The Minimally Invasive Repair of Pectus Excavatum Using a Subxiphoid Incision

Abstract

Several surgeons have documented outcomes following the Nuss operation. Most reports have described the use of thoracoscopy to avoid cardiac injury. Since 1999, our group has utilized a subxiphoid incision, allowing insertion of the surgeon's finger into the substernal space to help guide the bar across the mediastinum. Our initial experience has been reported and we are now reporting our entire experience to date. A retrospective review was conducted on all patients who underwent pectus excavatum repair using a subxiphoid incision from December, 1999 to September, 2015. During the study period, 554 repairs were performed. A total of 80% of the patients were male. The mean age was 14.3 years ± 3.1, the mean operating time was 52 minutes ± 17.4, the mean length of stay was 4.2 days ± 1.1, and the mean time to bar removal was 2.7 years ± 0.7. A total of 20 patients (3.6%) received two bars. No patients sustained cardiac injury or evidence of pericarditis. Postoperatively, 22 patients (4%) developed an infection, either cellulitis or a local abscess requiring incision and drainage and/or antibiotics. In four of these 22 patients, the wound infection developed after the bar had been removed. Only one patient required bar removal before 2 years due to an infection. A total of 12 patients required either repositioning of the bar due to rotation (4) or removal of a stabilizer due to chronic discomfort (8), 2 required early bar removal for chronic pain, and 1 patient developed a tension pneumothorax in the operating room. A recurrence has developed in two patients but neither patient has desired correction. In this relatively large series of patients, the addition of a subxiphoid incision to the technique has allowed for safe passage of the bar across the mediastinum to avoid cardiac injury during the Nuss operation.

Repetitive Imaging following Minimally Invasive Repair of Pectus Excavatum Is Unnecessary

“…The incidence of a pneumothorax can be as high as 65%, however, only a small percentage (0.4-5%) requires a thoracostomy tube placement. 4,5,[8][9][10] Historically, an immediate postoperative chest radiograph (CXR) has been used to confirm Nuss bar Introduction The objective of this study was to evaluate the necessity of repeat imaging after an initial chest radiograph (CXR) following minimally invasive repair of pectus excavatum (MIRPE). Materials and Methods A retrospective review was performed on patients who underwent MIRPE from January 2012 to July 2016 at two academic children's hospitals.…”

Letter to the Editor concerning: “Results of pectus excavatum correction using a minimally invasive approach with subxyphoid incision and three-point fixation”

“…Our institution recently reviewed our experience with the modified Nuss procedure. In our analysis of 554 patients over a 15-year period, our rate of bar repositioning for rotation was < 1% and our rate of stabilizer removal due to chronic discomfort was similarly low at 1.4% [2]. We have also not encountered any cardiac injury or required multiple bars.…”

Sternal elevation by the crane technique during pectus excavatum repair: A quantitative analysis

“…Sternal lift by the crane technique was found to facilitate a median pectus depth reduction of 78%, ranging from 52% to 100% per individual patient and diminishing with increasing pectus depth. This corresponded with a median reduction of 13 mm (IQR, [11][12][13][14][15][16][17][18][19], while at the same time, a maximum anterior chest wall elevation of 26 mm (IQR, 19-32) was achieved. This greater elevation of the chest wall compared with reduction of the deformity at its deepest point is likely to be caused by the greater rigidity of the deformity (ie, sternum and adjacent costal cartilage) in comparison with the remainder of the thoracic wall.…”

“…Reduction of the external pectus excavatum depth was expressed as a percentage.Results: Thirty patients were included. Ninety percent were male, with a median age of 15.5 years (interquartile range [IQR], 14.5-17.4), Haller index of 3.56 (IQR, 3.09-4.65), and external pectus depth of 18 mm (IQR,(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23). Sternal elevation by the crane provided a median 78% (IQR, 63-100) reduction of the deformity, corresponding with a residual depth of 3 mm (IQR, 0-7).…”

“…The percentual reduction diminished with increasing depth of the sternal depression (correlation, -0.86). Besides reducing the deformity, the crane caused an elevation of the anterior chest over a large surface area with a maximum lift of 26 mm (IQR,(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32).…”