Advertisement

Minimally Invasive Pectus Excavatum Repair (MIRPE)

Open ArchivePublished:May 28, 2019DOI:https://doi.org/10.1053/j.optechstcvs.2019.05.003
      Pectus excavatum (PE) involves the inward deformity of the sternum and accompanying cartilage attachments. Compression of the right heart and lungs can cause cardiopulmonary disability. Surgical correction is recommended for severe, symptomatic cases. Pectus excavatum can be corrected with a minimally invasive technique that involves placing temporary intrathoracic support bars under the sternum. These bars are then removed after 2-3 years. The minimally invasive Nuss procedure is the standard of care for PE repair in children and adolescents. Minimally invasive repair in more difficult patient repairs, including older teenagers and adults, has required modifications of the original Nuss technique. Our technique for pectus excavatum repair can be used for successful repair of PE patient of all ages and is described to follow.

      Keywords

      Introduction

      Pectus excavatum (PE) is the most common congenital chest wall deformity and in severe cases is recommended for surgical repair.
      • Nuss D.
      • Kelly R.E.
      • Croitoru D.P.
      • Katz M.E.
      A 10-year review of a minimally invasive technique for the correction of pectus excavatum.
      • Jaroszewski D.
      • Notrica D.
      • McMahon L.
      • Steidley D.E.
      • Deschamps C.
      Current management of pectus excavatum: A review and update of therapy and treatment recommendations.
      PE can be successfully corrected with a minimally invasive technique (MIRPE) performed with insertion of curved metal bars under the sternum. This technique has been used for repair of children and adolescents for more than 2 decades and is considered the treatment of choice at most pediatric surgical centers.
      • Kelly R.E.
      • Goretsky M.J.
      • Obermeyer R.
      • et al.
      Twenty-one years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients.
      • Park H.J.
      • Lee S.Y.
      • Lee C.S.
      • Youm W.
      • Lee K.R.
      The Nuss procedure for pectus excavatum: Evolution of techniques and early results on 322 patients.
      There have been multiple modifications of the original technique reported by Nuss in 1998
      • Nuss D.
      • Kelly R.E.
      • Croitoru D.P.
      • Katz M.E.
      A 10-year review of a minimally invasive technique for the correction of pectus excavatum.
      ,
      • Notrica D.M.
      Modifications to the Nuss procedure for pectus excavatum repair: A 20-year review.
      which have allowed adult patients to be treated with MIRPE.
      • Park H.J.
      • Lee S.Y.
      • Lee C.S.
      • Youm W.
      • Lee K.R.
      The Nuss procedure for pectus excavatum: Evolution of techniques and early results on 322 patients.
      ,
      • Jaroszewski D.E.
      • Ewais M.M.
      • Chao C.-J.
      • et al.
      Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (?30 years).
      • Olbrecht V.A.
      • Arnold M.A.
      • Nabaweesi R.
      • et al.
      Lorenz bar repair of pectus excavatum in the adult population: Should it be done?.
      • Aronson D.C.
      • Bosgraaf R.P.
      • van der Horst C.
      • Ekkelkamp S.
      Nuss procedure: Pediatric surgical solution for adults with pectus excavatum.
      • Cheng Y.-L.
      • Lee S.-C.
      • Huang T.-W.
      • Wu C.-T.
      Efficacy and safety of modified bilateral thoracoscopy-assisted Nuss procedure in adult patients with pectus excavatum.
      • Mansour K.A.
      • Thourani V.H.
      • Odessey E.A.
      • Durham M.M.
      • Miller J.I.
      • Miller D.L.
      Thirty-year experience with repair of pectus deformities in adults.
      • Hanna W.C.
      • Ko M.A.
      • Blitz M.
      • Shargall Y.
      • Compeau C.G.
      Thoracoscopic Nuss procedure for young adults with pectus excavatum: Excellent midterm results and patient satisfaction.
      • Pilegaard H.K.
      Nuss technique in pectus excavatum: A mono-institutional experience.
      • Yoon Y.S.
      • Kim H.K.
      • Choi Y.S.
      • Kim K.
      • Shim Y.M.
      • Kim J.
      A modified Nuss procedure for late adolescent and adult pectus excavatum.
      • Pawlak K.
      • Gąsiorowski Ł
      • Gabryel P.
      • Gałęcki B.
      • Zieliński P.
      • Dyszkiewicz W.
      Early and late results of the Nuss procedure in surgical treatment of pectus excavatum in different age groups.
      • Ashfaq A.
      • Beamer S.
      • Ewais M.M.
      • Lackey J.
      • Jaroszewski D.
      Revision of failed prior Nuss in adult patients with pectus excavatum.
      • Jaroszewski D.E.
      • Fonkalsrud E.W.
      Repair of pectus chest deformities in 320 adult patients: 21 year experience.
      • Hebra A.
      • Jacobs J.P.
      • Feliz A.
      • Arenas J.
      • Moore C.B.
      • Larson S.
      Minimally invasive repair of pectus excavatum in adult patients.
      • Park H.J.
      • Jeong J.Y.
      • Kim K.T.
      • Choi Y.H.
      Hinge reinforcement plate for adult pectus excavatum repair: A novel tool for the prevention of intercostal muscle strip.
      • Schalamon J.
      • Pokall S.
      • Windhaber J.
      • Hoellwarth M.E.
      Minimally invasive correction of pectus excavatum in adult patients.
      Our MIRPE technique can be used for successful repair of PE deformities in all age groups including older adults.
      Although the PE can be present at birth, many patients do not develop the defect until late childhood or adolescence. In the majority of patients, the pectus is visibly present and progresses during adolescent growth. Symptoms often occur as the deformity worsens however some patients may not become symptomatic until adulthood.
      • Jaroszewski D.
      • Notrica D.
      • McMahon L.
      • Steidley D.E.
      • Deschamps C.
      Current management of pectus excavatum: A review and update of therapy and treatment recommendations.
      • Jaroszewski D.E.
      • Fonkalsrud E.W.
      Repair of pectus chest deformities in 320 adult patients: 21 year experience.
      • Colombani P.M.
      Preoperative assessment of chest wall deformities.
      • Kragten H.A.
      • Siebenga J.
      • Höppener P.F.
      • Verburg R.
      • Visker N.
      Symptomatic pectus excavatum in seniors (SPES): A cardiovascular problem?  A prospective cardiological study of 42 senior patients with a symptomatic pectus excavatum.
      The worsening of symptoms seen with aging may in part be secondary to loss of chest wall compliance.
      • Jaroszewski D.
      • Notrica D.
      • McMahon L.
      • Steidley D.E.
      • Deschamps C.
      Current management of pectus excavatum: A review and update of therapy and treatment recommendations.
      • Jaroszewski D.E.
      • Fonkalsrud E.W.
      Repair of pectus chest deformities in 320 adult patients: 21 year experience.
      • Kragten H.A.
      • Siebenga J.
      • Höppener P.F.
      • Verburg R.
      • Visker N.
      Symptomatic pectus excavatum in seniors (SPES): A cardiovascular problem?  A prospective cardiological study of 42 senior patients with a symptomatic pectus excavatum.
      • Coln E.
      • Carrasco J.
      • Coln D.
      Demonstrating relief of cardiac compression with the Nuss minimally invasive repair for pectus excavatum.
      More common symptoms described include exercise intolerance, exertional dyspnea and tachycardia, and chest pressure or pain.
      • Jaroszewski D.E.
      • Ewais M.M.
      • Chao C.-J.
      • et al.
      Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (?30 years).
      • Olbrecht V.A.
      • Arnold M.A.
      • Nabaweesi R.
      • et al.
      Lorenz bar repair of pectus excavatum in the adult population: Should it be done?.
      • Cheng Y.-L.
      • Lee S.-C.
      • Huang T.-W.
      • Wu C.-T.
      Efficacy and safety of modified bilateral thoracoscopy-assisted Nuss procedure in adult patients with pectus excavatum.
      • Hanna W.C.
      • Ko M.A.
      • Blitz M.
      • Shargall Y.
      • Compeau C.G.
      Thoracoscopic Nuss procedure for young adults with pectus excavatum: Excellent midterm results and patient satisfaction.
      • Pawlak K.
      • Gąsiorowski Ł
      • Gabryel P.
      • Gałęcki B.
      • Zieliński P.
      • Dyszkiewicz W.
      Early and late results of the Nuss procedure in surgical treatment of pectus excavatum in different age groups.
