan, Dechra, Netherlands) and maintained with iso- heart therefore varied from approximately 1.3 to 12 mm
fluorane (Vetflurane, Virbac, France) in 100% oxygen with the pneumothorax. In addition, the caudal sterneb-
with mechanical ventilation provided (Datex Omehda rae were axially rotated approximately 15 counter-
Aestiva, General Electronics, UK). Once in theater, the clockwise when looking caudally. The sternebrae
patient was ventilated using pressure control at a rate of remained in the midline during respiration and the lat-
20 breaths/min. Perioperative meloxicam 0.2 mg/kg IV eral aspect of the sternebrae abutted the heart on full
(Metacam, Boehringer Ingelheim, Germany) was admin- inspiration only.
istered, no antibiotics were administered.
Once anesthetized, the patient was placed in dorsal
recumbency and a sternal cast was made using Delta-cast
Elite 7.5 cm  3.6 cm (BSN Medical, France) taking care
so that the caudal portion of the cast matched the
desired, not the actual, conformation of the sternum. The
whole ventral thorax and cranial abdomen were then
routinely prepared for surgery using chlorhexidine gluco-
nate 4% (antimicrobial skin cleanser, Hibiscrub), and
then using an applicator with chlorhexidine gluconate
and isopropyl alcohol (chloraprep 3 ml applicator, Becton
Dickinson, New Jersey).

F I G U R E 3 Intraoperative thoracoscopic image showing

passage of the needle around the sternebrae. Although minor F I G U R E 4 Intraoperative photos showing view of sternal
bleeding has occurred, major vessels and heart can be visualized deformity without (A) and with (B) ventral traction applied to
and avoided circumsternal suture
 4

(B)
(A)

F I G U R E 5 (A) Dorsoventral and right lateral thoracic radiographs taken at time of neutering (5.5 months postoperatively) adjacent to the original preoperative radiographs (B). The
preoperative lateral radiograph is slightly rotated. Preoperative vertebral index: 4.5, postoperative vertebral index: 9
BOBIS VILLAGRÀ AND CHARLESWORTH
BOBIS VILLAGRÀ AND CHARLESWORTH 5

Five circumsternal sutures were placed under direct 4 | DISCUSSION

guidance using 3 M polypropylene (Prolene, Ethicon)
with a taper-point needle (26 mm 1/2C), taking care to Both CT scans and radiographs have previously been
always keep the needle in the field of view when inside used to calculate FSI and VI in cats. Although the two
the thoracic cavity (Figure 3). The sternebrae were tem- modalities correlated well, CT gave a lower value for the
porarily tractioned ventrally using the first (caudal) VI with a mean difference of 0.53 and a higher value for
sutures placed and the effect on the distance between the FSI with a mean difference of 0.83.4 Radiographic
sternum and heart evaluated (Figures 4A,B). Once the assessment of PE can vary depending on patient posi-
remaining sutures had been passed, a chest drain tioning and phase of respiration. We suspect that the
(12 ga  30 cm, Mila, DMS, UK) was placed under guid- apparent slight worsening of the VI from 7.1 (immedi-
ance and then the scope and cannula were removed. The ately postoperatively) to 6 simply reflected loss of lateral
thoracoscopic port was closed using 2 metric glycomer compression achieved by the sternal cast and bandage.
631 (Biosyn, Covidien) in the muscle and subcutaneous This does, however, emphasize that these radiographic
tissues. The thorax was then evacuated of air using the indices represent relatively crude assessments of the
thoracostomy tube. The sternal sutures were then passed severity of PE and the importance of repeated clinical
through predrilled holes made in the cast and tied after assessment of these cases.
the sternum had been raised against the splint which was Although conservative treatment (including serial
further facilitated by gentle lateral compression applied assessment of any progression of the defect), has been
by a surgical assistant. A chest bandage was used to cover recommended for mild cases of PE,2,3,5,7,8,10,11,13–15,20,22,24
the cast. Repeat thoracic radiographs were taken showing surgical correction is more commonly recommended for
an improved VI of 7.3 mm and no residual pneumotho- either cases radiographically judged to be moderate or
rax. The thoracostomy tube was removed at this stage. severe or cases judged to have moderate or severe clinical
The patient was recovered in an oxygen tent and signs.2,3,5,7,8,10,11,13–15,20,22,24,25
administered methadone (0.1–0.2 mg/kg q. 4 h) depend- Placement of a sternal cast is the most commonly per-
ing on pain score assessments. Respiratory rate was ini- formed surgical corrective technique for PE but other
tially increased (36 breaths/min) but soon settled as the techniques have been described.2,3,25 The modified
patient adapted to the sternal cast. The patient was then Ravitch technique involves transection of the costochon-
discharged 2 days after surgery at which time they were dral insertions to facilitate flattening of the sternum
eating well. Respiratory effort and rate (24/min) were which is then held in place by a ventrally applied
within normal limits at the time of discharge. plate.2,3,25 Sternal cast placement is less invasive but can
only be used in skeletally immature cases. There is there-
fore a certain time pressure on managing these cases as
3 | R E SUL T S prolonged monitoring can not only lead to irreversible
cardiopulmonary changes but surgeons will lose the
The dog tolerated the splint well. The chest bandage was option of cast placement once the animal is skeletally
checked and adjusted/loosened as needed every 2 weeks mature. This case displayed both clinical signs and severe
but overall maintained for 6 weeks at which point the radiographic abnormalities and was therefore considered
cast and sternal sutures were removed. The circumsternal a surgical candidate as inaction had a significant risk of
sutures had remained intact and there was no evidence allowing development of severe respiratory compromise
of dermatitis associated with the cast. due to decreased thoracic volume and altered thoracic
The surgical site had healed well and repeat radio- wall compliance.26
graphs after cast removal showed a residual deformity in Passage of suture around the sternum can be associ-
the sternum and a VI of 6. Routine clinical examination ated with a risk of perforation of the heart, great vessels
at the time was within normal limits other than the resid- or lungs. This is particularly challenging when the ven-
ual palpable sternal deformity. trolateral flaring of the costochondral cartilages hinders
Radiographs were then repeated at the time of neuter- passage of the needle in severe cases such as the case pre-
ing 4 months later and this showed an improved VI of sented here. Introduction of a pneumothorax has been
9 and FSI of 1.9 (Figure 5A,B). previously described to introduce more space to allow
The dog was considered normal by her owner with no safe passage of the needle and to reduce the risk of both
clinical signs attributed to PE being reported at last fol- iatrogenic pulmonary injury and re-expansion pulmonary
low up (telephone call 6 months after surgery). Subse- oedema.26,27 We therefore planned to introduce pneumo-
quent examinations by the referring veterinarian have thorax for the same reason but sought to utilize the inter-
not detected any evidence of respiratory compromise. costal incision as a thoracoscopic port to help guide the
6 BOBIS VILLAGRÀ AND CHARLESWORTH

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sternal deformity. It was very easy in this case to break computed tomography and medium-term surgical outcome in
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