Download PDF
Eur J Pediatr Surg 2010; 20(4): 217-221
DOI: 10.1055/s-0030-1254143
Review

© Georg Thieme Verlag KG Stuttgart · New York

Review of the Technical Variants in the Repair of Pectus Excavatum

C. A.  Laituri1 , C. L. Garey1 , S. D. St. Peter2
  • 1Children's Mercy Hospital and Clinics, Pediatric Surgery, Kansas City, United States
  • 2Children's Mercy Hospital, Department of Surgery, Center for Prospective Trials, Kansas City, United States
Further Information

Publication History

received January 20, 2010

accepted after revision April 05, 2010

Publication Date:
07 June 2010 (online)

Also available at
    Permissions and Reprints

Abstract

Introduction: Many technical variations have been introduced for the surgical correction of pectus excavatum (PE). The authors reviewed the literature to provide a detailed overview of the general principles of pectus excavatum repair, bar insertion and removal techniques.

Materials and Methods: A comprehensive review of the literature was undertaken.

Results: A summary of the different approaches and techniques of pectus excavatum repair, bar insertion and removal is presented. Various procedures, their advantages and disadvantages, the techniques employed and associated complications are discussed in depth.

Conclusion: Pectus excavatum repair has undergone many changes since its first description. Despite previous descriptions of evolving procedures, comparative overviews of surgical variations, outcomes after pectus bar insertion and removal techniques are rare in the literature. The authors reviewed the literature to summarize the previous and current understanding of techniques and highlight the variations.