      • Kragten H.A.
      • Siebenga J.
      • Höppener P.F.
      • Verburg R.
      • Visker N.
      Symptomatic pectus excavatum in seniors (SPES): A cardiovascular problem?  A prospective cardiological study of 42 senior patients with a symptomatic pectus excavatum.
      • Sacco Casamassima M.G.
      • Gause C.
      • Goldstein S.D.
      • et al.
      Patient satisfaction after minimally invasive repair of pectus excavatum in adults: Long-term results of nuss procedure in adults.
      • Erşen E.
      • Demirkaya A.
      • Kılıç B.
      • et al.
      Minimally invasive repair of pectus excavatum (MIRPE) in adults: Is it a proper choice?.
      When a patient presents with PE, a thorough work up should be completed to understand the severity of the condition as well as to rule out the presence of other confounding cardiopulmonary issues. Workup can be tailored to patient age and at a minimum should include history and physical, thoracic imaging, blood chemistry analysis, electrocardiogram, and echocardiogram. More in depth assessment of cardiopulmonary function may be indicated included, exercise testing through measurement of peak oxygen uptake (VO2), pulmonary function tests, and cardiac stress imaging.
      Our initial evaluation includes magnetic resonance imaging or noncontrast computed tomography. This allows for visualization of the deformity and may demonstrate cardiac compression or displacement, atelectasis or tracheobronchial compression.
      • Jaroszewski D.
      • Notrica D.
      • McMahon L.
      • Steidley D.E.
      • Deschamps C.
      Current management of pectus excavatum: A review and update of therapy and treatment recommendations.
      • Kelly R.E.
      Pectus excavatum: Historical background, clinical picture, preoperative evaluation and criteria for operation.
      The scan should be performed with both inspiratory and expiratory phases as the severity of the defect may substantially worsen on exhalation.
      • Coln E.
      • Carrasco J.
      • Coln D.
      Demonstrating relief of cardiac compression with the Nuss minimally invasive repair for pectus excavatum.
      Imaging is used to calculate the index of severity at the lowest level of the pectus deformity and can be assessed using the Haller index
      • Haller J.A.
      • Kramer S.S.
      • Lietman S.A.
      Use of CT scans in selection of patients for pectus excavatum surgery: A preliminary report.
      or the correction index.
      • St. Peter S.D.
      • Juang D.
      • Garey C.L.
      et al. A novel measure for pectus excavatum: The correction index.
      Surgery is recommended for patients with a Haller Index score of more than 3.25 (normal 2.5-2.7) or a correction index score of more than 10%.
      • Mortellaro V.E.
      • Iqbal C.W.
      • Fike F.B.
      • et al.
      The predictive value of haller index in patients undergoing pectus bar repair for pectus excavatum.
      Beyond indices, any evidence for cardiopulmonary disability should prompt consideration of surgical repair including decreased peak anaerobic VO2,
      • Neviere R.
      • Montaigne D.
      • Benhamed L.
      • et al.
      Cardiopulmonary response following surgical repair of pectus excavatum in adult patients.
      restrictive pulmonary disease,
      • Lawson M.L.
      • Mellins R.B.
      • Paulson J.F.
      • et al.
      Increasing severity of pectus excavatum is associated with reduced pulmonary function.
      and right-sided cardiac compression.
      • Colombani P.M.
      Preoperative assessment of chest wall deformities.
      ,
      • Chao C.-J.
      • Jaroszewski D.E.
      • Kumar P.N.
      • et al.
      Surgical repair of pectus excavatum relieves right heart chamber compression and improves cardiac output in adult patients? An intraoperative transesophageal echocardiographic study.
      • Mocchegiani R.
      • Badano L.
      • Lestuzzi C.
      • Nicolosi G.L.
      • Zanuttini D.
      Relation of right ventricular morphology and function in pectus excavatum to the severity of the chest wall deformity.
      • Krueger T.
      • Chassot P.-G.
      • Christodoulou M.
      • Cheng C.
      • Ris H.-B.
      • Magnusson L.
      Cardiac function assessed by transesophageal echocardiography during pectus excavatum repair.
      • Jaroszewski D.
      • Velazco C.
      • Pulivarthi V.
      • Arsanjani R.
      • Obermeyer R.
      Cardiopulmonary function in thoracic wall deformities: What do we really know?.
      • Chao C.-J.
      • Jaroszewski D.
      • Gotway M.
      • et al.
      Effects of pectus excavatum repair on right and left ventricular strain.
      • Ewais M.
      • Chaparala S.
      • Uhl R.
      • Jaroszewski D.
      Outcomes in adult pectus excavatum patients undergoing Nuss repair.
      • Obermeyer R.J.
      • Cohen N.S.
      • Jaroszewski D.E.
      The physiologic impact of pectus excavatum repair.
      • Pulivarthi V.S.K.K.
      • Jaroszewski D.
      • Arsanjani R.
      • Cabrera A.
      • Appleton C.
      Pectus excavatum patients have abnormal mitral valve leaflet lengths and coaptation point without significant MR.
      In addition, significant decrease in cardiac output due to positional change from supine to sitting warrants repair and can be assessed by positional echocardiogram.
      We currently utilize the pectus excavatum repair kit from Zimmer Biomet (Jacksonville, FL) and until 2018 this was the only FDA approved Nuss implant system. MedXpert (Heitersheim, Germany) has recently introduced a pectus repair and implant product to the US market that is now also commercially available (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8).
      Figure 1
      Figure 1The patient is positioned supine on the operating room table with longitudinal gel rolls placed parallel to the spine. The arms are tucked at sides with padding underneath. Patients receive preoperative antibiotic prophylaxis with intravenous cefazolin unless contraindicated. Use of cefazolin is associated with lower infection rates and should be prioritized.
      • Jaroszewski D.E.
      • Mahmoud L.
      Letter to the editor.
      • Obermeyer R.J.
      • Godbout E.
      • Goretsky M.J.
      • et al.
      Risk factors and management of Nuss bar infections in 1717 patients over 25 years.
      A double-lumen endotracheal tube is placed after general anesthesia induction.
      Figure 2
      Figure 2(A) Intercostal spaces are marked with surgical marking ink and the extent of the defect defined. Incisions are marked lateral to the nipple and positioned at an angle to follow the contour of the rib. The ideal incision allows access to all interspaces that will hold bars and should be planned and marked out prior to starting the procedure. The patient is prepped with chlorhexidine and draped in the standard sterile fashion including Ioban (3M, St. Paul, MN) sheeting. Preoperatively, the patient uses a chlorhexidine scrub brushes the night and morning before surgery.
      • Jaroszewski D.E.
      • Mahmoud L.
      Letter to the editor.
      Studies have shown using chlorhexidine prep intraoperatively reduces the risk of surgical site infection compared to povidone iodine.
      • Dumville J.C.
      • McFarlane E.
      • Edwards P.
      • Lipp A.
      • Holmes A.
      Preoperative skin antiseptics for preventing surgical wound infections after clean surgery.
      Before incisions are made, an intercostal block of ribs 3-9 are performed bilateral with a combination of 0.25% plain Marcaine and Dexamethasone. The subcutaneous tissues around the sternum at the defect were also injected. (B) Bilateral 3-cm incisions are made at the designated site along the contour of the ribs and carried down through the soft tissues and muscle using electrocautery. The pectoralis major muscle is elevated off the bony chest medial and the serratus lateral using a combination of electrocautery and blunt dissection. A subpectoral pocket is created along the interspaces which will allow the bars to sit underneath muscular attachments. Single lung ventilation is initiated with the right lung isolated. A 5-mm port is placed into the chest through the incision on the right. The right chest is then insufflated with CO2 to a pressure of 6-8 mm Hg and a 5 mm camera placed. We use the articulating-tip ENDOEYE FLEX (Olympus, Center Valley, PA) which allows for excellent visualization of the thoracic space bilateral. A second 5-mm port is subsequently placed under direct visualization in the right lower chest, superior to the diaphragm. The camera is then moved to this port site.
      Figure 2
      Figure 2(A) Intercostal spaces are marked with surgical marking ink and the extent of the defect defined. Incisions are marked lateral to the nipple and positioned at an angle to follow the contour of the rib. The ideal incision allows access to all interspaces that will hold bars and should be planned and marked out prior to starting the procedure. The patient is prepped with chlorhexidine and draped in the standard sterile fashion including Ioban (3M, St. Paul, MN) sheeting. Preoperatively, the patient uses a chlorhexidine scrub brushes the night and morning before surgery.
