Original paper Videosurgery

Minimally invasive repair of pectus excavatum (MIRPE) in adults:

is it a proper choice?

Ezel Erşen1, Ahmet Demirkaya2, Burcu Kılıç1, Hasan Volkan Kara1, Osman Yakşi1, Nurlan Alizade1, Özkan Demirhan3,
Cem Sayılgan4, Akif Turna1, Kamil Kaynak1
1
Department of Thoracic Surgery, Cerrahpaşa Medical Faculty, Istanbul University, Istanbul, Turkey
2
Department of Thoracic Surgery, School of Medicine, Istanbul Acıbadem University, Istanbul, Turkey
3
Department of Thoracic Surgery, Medical Faculty, Istanbul Bilim University, Istanbul, Turkey
4
Department of Anesthesia and Reanimation, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey

Videosurgery Miniinv 2016; 11 (2): 98–104

DOI: 10.5114/wiitm.2016.60456

Abstract
Introduction: The Nuss procedure is suitable for prepubertal and early pubertal patients but can also be used in adult
patients.
Aim: To determine whether the minimally invasive technique (MIRPE) can also be performed successfully in adults.
Material and methods: Between July 2006 and January 2016, 836 patients (744 male, 92 female) underwent correc-
tion of pectus excavatum with the MIRPE technique at our institution. The mean age was 16.8 years (2–45 years).
There were 236 adult patients (28.2%) (> 18 years) – 20 female, 216 male. The mean age among the adult patients
was 23.2 years (18–45 years). The recorded data included length of hospital stay, postoperative complications,
number of bars used, duration of the surgical procedure and signs of pneumothorax on the postoperative chest
X-ray.
Results: The MIRPE was performed in 236 adult patients. The average operative time was 44.4 min (25–90 min). The
median postoperative stay was 4.92 ±2.81 days (3–21 days) in adults and 4.64 ±1.58 (2–13) in younger patients.
The difference was not statistically significant (p = 0.637). Two or more bars were used in 36 (15.8%) adult patients
and in 44 (7.5%) younger patients. The difference was not statistically significant either (p = 0.068). Regarding the
overall complications, complication rates among the adult patients and younger patients were 26.2% and 11.8%
respectively. The difference was statistically significant (p = 0.007).
Conclusions: MIRPE is a feasible procedure that produces good long-term results in the treatment of pectus excava-
tum in adults.

Key words: adult, pectus, excavatum, minimally invasive, Nuss.

Meyer was the first surgeon to try to repair the

Introduction deformity, in 1911 [2]. He was followed by Sauer-
Pectus excavatum (PE), also known as “funnel bruch, who performed the first pectus repair using
chest”, is the most common congenital chest wall bilateral costal cartilage resection and sternal oste-
anomaly associated with anterior chest wall defor- otomy [3].
mity and depression, which affects approximately In 1949, Ravitch published his first paper, “The
1 : 400 live births [1]. operative treatment of pectus excavatum,” and de-

Address for correspondence

Ezel Erşen, Department of Thoracic Surgery, Cerrahpaşa Medical Faculty, Istanbul University, 34098 Istanbul, Turkey,
phone: +90 5057311567, e-mail: [email protected]

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 Minimally invasive repair of pectus excavatum (MIRPE) in adults: is it a proper choice?