Key words

pectus excavatum - pectus bar - Nuss - Ravitch - subxiphoid technique

References

  • 1 Ashcraft KW, Holcomb GW, Murphy JP. Congenital chest wall deformities.. In: Ashcraft KW, Holcomb GW (eds). Pediatric Surgery. Philadelphia, PA: Elsevier Saunders; 2004: 245-256
    Google Scholar
  • 2 Fonkalsrud EW, Dunn JCY, Atkinson JB. Repair of pectus excavatum deformities: 30 years of experience with 375 patients.  Annals of Surgery. 2000;  231 443-448
    Google Scholar
  • 3 Taguchi TK, Mochizuki T, Nakagaki M. et al . A new plastic operation for pectus excavatum: sternal turnover surgical procedure with preserved internal mammary vessels.  Chest. 1975;  67 606-608
    Google Scholar
  • 4 Meyer L. Zur Chirurgischen Behandlung der angeborenen Trichterbrust.  Verh Berl Med Ges. 1911;  42 364
    Google Scholar
  • 5 Sauerbruch F. Die Chirurgie der Brustorgane.  Berlin, Springer. 1920;  1 437
    Google Scholar
  • 6 Nuss D, Kelly Jr RE. Minimally invasive surgical correction of chest wall deformities in children (Nuss procedure).  Advances in Pediatrics. 2008;  55 395-410
    Google Scholar
  • 7 Sauerbruch F. Die Chirurgie der Brustorgane, Berlin.  Julius Springer. 1920;  1 437
    Google Scholar
  • 8 Sauerbruch F. Operative Beseitigung der angeborenen Trichterbrust.  Deutsche Zeitschr f Chir. 1931;  234 437-446
    Google Scholar
  • 9 Ochsner A, DeBakey M. Chone-Chondrosternon.  J Thorac Surg. 1939;  8 469-511
    Google Scholar
  • 10 Ravitch MM. The operative treatment of pectus excavatum.  Ann Surg. 1949;  129 429-444
    Google Scholar
  • 11 Kuenzler KA, Stolar CJH. Surgical correction of pectus excavatum.  Paediatric Resp Reviews. 2009;  10 7-11
    Google Scholar
  • 12 Haller Jr JA, Colombani PM, Humphries CT. et al . Chest wall constriction after too extensive and too early operations for pectus excavatum.  Ann Thorac Surg. 1996;  61 1618-1625
    Google Scholar
  • 13 Prabhakaran K, Paidas CN, Haller JA. et al . Management of a floating sternum after repair of pectus excavatum.  J Pediatr Surg. 2001;  36 159-164
    Google Scholar
  • 14 Welch KJ. Satisfactory surgical correction of pectus excavatum deformity in childhood.  J Thorac Surg. 1958;  36 697-713
    Google Scholar
  • 15 Fonkalsurd EW, Beanes S, Hebra A. et al . Comparison of minimally invasive and modified Ravitch pectus excavatum repair.  J Pediat Surg. 2002;  37 413-417
    Google Scholar
  • 16 Vohra HA, Adamson L, Weedon DF. et al . Use of extracorporeal membrane oxygenation in the management of septic shock with severe cardiac dysfunction after Ravitch procedure.  Ann Thoracic Surg. 2009;  8 7 4-5
    Google Scholar
  • 17 Horch Re, Stoelben E, Carbon R. et al . Pectus excavatum breast and chest deformity: indications for aesthetic plastic surgery versus thoracic surgery in a multicenter experience.  Aesthetic Plast Surg. 2006;  30 403-411
    Google Scholar
  • 18 Weber PG, Huemmer HP, Reingruber B. Forces to be overcome in correction of pectus excavatum.  J Thoracic Cardiovasc Surg. 2006;  132 1369-1373
    Google Scholar
  • 19 Fonkalsud EW. Open repair of pectus excavatum with minimal cartilage resection.  Ann Surg. 2004;  240 231-235
    Google Scholar
  • 20 Antonoff MB, Erickson AE, Hess DJ. et al . When patients choose: comparison of Nuss, Ravitch, and Leonard procedures for primary repair of pectus excavatum.  J Pediatr Surg. 2009;  44 1113-1119
    Google Scholar
  • 21 Wada J, Ikeda K, Ishida T. et al . Results of 27 funnel chest operations.  Ann Thorac Surg. 1970;  10 526
    Google Scholar
  • 22 Nuss D, Kelly Jr RE, Croitoru DP. et al . A 10-year review of a minimally invasive technique for the correction of pectus excavatum.  J Pediatr Surg. 1998;  33 545-552
    Google Scholar
  • 23 Nuss D, Kelly Jr RE, Croitoru DP. et al . Repair of pectus excavatum.  Pediat Endosurg Innov Tech. 1998;  2 205-221
    Google Scholar
  • 24 Metzelder ML, Ure BM, Leonhardt J. et al . Impact of concomitant thoracic interventions on feasibility of Nuss procedure.  J Pediatr Surg. 2007;  42 1853-1859
    Google Scholar
  • 25 Metzelder ML, Kuebler JF, Leonhardt J. et al . Self and parental assessment after minimally invasive repair of pectus excavatum: lasting satisfaction after bar removal.  Ann Thorac Surg. 2007;  83 1844-1849
    Google Scholar
  • 26 Al-Assiri A, Kravarusic D, Wong V. et al . Operative innovation to the “Nuss” procedure for pectus excavatum: operative and functional effects.  J Pediatr Surg. 2009;  44 888-892
    Google Scholar
  • 27 Bufo AJ, Stone MM. Addition of thoracoscopy to Nuss pectus excavatum repair.  Pediat Endosurg Innov Tech. 2001;  5 159-162
    Google Scholar
  • 28 Saxena Ak, Castellani C, Hollwarth ME. Surgical aspects of thoracoscopy and efficacy of right thoracoscopy in minimally invasive repair of pectus excavatum.  J Thorac Cardiovasc Surg. 2007;  133 1201-1205
    Google Scholar
  • 29 Zallen GS, Glick Pl. Miniature access pectus excavatum repair: lessons we have learned.  J Pediatr Surg. 2004;  39 685-689
    Google Scholar
  • 30 Belcher E, Arora S, Samancilar O. et al . Reducing cardiac injury during minimally invasive repair of pectus excavatum.  Eur J Cardiothorac Surg. 2008;  33 931-933
    Google Scholar