      • Jaroszewski D.E.
      • Mahmoud L.
      Letter to the editor.
      Studies have shown using chlorhexidine prep intraoperatively reduces the risk of surgical site infection compared to povidone iodine.
      • Dumville J.C.
      • McFarlane E.
      • Edwards P.
      • Lipp A.
      • Holmes A.
      Preoperative skin antiseptics for preventing surgical wound infections after clean surgery.
      Before incisions are made, an intercostal block of ribs 3-9 are performed bilateral with a combination of 0.25% plain Marcaine and Dexamethasone. The subcutaneous tissues around the sternum at the defect were also injected. (B) Bilateral 3-cm incisions are made at the designated site along the contour of the ribs and carried down through the soft tissues and muscle using electrocautery. The pectoralis major muscle is elevated off the bony chest medial and the serratus lateral using a combination of electrocautery and blunt dissection. A subpectoral pocket is created along the interspaces which will allow the bars to sit underneath muscular attachments. Single lung ventilation is initiated with the right lung isolated. A 5-mm port is placed into the chest through the incision on the right. The right chest is then insufflated with CO2 to a pressure of 6-8 mm Hg and a 5 mm camera placed. We use the articulating-tip ENDOEYE FLEX (Olympus, Center Valley, PA) which allows for excellent visualization of the thoracic space bilateral. A second 5-mm port is subsequently placed under direct visualization in the right lower chest, superior to the diaphragm. The camera is then moved to this port site.
      Figure 3
      Figure 3(A, B) The use of forced sternal elevation can decrease the force required to insert and rotate bars.
      • Jaroszewski D.E.
      • Johnson K.
      • McMahon L.
      • Notrica D.
      Sternal elevation before passing bars: A technique for improving visualization and facilitating minimally invasive pectus excavatum repair in adult patients.
      • Tedde M.L.
      • de Campos J.R.M.
      • Wihlm J.-M.
      • Jatene F.B.
      The Nuss procedure made safer: An effective and simple sternal elevation manoeuvre.
      Variations of this have been reported by other authors with good results.
      • Yoon Y.S.
      • Kim H.K.
      • Choi Y.S.
      • Kim K.
      • Shim Y.M.
      • Kim J.
      A modified Nuss procedure for late adolescent and adult pectus excavatum.
      • Park H.J.
      • Jeong J.Y.
      • Kim K.T.
      • Choi Y.H.
      Hinge reinforcement plate for adult pectus excavatum repair: A novel tool for the prevention of intercostal muscle strip.
      ,
      • Jaroszewski D.E.
      • Johnson K.
      • McMahon L.
      • Notrica D.
      Sternal elevation before passing bars: A technique for improving visualization and facilitating minimally invasive pectus excavatum repair in adult patients.
      • Tedde M.L.
      • de Campos J.R.M.
      • Wihlm J.-M.
      • Jatene F.B.
      The Nuss procedure made safer: An effective and simple sternal elevation manoeuvre.
      • Takagi S.
      • Oyama T.
      • Tomokazu N.
      • Kinoshita K.
      • Makino T.
      • Ohjimi H.
      A new sternum elevator reduces severe complications during minimally invasive repair of the pectus excavatum.
      • Kim D.
      • Idowu O.
      • Palmer B.
      • Kim S.
      Anterior chest wall elevation using a T-fastener suture technique during a Nuss procedure.
      • Haecker F.-M.
      • Sesia S.B.
      Intraoperative use of the vacuum bell for elevating the sternum during the Nuss procedure.
      • Johnson W.R.
      • Fedor D.
      • Singhal S.
      A novel approach to eliminate cardiac perforation in the Nuss procedure.
      Elevation of the sternum also improves visibility and may decrease the risks of mediastinal dissection and bar passage. (C) A RulTract Retractor (Rultract Inc., Cleveland, OH) with an extension arm is attached to the left side of the operating room table at the level of the clavicle. Stab incisions are placed on either side of the sternal defect and the tips of a perforating clamp (we utilize the Lewin Spinal Perforating Forceps, V. Mueller NL6960; CareFusion, Inc, San Diego, CA) are manipulated into the anterior table of the sternum. The cable connector is then attached to the clamp and the sternum elevated. Ideally the defect is elevated completely; however, in older and larger patients, only partial reduction of the defect can be obtained. Careful cranking of the RulTract is performed and ceased when the defect resists any further elevation. There will be significant tension which increases as the defect reduces. Attempting to force further elevation can lead to sternal fracture or the clamp tearing thru and off. For very low defects involving the distal third of the sternum and accompanying costal cartilages, the clamp will need to be at the superior aspect of the deformity to prevent attaching the clamp to cartilage, which will tear through. One can also place the clamp parallel in the center of the sternum using deep bites through the anterior table. It is more difficult to place the clamp, however, may have less of a risk to fracture the sternum in older and or very deep patients.
      Figure 3
      Figure 3(A, B) The use of forced sternal elevation can decrease the force required to insert and rotate bars.
      • Jaroszewski D.E.
      • Johnson K.
      • McMahon L.
      • Notrica D.
      Sternal elevation before passing bars: A technique for improving visualization and facilitating minimally invasive pectus excavatum repair in adult patients.
      • Tedde M.L.
      • de Campos J.R.M.
      • Wihlm J.-M.
      • Jatene F.B.
      The Nuss procedure made safer: An effective and simple sternal elevation manoeuvre.
      Variations of this have been reported by other authors with good results.
      • Yoon Y.S.
      • Kim H.K.
      • Choi Y.S.
      • Kim K.
      • Shim Y.M.
      • Kim J.
      A modified Nuss procedure for late adolescent and adult pectus excavatum.
      • Park H.J.
      • Jeong J.Y.
      • Kim K.T.
      • Choi Y.H.
      Hinge reinforcement plate for adult pectus excavatum repair: A novel tool for the prevention of intercostal muscle strip.
      ,
      • Jaroszewski D.E.
      • Johnson K.
      • McMahon L.
      • Notrica D.
      Sternal elevation before passing bars: A technique for improving visualization and facilitating minimally invasive pectus excavatum repair in adult patients.
      • Tedde M.L.
      • de Campos J.R.M.
      • Wihlm J.-M.
      • Jatene F.B.
      The Nuss procedure made safer: An effective and simple sternal elevation manoeuvre.
      • Takagi S.
      • Oyama T.
      • Tomokazu N.
      • Kinoshita K.
      • Makino T.
      • Ohjimi H.
      A new sternum elevator reduces severe complications during minimally invasive repair of the pectus excavatum.
      • Kim D.
      • Idowu O.
      • Palmer B.
      • Kim S.
      Anterior chest wall elevation using a T-fastener suture technique during a Nuss procedure.
      • Haecker F.-M.
      • Sesia S.B.
      Intraoperative use of the vacuum bell for elevating the sternum during the Nuss procedure.
      • Johnson W.R.
      • Fedor D.
      • Singhal S.
      A novel approach to eliminate cardiac perforation in the Nuss procedure.
      Elevation of the sternum also improves visibility and may decrease the risks of mediastinal dissection and bar passage. (C) A RulTract Retractor (Rultract Inc., Cleveland, OH) with an extension arm is attached to the left side of the operating room table at the level of the clavicle. Stab incisions are placed on either side of the sternal defect and the tips of a perforating clamp (we utilize the Lewin Spinal Perforating Forceps, V. Mueller NL6960; CareFusion, Inc, San Diego, CA) are manipulated into the anterior table of the sternum. The cable connector is then attached to the clamp and the sternum elevated. Ideally the defect is elevated completely; however, in older and larger patients, only partial reduction of the defect can be obtained. Careful cranking of the RulTract is performed and ceased when the defect resists any further elevation. There will be significant tension which increases as the defect reduces. Attempting to force further elevation can lead to sternal fracture or the clamp tearing thru and off. For very low defects involving the distal third of the sternum and accompanying costal cartilages, the clamp will need to be at the superior aspect of the deformity to prevent attaching the clamp to cartilage, which will tear through. One can also place the clamp parallel in the center of the sternum using deep bites through the anterior table. It is more difficult to place the clamp, however, may have less of a risk to fracture the sternum in older and or very deep patients.
