Current Development of Minimally Invasive Repair of Pectus Excavatum (MIRPE)

Abstract

For decades, open surgical repair was the only available method to treat congenital and acquired chest wall deformities (CWDs). In 1998, D. Nuss described a minimally invasive procedure for surgical repair of Pectus excavatum (PE). Today, the Nuss procedure is performed with increasing frequency worldwide and considered as the "gold standard". After its introduction, the method experienced numerous modifications such as routine thoracoscopy and/or sternal elevation, increasing safety of the procedure. Placement of multiple bars and/or the so called cross-bar technique were introduced to correct complex CWDs. Standardized pain management, the introduction of cryo-analgesia and a standardized postoperative physiotherapy program including deep breathing exercises facilitate the establishment of an enhanced recovery after surgery (ERAS) process. However, the widespread use of the minimally invasive repair of pectus excavatum (MIRPE) procedure has been associated with a significant number of serious complications. Furthermore, several studies report near-fatal complications, not only during bar placement, but also during bar removal. This review focuses upon the most relevant modifications, including recent published surgical techniques of MIRPE, in order to describe current developments in the field.

Keywords: MIRPE; cross bar-technique; pectus excavatum; sternal elevation; thoracoscopy.

Figure 1

Clinical aspect and ct-scan of a 18 years old male patient with severe PE and combined severe scoliosis.

Figure 2

Same patient, clinical aspect after open pectus repair.

Figure 3

Intraoperative application of the vacuum bell.

Figure 4

17 years old male patient with PE and bilateral costal flaring, before MIRPE (Cross bar technique).

Figure 5

17 years old male patient with PE and bilateral costal flaring, thoracoscopic view (Cross bar technique).

Figure 6

17 years old male patient with PE and bilateral costal flaring, after MIRPE (Cross bar technique); notice mild hematoma as side effect of intraoperative application of the vacuum bell.

Figure 7

17 years old male patient with PE and bilateral costal flaring, 1 year after PBR.