  • 31 Hendrickson RJ, Bensard DD, Janik JS. et al . Efficacy of left thoracoscopy and blunt mediastinal dissection during the Nuss procedure for pectus excavatum.  J Pediatr Surg. 2005;  40 1312-1314
    Google Scholar
  • 32 Palmer B, Yedlin S, Kim S. Decreased risk of complications with bilateral thoracoscopy and left-to-right mediastinal dissection during minimally invasive repair of pectus excavatum.  Eur J Pediatr Surg. 2007;  17 81-83
    Google Scholar
  • 33 St Peter SD, Sharp SW, Ostlie DJ. et al . Use of a subxiphoid incision for pectus bar placement in the repair of pectus excavatum.  J Pediatric Surg (in press).
    Google Scholar
  • 34 Cheng YL, Lee SC, Huang TW. et al . Efficacy and safety of modified bilateral thoracoscopy-assisted Nuss procedure in adult patients with pectus excavatum.  Eur J Cardiothorac Surg. 2008;  34 1057-1061
    Google Scholar
  • 35 Jacobs JP, Quintessenza JA, Morell VO. et al . Minimally invasive repair of pectus excavatum.  Eur J Cardiothorac Surg. 2002;  21 869-873
    Google Scholar
  • 36 Kimura H, Kobayashi S. Indications and limitations of endoscopic surgery for the correction of pectus excavatum.  Japanese J Plastic and Recon Surg. 2004;  47 41-49
    Google Scholar
  • 37 Huang PM, Wu ET, Tseng YT. et al . Modified Nuss operation for pectus excavatum: design for decreasing cardiopulmonary complications.  Thorac Cardiovasc Surg. 2006;  54 134-137
    Google Scholar
  • 38 Dzielicki J, Korlacki W, Janicka I. et al . Difficulties and limitations in minimally invasive repair of pectus excavatum – 6 years experiences with Nuss technique.  Eur J of Cardio-Thoracic Surg. 2006;  30 801-804
    Google Scholar
  • 39 Fonkalsrud EW, Beanes S, Hebra A. et al . Comparison of minimally invasive and modified Ravitch pectus excavatum repair.  J Pediatr Surg. 2002;  37 413-417
    Google Scholar
  • 40 Hosie S, Sitkiewicz T, Petersen C. et al . Minimally invasive repair of pectus excavatum – the Nuss procedure. A European multicentre experience.  Eur J Pediatr Surg. 2002;  12 235-238
    Google Scholar
  • 41 Ostlie DJ, Marosky JK, Spilde TL. et al . Evaluation of pectus bar position and osseous bone formation.  J Pediatr Surg. 2003;  38 953-956
    Google Scholar
  • 42 Adam LA, Lawrence JL, Meehan JJ. Erosion of the Nuss bar into the internal mammary artery 4 months after minimally invasive repair of pectus excavatum.  J Pediatr Surg. 2008;  43 394-397
    Google Scholar
  • 43 Park HJ, Lee SY, Lee CS. et al . The Nuss procedure for pectus excavatum: evolution of techniques and early results on 322 patients.  Ann Thorac Surg. 2004;  77 289-295
    Google Scholar
  • 44 Moss RL, Albanese CT, Reynolds M. Major complications after minimally invasive repair of pectus excavatum: Case Reports.  J Pediatr Surg. 2001;  36 155-158
    Google Scholar
  • 45 Hebra A, Swoveland B, Egbert M. et al . Outcome analysis of minimally invasive repair of pectus excavatum: Review of 251 cases.  J Pediatr Surg. 2000;  35 252-258
    Google Scholar
  • 46 Engum S, Rescorla F, West K. et al . Is the grass greener? Early results of the Nuss procedure.  J Pediatr Surg. 2000;  35 246-251
    Google Scholar
  • 47 Castellani C, Schalamon J, Saxena AK. et al . Early complications of the Nuss procedure for pectus excavatum: a prospective study.  Pediatr Surg Int. 2008;  24 659-666
    Google Scholar
  • 48 Teh SH, Hanna AM, Pham TH. et al . Minimally invasive repair for pectus excavatum in adults.  Ann Thorac Surg. 2008;  85 1914-1918
    Google Scholar
  • 49 Nuss D, Criotoru DP, Kelly Jr RE. et al . Review and discussion of the complications of minimally invasive pectus excavatum repair.  Eur J Pediatr Surg. 2002;  12 230-234
    Google Scholar
  • 50 St Peter SD, Sharp RJ, Upadhyaya P. et al . A straightforward technique for removal of the substernal bar following the Nuss operation.  J Pediatr Surg. 2007;  42 1789-1791
    Google Scholar
  • 51 Pilegaard HK, Licht PB. Can absorbable stabilizers be used routinely in the Nuss procedure?.  Eur J Cardiothorac Surg. 2009;  35 561-564
    Google Scholar
  • 52 Croitoru DP, Kelly Jr RE, Goretsky MJ. et al . Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients.  J Pediatr Surg. 2002;  37 437-445
    Google Scholar
  • 53 Saxena AK. Pectus bar removal after minimally invasive repair of pectus excavatum: advantages of bar stabilizer anvil tool.  Ann Thoracic Surg. 2007;  84 1364-1366
    Google Scholar
  • 54 Noguchi M, Fujita K. A new technique for removing the pectus bar in the Nuss procedure.  J Pediatr Surg. 2005;  40 674-677
    Google Scholar
  • 55 Harrison MR, Estefan-Ventura D, Fechter R. et al . Magnetic mini-mover procedure for pectus excavatum: I. development, design, and simulations for feasibility and safety.  J Pediatr Surg. 2007;  42 81-86
    Google Scholar
  • 56 Horch RE, Springer O. Minimally-invasive endoscopic correction of funnel chest deformity via and umbilical incision.  Aesth Plast Surg. 2002;  26 295-298
    Google Scholar

Correspondence

Dr. Shawn David St. Peter

Children's Mercy Hospital

Department of Surgery

Center for Prospective Trials

2401

Gillham Road

MO 64108 Kansas City

United States

Phone: +1 816 983 6465

Fax: +1 816 983 6885

Email: sspeter@cmh.edu