      Figure 4
      Figure 4Once the defect is elevated, measurement of bars is performed. There is an option to special order prebent bars from Zimmer BioMet for a fee. We prefer a bar length that does not cross the mid-axillary line. The bar must be sufficiently long to curve around the side of the chest and cross over several ribs to prevent the end from migrating into the interspace. Bars should be bent with a gradual curve and closely approximate the chest wall. Under direct visualization, dissection across the mediastinum is performed with an endoscopic kittner. Once the left pleural reflection is opened, CO2 will dissect into the left thorax and increase visualization and ease of further dissection.
      Figure 5
      Figure 5(A) The dissector (Pectus Introducer, Zimmer Biomet, Jacksonville, FL) is brought in under the pectoralis pocket and introduced into the interspace at the superior aspect of the defect through the right interspace and brought out through the contralateral interspace with careful avoidance of the internal mammary artery. It is critical that the entrance site be medial as shown on A with “X” marking ideal location. (B) A #5 FiberWire (Arthrex, Inc, Naples, FL) is then attached to the dissector end. The dissector is removed and the FiberWire left in to serve as a guide for bar placement.
      Figure 5
      Figure 5(A) The dissector (Pectus Introducer, Zimmer Biomet, Jacksonville, FL) is brought in under the pectoralis pocket and introduced into the interspace at the superior aspect of the defect through the right interspace and brought out through the contralateral interspace with careful avoidance of the internal mammary artery. It is critical that the entrance site be medial as shown on A with “X” marking ideal location. (B) A #5 FiberWire (Arthrex, Inc, Naples, FL) is then attached to the dissector end. The dissector is removed and the FiberWire left in to serve as a guide for bar placement.
      Figure 6
      Figure 6(A, B) The bar must enter the thorax medially to be able to forcefully push the sternum and defect anterior. Even when bars are inserted in the proper medial location, striping of the intercostal muscles and subsequent widening of the intercostal space can allow posterior-lateral bar migration. The inability for the intercostal muscle and space to support the weight of the bar in larger and older patients is a major cause for failure of MIRPE in this group.
      • Notrica D.M.
      Modifications to the Nuss procedure for pectus excavatum repair: A 20-year review.
      • Jaroszewski D.E.
      • Ewais M.M.
      • Chao C.-J.
      • et al.
      Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (?30 years).
      • Ashfaq A.
      • Beamer S.
      • Ewais M.M.
      • Lackey J.
      • Jaroszewski D.
      Revision of failed prior Nuss in adult patients with pectus excavatum.
      • Velazco C.S.
      • Arsanjani R.
      • Jaroszewski D.E.
      Nuss procedure in the adult population for correction of pectus excavatum.
      (C, D) Stripping of the intercostal muscle and lateral-posterior migration can be easily identified with an A-P chest X-ray showing distal bar tips converging. Imaging with computerized tomography can confirm these findings. (E) We routinely reinforce the intercostal spaces that will hold the bar with a figure-of-eight FiberWire “hammock
      • Notrica D.M.
      Modifications to the Nuss procedure for pectus excavatum repair: A 20-year review.
      • Jaroszewski D.
      • Velazco C.
      • Pulivarthi V.
      • Arsanjani R.
      • Obermeyer R.
      Cardiopulmonary function in thoracic wall deformities: What do we really know?.
      • Velazco C.S.
      • Arsanjani R.
      • Jaroszewski D.E.
      Nuss procedure in the adult population for correction of pectus excavatum.
      ” which incorporates the rib above and below the interspace. FiberWire is a braided polyester jacket with a core of ultra-high molecular weight polyethylene that is used by orthopedics for tendon and joint repair.
      • McMahon L.E.
      • Johnson K.N.
      • Jaroszewski D.E.
      • et al.
      Experience with FiberWire for pectus bar attachment.
      The hammock is placed slightly lateral to the bar exit site to prevent the ribs and interspace from widening out and intercostal muscle stripping. It allows the weight of the bar to rest on the suture versus the intercostal muscles as it exits the chest. Once the hammock is created, placement of the bars can occur. The bar is brought to the field and the FiberWire tied to the islet at the end. The bar is inserted through the right interspace in the “U” position and brought across the mediastinum and out the left interspace. The FiberWire is kept on tension to assist with guiding and pulling the bar through the left interspace.
      Figure 6
      Figure 6(A, B) The bar must enter the thorax medially to be able to forcefully push the sternum and defect anterior. Even when bars are inserted in the proper medial location, striping of the intercostal muscles and subsequent widening of the intercostal space can allow posterior-lateral bar migration. The inability for the intercostal muscle and space to support the weight of the bar in larger and older patients is a major cause for failure of MIRPE in this group.
      • Notrica D.M.
      Modifications to the Nuss procedure for pectus excavatum repair: A 20-year review.
      • Jaroszewski D.E.
      • Ewais M.M.
      • Chao C.-J.
      • et al.
      Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (?30 years).
      • Ashfaq A.
      • Beamer S.
      • Ewais M.M.
      • Lackey J.
      • Jaroszewski D.
      Revision of failed prior Nuss in adult patients with pectus excavatum.
      • Velazco C.S.
      • Arsanjani R.
      • Jaroszewski D.E.
      Nuss procedure in the adult population for correction of pectus excavatum.
      (C, D) Stripping of the intercostal muscle and lateral-posterior migration can be easily identified with an A-P chest X-ray showing distal bar tips converging. Imaging with computerized tomography can confirm these findings. (E) We routinely reinforce the intercostal spaces that will hold the bar with a figure-of-eight FiberWire “hammock
      • Notrica D.M.
      Modifications to the Nuss procedure for pectus excavatum repair: A 20-year review.
      • Jaroszewski D.
      • Velazco C.
      • Pulivarthi V.
      • Arsanjani R.
      • Obermeyer R.
      Cardiopulmonary function in thoracic wall deformities: What do we really know?.
      • Velazco C.S.
      • Arsanjani R.
      • Jaroszewski D.E.
      Nuss procedure in the adult population for correction of pectus excavatum.
      ” which incorporates the rib above and below the interspace. FiberWire is a braided polyester jacket with a core of ultra-high molecular weight polyethylene that is used by orthopedics for tendon and joint repair.
      • McMahon L.E.
      • Johnson K.N.
      • Jaroszewski D.E.
      • et al.
      Experience with FiberWire for pectus bar attachment.
      The hammock is placed slightly lateral to the bar exit site to prevent the ribs and interspace from widening out and intercostal muscle stripping. It allows the weight of the bar to rest on the suture versus the intercostal muscles as it exits the chest. Once the hammock is created, placement of the bars can occur. The bar is brought to the field and the FiberWire tied to the islet at the end. The bar is inserted through the right interspace in the “U” position and brought across the mediastinum and out the left interspace. The FiberWire is kept on tension to assist with guiding and pulling the bar through the left interspace.
      Figure 6
      Figure 6(A, B) The bar must enter the thorax medially to be able to forcefully push the sternum and defect anterior. Even when bars are inserted in the proper medial location, striping of the intercostal muscles and subsequent widening of the intercostal space can allow posterior-lateral bar migration. The inability for the intercostal muscle and space to support the weight of the bar in larger and older patients is a major cause for failure of MIRPE in this group.
      • Notrica D.M.
      Modifications to the Nuss procedure for pectus excavatum repair: A 20-year review.
      • Jaroszewski D.E.
      • Ewais M.M.
      • Chao C.-J.
      • et al.
      Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (?30 years).
      • Ashfaq A.
      • Beamer S.
      • Ewais M.M.
      • Lackey J.
      • Jaroszewski D.
      Revision of failed prior Nuss in adult patients with pectus excavatum.
      • Velazco C.S.
      • Arsanjani R.
      • Jaroszewski D.E.
      Nuss procedure in the adult population for correction of pectus excavatum.
      (C, D) Stripping of the intercostal muscle and lateral-posterior migration can be easily identified with an A-P chest X-ray showing distal bar tips converging. Imaging with computerized tomography can confirm these findings. (E) We routinely reinforce the intercostal spaces that will hold the bar with a figure-of-eight FiberWire “hammock
      • Notrica D.M.
      Modifications to the Nuss procedure for pectus excavatum repair: A 20-year review.
      • Jaroszewski D.
      • Velazco C.
      • Pulivarthi V.
      • Arsanjani R.
      • Obermeyer R.
      Cardiopulmonary function in thoracic wall deformities: What do we really know?.
      • Velazco C.S.
      • Arsanjani R.
      • Jaroszewski D.E.
      Nuss procedure in the adult population for correction of pectus excavatum.
      ” which incorporates the rib above and below the interspace. FiberWire is a braided polyester jacket with a core of ultra-high molecular weight polyethylene that is used by orthopedics for tendon and joint repair.
      • McMahon L.E.
      • Johnson K.N.
      • Jaroszewski D.E.
      • et al.
      Experience with FiberWire for pectus bar attachment.
      The hammock is placed slightly lateral to the bar exit site to prevent the ribs and interspace from widening out and intercostal muscle stripping. It allows the weight of the bar to rest on the suture versus the intercostal muscles as it exits the chest. Once the hammock is created, placement of the bars can occur. The bar is brought to the field and the FiberWire tied to the islet at the end. The bar is inserted through the right interspace in the “U” position and brought across the mediastinum and out the left interspace. The FiberWire is kept on tension to assist with guiding and pulling the bar through the left interspace.
      Figure 7
      Figure 7The bar is then rotated into position using the “flippers” (Pectus Flipper, Zimmer Biomet, Jacksonville, FL). In larger sized and/or older patients, 2 or more bars should be placed to balance the weight distribution of the defect.
      • Park H.J.
      • Lee S.Y.
      • Lee C.S.
      • Youm W.
      • Lee K.R.
      The Nuss procedure for pectus excavatum: Evolution of techniques and early results on 322 patients.
      • Jaroszewski D.E.
      • Ewais M.M.
      • Chao C.-J.
      • et al.
      Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (?30 years).
      ,
      • Pilegaard H.K.
      • Licht P.B.
      Routine use of minimally invasive surgery for pectus excavatum in adults.
      • Stanfill A.B.
      • DiSomma N.
      • Henriques S.M.
      • Wallace L.J.
      • Vegunta R.K.
      • Pearl R.H.
      Nuss procedure: Decrease in bar movement requiring reoperation with primary placement of two bars.
      • Pilegaard H.K.
      Extending the use of Nuss procedure in patients older than 30 years.
      Multiple bars may help to decrease the risk of bar rotation and pain.
      • Park H.J.
      • Lee S.Y.
      • Lee C.S.
      • Youm W.
      • Lee K.R.
      The Nuss procedure for pectus excavatum: Evolution of techniques and early results on 322 patients.
      • Jaroszewski D.E.
      • Ewais M.M.
      • Chao C.-J.
      • et al.
      Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (?30 years).
      ,
      • Pilegaard H.K.
      • Licht P.B.
      Routine use of minimally invasive surgery for pectus excavatum in adults.
      • Stanfill A.B.
      • DiSomma N.
      • Henriques S.M.
      • Wallace L.J.
      • Vegunta R.K.
      • Pearl R.H.
      Nuss procedure: Decrease in bar movement requiring reoperation with primary placement of two bars.
      • Pilegaard H.K.
      Extending the use of Nuss procedure in patients older than 30 years.
      • Tedde M.L.
      • de Campos J.R.M.
      • Das-Neves-Pereira J.-C.
      • Abrāo F.C.
      • Jatene F.B.
      The search for stability: Bar displacement in three series of pectus excavatum patients treated with the Nuss technique.
      • Nagaso T.
      • Miyamoto J.
      • Kokaji K.
      • et al.
      Double-bar application decreases postoperative pain after the Nuss procedure.
      In our adult practice, we have placed 2 or more bars in 99% of patients undergoing primary pectus repair (over 30) and 100% of patients undergoing revision of prior failed MIRPE.
      • Ashfaq A.
      • Beamer S.
      • Ewais M.M.
      • Lackey J.
      • Jaroszewski D.
      Revision of failed prior Nuss in adult patients with pectus excavatum.
      A decreased risk of migration and reoperation with multiple bars has also been reported by others.
      • Park H.J.
      • Lee S.Y.
      • Lee C.S.
      • Youm W.
      • Lee K.R.
      The Nuss procedure for pectus excavatum: Evolution of techniques and early results on 322 patients.
      • Pilegaard H.K.
      • Licht P.B.
      Routine use of minimally invasive surgery for pectus excavatum in adults.
      • Stanfill A.B.
      • DiSomma N.
      • Henriques S.M.
      • Wallace L.J.
      • Vegunta R.K.
      • Pearl R.H.
      Nuss procedure: Decrease in bar movement requiring reoperation with primary placement of two bars.
      In one report, reoperation for bar migration or incomplete correction was reported for 15.5% of single-bar repairs versus no reoperations required for patients repaired with 2 bars.
      • Stanfill A.B.
      • DiSomma N.
      • Henriques S.M.
      • Wallace L.J.
      • Vegunta R.K.
      • Pearl R.H.
      Nuss procedure: Decrease in bar movement requiring reoperation with primary placement of two bars.
      A second bar is then placed 1 or 2 interspaces below the superior bar in a similar fashion. If any inferior residual defect persisted, a third bar can be placed. Bars should be rotated into place while the sternum is elevated with the RulTract to minimize rotational force.
      Figure 8
      Figure 8(A) FiberWire is now used to secure the bars at multiple points. A unilateral stabilizer was recommended by Nuss et al.;
      • Croitoru D.P.
      • Kelly R.E.
      • Goretsky M.J.
      • Lawson M.L.
      • Swoveland B.
      • Nuss D.
      Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients.
      however, we discontinued its use in 2008 due to chronic pain issues and a significantly high rate of bar migration. Circumferential fixation of the bar and rib
      • Jaroszewski D.E.
      • Ewais M.M.
      • Chao C.-J.
      • et al.
      Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (?30 years).
      • Ashfaq A.
      • Beamer S.
      • Ewais M.M.
      • Lackey J.
      • Jaroszewski D.
      Revision of failed prior Nuss in adult patients with pectus excavatum.
      • Velazco C.S.
      • Arsanjani R.
      • Jaroszewski D.E.
      Nuss procedure in the adult population for correction of pectus excavatum.
      • McMahon L.E.
      • Johnson K.N.
      • Jaroszewski D.E.
      • et al.
      Experience with FiberWire for pectus bar attachment.
      • Velazco C.S.
      • Pulivarthi V.S.
      • Jaroszewski D.E.
      Pectus excavatum repair in adults: Indications and how to do it.
      with FiberWire is performed as well as medial sternal fixation.
      • Jaroszewski D.E.
      • Ewais M.M.
      • Chao C.-J.
      • et al.
      Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (?30 years).
      • Pilegaard H.K.
      Nuss technique in pectus excavatum: A mono-institutional experience.
      • Yoon Y.S.
      • Kim H.K.
      • Choi Y.S.
      • Kim K.
      • Shim Y.M.
      • Kim J.
      A modified Nuss procedure for late adolescent and adult pectus excavatum.
      • Ashfaq A.
      • Beamer S.
      • Ewais M.M.
      • Lackey J.
      • Jaroszewski D.
      Revision of failed prior Nuss in adult patients with pectus excavatum.
      • Park H.J.
      • Jeong J.Y.
      • Kim K.T.
      • Choi Y.H.
      Hinge reinforcement plate for adult pectus excavatum repair: A novel tool for the prevention of intercostal muscle strip.
      Sternal fixation is routinely recommended to secure the lower bar and may help prevent rotation. A drill bit guide with sleeve depth protector is used to create a hole in the sternum above and below the bar the Rultract Retractor and clamp are removed. (B) Under thoracoscopic visualization, a suture passer or Hewson Suture Retriever (Smith & Nephew, Andover, MA) is used to pass the FiberWire up from the mediastinum to encircle the bar and sternum. This is tied on the anterior chest wall under the skin. Through the inferior port incision, a 16-French chest tube is placed and removed postoperative day 1.
      Figure 8
      Figure 8(A) FiberWire is now used to secure the bars at multiple points. A unilateral stabilizer was recommended by Nuss et al.;
      • Croitoru D.P.
      • Kelly R.E.
      • Goretsky M.J.
      • Lawson M.L.
      • Swoveland B.
      • Nuss D.
      Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients.
      however, we discontinued its use in 2008 due to chronic pain issues and a significantly high rate of bar migration. Circumferential fixation of the bar and rib
      • Jaroszewski D.E.
      • Ewais M.M.
      • Chao C.-J.
      • et al.
      Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (?30 years).
      • Ashfaq A.
      • Beamer S.
      • Ewais M.M.
      • Lackey J.
      • Jaroszewski D.
      Revision of failed prior Nuss in adult patients with pectus excavatum.
      • Velazco C.S.
      • Arsanjani R.
      • Jaroszewski D.E.
      Nuss procedure in the adult population for correction of pectus excavatum.
      • McMahon L.E.
      • Johnson K.N.
      • Jaroszewski D.E.
      • et al.
      Experience with FiberWire for pectus bar attachment.
      • Velazco C.S.
      • Pulivarthi V.S.
      • Jaroszewski D.E.
      Pectus excavatum repair in adults: Indications and how to do it.
      with FiberWire is performed as well as medial sternal fixation.
      • Jaroszewski D.E.
      • Ewais M.M.
      • Chao C.-J.
      • et al.
      Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (?30 years).
      • Pilegaard H.K.
      Nuss technique in pectus excavatum: A mono-institutional experience.
      • Yoon Y.S.
      • Kim H.K.
      • Choi Y.S.
      • Kim K.
      • Shim Y.M.
      • Kim J.
      A modified Nuss procedure for late adolescent and adult pectus excavatum.
      • Ashfaq A.
      • Beamer S.
      • Ewais M.M.
      • Lackey J.
      • Jaroszewski D.
      Revision of failed prior Nuss in adult patients with pectus excavatum.
      • Park H.J.
      • Jeong J.Y.
      • Kim K.T.
      • Choi Y.H.
      Hinge reinforcement plate for adult pectus excavatum repair: A novel tool for the prevention of intercostal muscle strip.
      Sternal fixation is routinely recommended to secure the lower bar and may help prevent rotation. A drill bit guide with sleeve depth protector is used to create a hole in the sternum above and below the bar the Rultract Retractor and clamp are removed. (B) Under thoracoscopic visualization, a suture passer or Hewson Suture Retriever (Smith & Nephew, Andover, MA) is used to pass the FiberWire up from the mediastinum to encircle the bar and sternum. This is tied on the anterior chest wall under the skin. Through the inferior port incision, a 16-French chest tube is placed and removed postoperative day 1.

      MIRPE Technique

      Pain control is an essential part of recovery. Before skin incisions, an intercostal block is performed bilateral with 0.25% bupivacaine. In all our patients we additionally use anesthetic-infiltrating, subcutaneous, continuous flow catheters (7.5 inch On-Q Pain Relief System with a Select-A-Flow Variable Rate Controller @ 7 ml/hour, Halyard Health, Inc, Irvine, CA) that remain in for 3-4 days after surgery. The introducers are tunneled along the lateral chest wall on top of the ribs and posterior to the axillary line and incision.
      • Jaroszewski D.E.
      • Ewais M.M.
      • Chao C.-J.
      • et al.
      Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (?30 years).
      • Jaroszewski D.E.
      • Mahmoud L.
      Letter to the editor.
      • Velazco C.S.
      • Arsanjani R.
      • Jaroszewski D.E.
      Nuss procedure in the adult population for correction of pectus excavatum.
      • Velazco C.S.
      • Pulivarthi V.S.
      • Jaroszewski D.E.
      Pectus excavatum repair in adults: Indications and how to do it.
      • Jaroszewski D.E.
      • Temkit M.
      • Ewais M.M.
      • et al.
      Randomized trial of epidural vs. subcutaneous catheters for managing pain after modified Nuss in adults.
      The reservoirs contain 750 ml of local anesthetic and are refilled prior to discharge and the patient sent home with them in place. In our experience, subcutaneous continuous flow catheters with a standardized multimodal anesthetic protocol (Table 1) achieve good pain control.
      • Jaroszewski D.E.
      • Temkit M.
      • Ewais M.M.
      • et al.
      Randomized trial of epidural vs. subcutaneous catheters for managing pain after modified Nuss in adults.
      • Sanniec K.J.
      • Velazco C.S.
      • Bryant L.A.
      • et al.
      Immediate versus delayed sarcoma reconstruction: Impact on outcomes.
      We have over the past year added to this method the use of intercostal nerve cryoablation in patients requesting this newer technology.
      • Harbaugh C.M.
      • Johnson K.N.
      • Kein C.E.
      • et al.
      Comparing outcomes with thoracic epidural and intercostal nerve cryoablation after Nuss procedure.
      • Keller B.A.
      • Kabagambe S.K.
      • Becker J.C.
      • et al.
      Intercostal nerve cryoablation versus thoracic epidural catheters for postoperative analgesia following pectus excavatum repair: Preliminary outcomes in twenty-six cryoablation patients.
      • Kim S.
      • Idowu O.
      • Palmer B.
      • Lee S.H.
      Use of transthoracic cryoanalgesia during the Nuss procedure.
      We have performed on a number of patients without complications and seen a decreased need for narcotics, including no time-released morphine and lower doses of oxycodone, in the majority. There are currently no long-term follow-up studies on this modality.
      Table 1Pain Control Regimen
      • Velazco C.S.
      • Pulivarthi V.S.
      • Jaroszewski D.E.
      Pectus excavatum repair in adults: Indications and how to do it.
      Perioperative
      • Gabapentin, 600 mg, PO
      • Celecoxib, 400 mg, PO
      • Acetaminophen, 1000 mg, PO
      • Dexamethasone, 8 mg, IV
      • Methadone, 0.2-0.35 mg/kg, IV
      • General anesthesia induced: single dose of IV fentanyl, 0.5-2 mcg/kg; lidocaine, 1-2 mg/kg; and Propofol, 2-4 mg/kg
      • Subcutaneous On-Q catheters: ropivacaine, 0.2%, at 7 mL/h
      • Marcaine 0.25 mg/kg with 10 mg dexamethasone by patient weight up to 60 mg
      Postoperative day 0
      • PCA- begin in recovery room
       ○ IV hydromorphone, 0.2 mg, at 8-min demand interval dosing with a 4.8 mg lockout at 4 h (can increase on-demand dosing up to 0.4 mg for pain consistently above 4/10)
      • Ketorolac, 30 mg, IV, every 8 h
      • Gabapentin, 300 mg, PO, every 8 h
      • Acetaminophen 1000 mg, PO every 6 h
      • Diazepam 5 mg, IV, every 6 h
      Postoperative day 1 – discharge medications
      • PCA discontinued the morning of postoperative day 1
      • Oxycodone, 5-10 mg, PO, every 3-4 h as needed;
      • Morphine ER, 20 mg, oral, every 12 h if Oxycodone not covering pain (most cryoablation patients do not require)
      • Ketorolac transitioned to ibuprofen, 600 mg, PO every 8 h
      • Gabapentin and acetaminophen continued
      • IV diazepam transitioned to 5 mg PO, every 8 h as needed
      Patients are typically discharged on postoperative day 1 or 2 with follow up at 1 week with a chest X-ray. Follow-up imaging of the chest with A/P and lateral views are recommended at 6 weeks, 6 months and annually until bar removal at 3 years.

      References

        • Nuss D.
        • Kelly R.E.
        • Croitoru D.P.
        • Katz M.E.
        A 10-year review of a minimally invasive technique for the correction of pectus excavatum.
        J Pediatr Surg. 1998; 33 (Accessed 18 July, 2017): 545-552
        • Jaroszewski D.
        • Notrica D.
        • McMahon L.
        • Steidley D.E.
        • Deschamps C.
        Current management of pectus excavatum: A review and update of therapy and treatment recommendations.
        J Am Board Fam Med. 2010; 23: 230-239https://doi.org/10.3122/jabfm.2010.02.090234
        • Kelly R.E.
        • Goretsky M.J.
        • Obermeyer R.
        • et al.
        Twenty-one years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients.
        Ann Surg. 2010; 252: 1072-1081https://doi.org/10.1097/SLA.0b013e3181effdce
        • Park H.J.
        • Lee S.Y.
        • Lee C.S.
        • Youm W.
        • Lee K.R.
        The Nuss procedure for pectus excavatum: Evolution of techniques and early results on 322 patients.
        Ann Thorac Surg. 2004; 77 (Accessed 18 July, 2017): 289-295
        • Notrica D.M.
        Modifications to the Nuss procedure for pectus excavatum repair: A 20-year review.
        Semin Pediatr Surg. 2018; 27: 133-150https://doi.org/10.1053/j.sempedsurg.2018.05.004
        • Jaroszewski D.E.
        • Ewais M.M.
        • Chao C.-J.
        • et al.
        Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (?30 years).
        Ann Thorac Surg. 2016; 102: 993-1003https://doi.org/10.1016/j.athoracsur.2016.03.105
        • Olbrecht V.A.
        • Arnold M.A.
        • Nabaweesi R.
        • et al.
        Lorenz bar repair of pectus excavatum in the adult population: Should it be done?.
        Ann Thorac Surg. 2008; 86 (discussion 408-9): 402-408https://doi.org/10.1016/j.athoracsur.2008.04.038
        • Aronson D.C.
        • Bosgraaf R.P.
        • van der Horst C.
        • Ekkelkamp S.
        Nuss procedure: Pediatric surgical solution for adults with pectus excavatum.
        World J Surg. 2007; 31 (discussion 30): 26-29https://doi.org/10.1007/s00268-005-0779-1
        • Cheng Y.-L.
        • Lee S.-C.
        • Huang T.-W.
        • Wu C.-T.
        Efficacy and safety of modified bilateral thoracoscopy-assisted Nuss procedure in adult patients with pectus excavatum.
        Eur J Cardiothorac Surg. 2008; 34: 1057-1061https://doi.org/10.1016/j.ejcts.2008.07.068
        • Mansour K.A.
        • Thourani V.H.
        • Odessey E.A.
        • Durham M.M.
        • Miller J.I.
        • Miller D.L.
        Thirty-year experience with repair of pectus deformities in adults.
        Ann Thorac Surg. 2003; 76 (discussion 395) (Accessed 18 July, 2017): 391-395
        • Hanna W.C.
        • Ko M.A.
        • Blitz M.
        • Shargall Y.
        • Compeau C.G.
        Thoracoscopic Nuss procedure for young adults with pectus excavatum: Excellent midterm results and patient satisfaction.
        Ann Thorac Surg. 2013; 96 (discussion 1037-8): 1033-1036https://doi.org/10.1016/j.athoracsur.2013.04.093
        • Pilegaard H.K.
        Nuss technique in pectus excavatum: A mono-institutional experience.
        J Thorac Dis. 2015; 7: S172-S176https://doi.org/10.3978/j.issn.2072-1439.2015.04.07
        • Yoon Y.S.
        • Kim H.K.
        • Choi Y.S.
        • Kim K.
        • Shim Y.M.
        • Kim J.
        A modified Nuss procedure for late adolescent and adult pectus excavatum.
        World J Surg. 2010; 34: 1475-1480https://doi.org/10.1007/s00268-010-0465-9
        • Pawlak K.
        • Gąsiorowski Ł
        • Gabryel P.
        • Gałęcki B.
        • Zieliński P.
        • Dyszkiewicz W.
        Early and late results of the Nuss procedure in surgical treatment of pectus excavatum in different age groups.
        Ann Thorac Surg. 2016; 102: 1711-1716https://doi.org/10.1016/j.athoracsur.2016.04.098
        • Ashfaq A.
        • Beamer S.
        • Ewais M.M.
        • Lackey J.
        • Jaroszewski D.
        Revision of failed prior Nuss in adult patients with pectus excavatum.
        Ann Thorac Surg. 2018; 105: 371-378https://doi.org/10.1016/j.athoracsur.2017.08.051
        • Jaroszewski D.E.
        • Fonkalsrud E.W.
        Repair of pectus chest deformities in 320 adult patients: 21 year experience.
        Ann Thorac Surg. 2007; 84: 429-433https://doi.org/10.1016/j.athoracsur.2007.03.077
        • Hebra A.
        • Jacobs J.P.
        • Feliz A.
        • Arenas J.
        • Moore C.B.
        • Larson S.
        Minimally invasive repair of pectus excavatum in adult patients.
        Am Surg. 2006; 72 (Accessed 18 July, 2017): 837-842
        • Park H.J.
        • Jeong J.Y.
        • Kim K.T.
        • Choi Y.H.
        Hinge reinforcement plate for adult pectus excavatum repair: A novel tool for the prevention of intercostal muscle strip.
        Interact Cardiovasc Thorac Surg. 2011; 12: 687-691https://doi.org/10.1510/icvts.2010.254995
        • Schalamon J.
        • Pokall S.
        • Windhaber J.
        • Hoellwarth M.E.
        Minimally invasive correction of pectus excavatum in adult patients.
        J Thorac Cardiovasc Surg. 2006; 132: 524-529https://doi.org/10.1016/j.jtcvs.2006.04.038
        • Colombani P.M.
        Preoperative assessment of chest wall deformities.
        Semin Thorac Cardiovasc Surg. 2009; 21: 58-63https://doi.org/10.1053/j.semtcvs.2009.04.003
        • Kragten H.A.
        • Siebenga J.
        • Höppener P.F.
        • Verburg R.
        • Visker N.
        Symptomatic pectus excavatum in seniors (SPES): A cardiovascular problem?  A prospective cardiological study of 42 senior patients with a symptomatic pectus excavatum.
        Neth Heart J. 2011; 19: 73-78https://doi.org/10.1007/s12471-010-0067-z
        • Coln E.
        • Carrasco J.
        • Coln D.
        Demonstrating relief of cardiac compression with the Nuss minimally invasive repair for pectus excavatum.
        J Pediatr Surg. 2006; 41 (discussion 683-6): 683-686https://doi.org/10.1016/j.jpedsurg.2005.12.009
        • Sacco Casamassima M.G.
        • Gause C.
        • Goldstein S.D.
        • et al.
        Patient satisfaction after minimally invasive repair of pectus excavatum in adults: Long-term results of nuss procedure in adults.
        Ann Thorac Surg. 2016; 101: 1338-1345https://doi.org/10.1016/j.athoracsur.2015.09.102
        • Erşen E.
        • Demirkaya A.
        • Kılıç B.
        • et al.
        Minimally invasive repair of pectus excavatum (MIRPE) in adults: Is it a proper choice?.
        Wideochirurgia i inne Tech maloinwazyjne = Videosurgery other miniinvasive Tech. 2016; 11: 98-104https://doi.org/10.5114/wiitm.2016.60456
        • Kelly R.E.
        Pectus excavatum: Historical background, clinical picture, preoperative evaluation and criteria for operation.
        Semin Pediatr Surg. 2008; 17: 181-193https://doi.org/10.1053/j.sempedsurg.2008.03.002
        • Haller J.A.
        • Kramer S.S.
        • Lietman S.A.
        Use of CT scans in selection of patients for pectus excavatum surgery: A preliminary report.
        J Pediatr Surg. 1987; 22 (Accessed 26 March, 2019): 904-906
        • St. Peter S.D.
        • Juang D.
        • Garey C.L.
        et al. A novel measure for pectus excavatum: The correction index.
        J Pediatr Surg. 2011; 46: 2270-2273https://doi.org/10.1016/j.jpedsurg.2011.09.009
        • Mortellaro V.E.
        • Iqbal C.W.
        • Fike F.B.
        • et al.
        The predictive value of haller index in patients undergoing pectus bar repair for pectus excavatum.
        J Surg Res. 2011; 170: 104-106https://doi.org/10.1016/j.jss.2011.02.014
        • Neviere R.
        • Montaigne D.
        • Benhamed L.
        • et al.
        Cardiopulmonary response following surgical repair of pectus excavatum in adult patients.
        Eur J Cardiothorac Surg. 2011; 40: e77-e82https://doi.org/10.1016/j.ejcts.2011.03.045
        • Lawson M.L.
        • Mellins R.B.
        • Paulson J.F.
        • et al.
        Increasing severity of pectus excavatum is associated with reduced pulmonary function.
        J Pediatr. 2011; 159 (256-61.e2)https://doi.org/10.1016/j.jpeds.2011.01.065
        • Chao C.-J.
        • Jaroszewski D.E.
        • Kumar P.N.
        • et al.
        Surgical repair of pectus excavatum relieves right heart chamber compression and improves cardiac output in adult patients? An intraoperative transesophageal echocardiographic study.
        Am J Surg. 2015; 210: 1118-1125https://doi.org/10.1016/j.amjsurg.2015.07.006
        • Mocchegiani R.
        • Badano L.
        • Lestuzzi C.
        • Nicolosi G.L.
        • Zanuttini D.
        Relation of right ventricular morphology and function in pectus excavatum to the severity of the chest wall deformity.
        Am J Cardiol. 1995; 76 (Accessed 18 July, 2017): 941-946
        • Krueger T.
        • Chassot P.-G.
        • Christodoulou M.
        • Cheng C.
        • Ris H.-B.
        • Magnusson L.
        Cardiac function assessed by transesophageal echocardiography during pectus excavatum repair.
        Ann Thorac Surg. 2010; 89: 240-243https://doi.org/10.1016/j.athoracsur.2009.06.126
        • Jaroszewski D.
        • Velazco C.
        • Pulivarthi V.
        • Arsanjani R.
        • Obermeyer R.
        Cardiopulmonary function in thoracic wall deformities: What do we really know?.
        Eur J Pediatr Surg. 2018; 28: 327-346https://doi.org/10.1055/s-0038-1668130
        • Chao C.-J.
        • Jaroszewski D.
        • Gotway M.
        • et al.
        Effects of pectus excavatum repair on right and left ventricular strain.
        Ann Thorac Surg. 2018; 105: 294-301https://doi.org/10.1016/j.athoracsur.2017.08.017
        • Ewais M.
        • Chaparala S.
        • Uhl R.
        • Jaroszewski D.
        Outcomes in adult pectus excavatum patients undergoing Nuss repair.
        Patient Relat Outcome Meas. 2018; 9: 65-90https://doi.org/10.2147/PROM.S117771
        • Obermeyer R.J.
        • Cohen N.S.
        • Jaroszewski D.E.
        The physiologic impact of pectus excavatum repair.
        Semin Pediatr Surg. 2018; 27: 127-132https://doi.org/10.1053/j.sempedsurg.2018.05.005
        • Pulivarthi V.S.K.K.
        • Jaroszewski D.
        • Arsanjani R.
        • Cabrera A.
        • Appleton C.
        Pectus excavatum patients have abnormal mitral valve leaflet lengths and coaptation point without significant MR.
        J Am Coll Cardiol. 2019; 73: 1224https://doi.org/10.1016/S0735-1097(19)31831-5
        • Jaroszewski D.E.
        • Mahmoud L.
        Letter to the editor.
        J Pediatr Surg. 2019; 54: 208-209https://doi.org/10.1016/j.jpedsurg.2018.09.015
        • Obermeyer R.J.
        • Godbout E.
        • Goretsky M.J.
        • et al.
        Risk factors and management of Nuss bar infections in 1717 patients over 25 years.
        J Pediatr Surg. 2016; 51: 154-158https://doi.org/10.1016/j.jpedsurg.2015.10.036
        • Dumville J.C.
        • McFarlane E.
        • Edwards P.
        • Lipp A.
        • Holmes A.
        Preoperative skin antiseptics for preventing surgical wound infections after clean surgery.
        Cochrane database Syst Rev. 2013; (Dumville JC, ed.)CD003949https://doi.org/10.1002/14651858.CD003949.pub3
        • Jaroszewski D.E.
        • Johnson K.
        • McMahon L.
        • Notrica D.
        Sternal elevation before passing bars: A technique for improving visualization and facilitating minimally invasive pectus excavatum repair in adult patients.
        J Thorac Cardiovasc Surg. 2014; 147: 1093-1095https://doi.org/10.1016/j.jtcvs.2013.09.049
        • Tedde M.L.
        • de Campos J.R.M.
        • Wihlm J.-M.
        • Jatene F.B.
        The Nuss procedure made safer: An effective and simple sternal elevation manoeuvre.
        Eur J Cardiothorac Surg. 2012; 42: 890-891https://doi.org/10.1093/ejcts/ezs442
        • Takagi S.
        • Oyama T.
        • Tomokazu N.
        • Kinoshita K.
        • Makino T.
        • Ohjimi H.
        A new sternum elevator reduces severe complications during minimally invasive repair of the pectus excavatum.
        Pediatr Surg Int. 2012; 28: 623-626https://doi.org/10.1007/s00383-012-3087-5
        • Kim D.
        • Idowu O.
        • Palmer B.
        • Kim S.
        Anterior chest wall elevation using a T-fastener suture technique during a Nuss procedure.
        Ann Thorac Surg. 2014; 98: 734-736https://doi.org/10.1016/j.athoracsur.2013.12.077
        • Haecker F.-M.
        • Sesia S.B.
        Intraoperative use of the vacuum bell for elevating the sternum during the Nuss procedure.
        J Laparoendosc Adv Surg Tech A. 2012; 22: 934-936https://doi.org/10.1089/lap.2012.0030
        • Johnson W.R.
        • Fedor D.
        • Singhal S.
        A novel approach to eliminate cardiac perforation in the Nuss procedure.
        Ann Thorac Surg. 2013; 95: 1109-1111https://doi.org/10.1016/j.athoracsur.2012.10.016
        • Velazco C.S.
        • Arsanjani R.
        • Jaroszewski D.E.
        Nuss procedure in the adult population for correction of pectus excavatum.
        Semin Pediatr Surg. 2018; 27: 161-169https://doi.org/10.1053/j.sempedsurg.2018.05.002
        • McMahon L.E.
        • Johnson K.N.
        • Jaroszewski D.E.
        • et al.
        Experience with FiberWire for pectus bar attachment.
        J Pediatr Surg. 2014; 49: 1259-1263https://doi.org/10.1016/j.jpedsurg.2014.03.004
        • Pilegaard H.K.
        • Licht P.B.
        Routine use of minimally invasive surgery for pectus excavatum in adults.
        Ann Thorac Surg. 2008; 86: 952-956https://doi.org/10.1016/j.athoracsur.2008.04.078
        • Stanfill A.B.
        • DiSomma N.
        • Henriques S.M.
        • Wallace L.J.
        • Vegunta R.K.
        • Pearl R.H.
        Nuss procedure: Decrease in bar movement requiring reoperation with primary placement of two bars.
        J Laparoendosc Adv Surg Tech A. 2012; 22: 412-415https://doi.org/10.1089/lap.2011.0080
        • Pilegaard H.K.
        Extending the use of Nuss procedure in patients older than 30 years.
        Eur J Cardiothorac Surg. 2011; 40: 334-337https://doi.org/10.1016/j.ejcts.2010.11.040
        • Tedde M.L.
        • de Campos J.R.M.
        • Das-Neves-Pereira J.-C.
        • Abrāo F.C.
        • Jatene F.B.
        The search for stability: Bar displacement in three series of pectus excavatum patients treated with the Nuss technique.
        Clinics (Sao Paulo). 2011; 66 (Accessed 3 March, 2018): 1743-1746
        • Nagaso T.
        • Miyamoto J.
        • Kokaji K.
        • et al.
        Double-bar application decreases postoperative pain after the Nuss procedure.
        J Thorac Cardiovasc Surg. 2010; 140 (44.e1-2): 39-44https://doi.org/10.1016/j.jtcvs.2009.12.027
        • Croitoru D.P.
        • Kelly R.E.
        • Goretsky M.J.
        • Lawson M.L.
        • Swoveland B.
        • Nuss D.
        Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients.
        J Pediatr Surg. 2002; 37 (Accessed 18 July, 2017): 437-445
        • Velazco C.S.
        • Pulivarthi V.S.
        • Jaroszewski D.E.
        Pectus excavatum repair in adults: Indications and how to do it.
        Curr Surg Reports. 2017; 5: 25https://doi.org/10.1007/s40137-017-0188-z
        • Jaroszewski D.E.
        • Temkit M.
        • Ewais M.M.
        • et al.
        Randomized trial of epidural vs. subcutaneous catheters for managing pain after modified Nuss in adults.
        J Thorac Dis. 2016; 8: 2102-2110https://doi.org/10.21037/jtd.2016.06.62
        • Sanniec K.J.
        • Velazco C.S.
        • Bryant L.A.
        • et al.
        Immediate versus delayed sarcoma reconstruction: Impact on outcomes.
        Sarcoma. 2016; 2016: 1-5https://doi.org/10.1155/2016/7972318
        • Harbaugh C.M.
        • Johnson K.N.
        • Kein C.E.
        • et al.
        Comparing outcomes with thoracic epidural and intercostal nerve cryoablation after Nuss procedure.
        J Surg Res. 2018; 231: 217-223https://doi.org/10.1016/j.jss.2018.05.048
        • Keller B.A.
        • Kabagambe S.K.
        • Becker J.C.
        • et al.
        Intercostal nerve cryoablation versus thoracic epidural catheters for postoperative analgesia following pectus excavatum repair: Preliminary outcomes in twenty-six cryoablation patients.
        J Pediatr Surg. 2016; 51: 2033-2038https://doi.org/10.1016/j.jpedsurg.2016.09.034
        • Kim S.
        • Idowu O.
        • Palmer B.
        • Lee S.H.
        Use of transthoracic cryoanalgesia during the Nuss procedure.
        J Thorac Cardiovasc Surg. 2016; 151: 887-888https://doi.org/10.1016/j.jtcvs.2015.09.110