scribed 8 patients who were treated surgically with evaluated asymptomatic adult patients with sym-
his technique [4]. metric and asymmetric deformities.
Since then, several papers have been published
regarding the modifications to Ravitch’s technique, Material and methods
although it maintained its prevalence as the stan-
Between July 2006 and January 2016, 836 pa-
dard technique for the correction of PE. Yet, Ravitch’s
tients (744 male and 92 female) underwent cor-
technique also has some difficulties, as indicated by
rection of pectus excavatum with the MIRPE tech-
several reports which have highlighted its morbidi-
nique at our institution. The mean patient age was
ties and difficulties [5].
16.8 years (range: 2 to 45 years). All patients ob-
In 1998, a  new era began, when Nuss et al. re-
tained an excellent cosmetic result (Photo 1). There
ported their experience with 42 patients using
were 236 adult patients (28.2%) (> 18 years) – 20 fe-
a  minimally invasive technique to correct the de-
male, 216 male. The mean age among the adult pa-
pression of PE [6].
tients was 23.2 years (range: 18–45 years). Patient
Their technique was based on the use of a stain-
demographics and preoperative characteristics are
less steel brace below the sternum, while there was
summarized in Table I. In all cases, a  preoperative
no need for costal cartilage resection or sternal os-
computed tomography (CT) scan was performed in
teotomy.
order to evaluate the intrathoracic cavity for surgical
Since then, the Nuss technique has been used
planning. Echocardiography and pulmonary function
extensively by many surgeons, who focused on the
tests were also performed in order to evaluate the
surgical repair of the chest wall deformities. Several
cardiac and pulmonary performance. In addition,
modifications in the Nuss technique have also been a  preoperative nickel allergy test was performed.
published. Some of them are currently in use (such Indications were psychosocial complaints due to
as the modified Nuss technique described by Pile- cosmetic appearance, reduced exercise tolerance,
gaard et al., which is applied routinely in our clinic for dyspnea on exertion and chest pain. The Haller in-
the correction of PE) [7]. dex (HI) was also used as an indication for surgery.
However, there are also non-surgical interven- HI greater than 3 was classified as severe deformity.
tions such as the vacuum bell and cosmetic inter- The HI was calculated with CT. The HI of the patients
ventions such as the silicon implants and polyeth- ranged from 3.30 to 11 (mean: 4.4). All patients were
ylene implants, which are manipulated in order to fix operated on by the same surgeon. The data were
the deformity cosmetically. The vacuum bell can also retrospectively collected and analyzed. The recorded
be used intraoperatively to facilitate the retrosternal data included the length of hospital stay, postopera-
dissection and the insertion of the pectus bar [8, 9]. tive complications, number of bars used, duration of
The Nuss technique is perfectly suitable for pre- the surgical procedure and signs of pneumothorax
pubertal and early pubertal patients because of their on the routine postoperative chest roentgenogram.
chest wall compliance. While the technique can also
be applied in adult patients due to the matured and Surgical technique
rigid chest cavity, there are a  number of problems
including the prolonged operative time, increased All patients were positioned in the supine posi-
rates of complications, bar displacement, higher tion with both arms abducted. An epidural catheter
pain rates and poor surgical outcome [10]. was placed for postoperative pain management be-
There is a tendency among surgeons not to oper- fore the general anesthesia. Double-lumen intuba-
ate on adult patients unless they have severe defor- tion was used routinely except for patients younger
mity that causes pulmonary and cardiac problems. than 10 years of age. In this group of patients, the
operation was carried out using apnea intervals.
The deepest point of the deformity, xiphoid and
Aim
entry and exit points of the bar were marked on the
The aim of our study was to determine wheth- skin. The incision for the scope was made from the
er the minimally invasive technique (MIRPE) could right lateral side at the mid-axillary line and just
be performed routinely and successfully not only in below the level of the nipple to visualize the chest
pediatric patients, but also in adults. In addition, we cavity cranially and caudally. A 5-mm trocar was in-

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Ezel Erşen, Ahmet Demirkaya, Burcu Kılıç, Hasan Volkan Kara, Osman Yakşi, Nurlan Alizade, Özkan Demirhan, Cem Sayılgan, Akif Turna, Kamil Kaynak

Photo 1. Pre- and postoperative images of a 45-year-old patient who underwent MIRPE

troduced into the thorax and the deepest point of how the chest was intended to look after the cor-
the deformity was defined using a 30° scope. rection. Following this, a  Pectus Support Bar (Zim-
A  template (Zimmer Biomet Inc., Warsaw, Indi- mer Biomet Inc., Warsaw, Indiana, USA) was bent to
ana, USA) was formed in order to make a model of match this template. Having employed the modified
Nuss technique as described by Pilegaard et al. [7,
Table I. Demographic variables and preoperative 11], we used bars that were shorter than the bars
characteristics of adults patients (n = 236) un- described by Nuss. Using a shorter bar, the stabilizer
dergoing MIRPE could be placed closer to the exit of the pectus bar
from the thoracic cavity. This modification is believed
Characteristic Results
to decrease the occurrence of bar displacement.
Age, mean [years] 23.2 (18–45) Lateral incisions for introducing the bar were ap-
Gender, n (%): proximately 2 cm on the right side and 3 cm on the
Male 216 (91.5) left side. We stabilized all bars on the left side.
Female 20 (8.4) With lateral incisions, a  subcutaneous tunnel
Depth of defect (Haller index) 4.4 (3.3–11)
was created with blunt dissection, through the entry
and exit points of the bar. A steel introducer (Zimmer
Preoperative symptoms (patients), n (%):
Biomet Inc., Warsaw, Indiana, USA) was inserted into
Cosmetic concern 126 (53)
the thoracic cavity at the level of the entry point. It
Dyspnea on exertion 16 (6) was pushed below the sternum and just above the
Shortness of breath at rest 0 pericardium securely using videothoracoscopy. An
Cardiac arrhythmia, palpitations 0 umbilical tape was secured to the tip of the intro-
Chest pain 38 (16) ducer, while the introducer was withdrawn with its
Fatigue, decreased energy 27 (11)
convex side facing down. This resulted in the tunnel-
ing of the umbilical tape from left to right. The tape
Electrocardiogram changes 8 (3)
was tied to the tip of the bar. With the guidance of
Mitral valve prolapse 21 (8)
the umbilical tape, the bar was passed through the

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 Minimally invasive repair of pectus excavatum (MIRPE) in adults: is it a proper choice?

thorax from the right to the left incision in a  con- karate and judo) were all forbidden until the removal
cave-up position. The bar was flipped 180° in order of the bar.
to buttress the sternum and correct the deformity.
A stabilizer was placed on the left side of the bar Statistical analysis
as closely as possible to the entry into the thorac-
Statistical analysis was performed using Pear-
ic cavity to avoid rotation. A no. 5 sternal wire was
son’s χ2 test for bivariate analysis. All statistical anal-
used to fix the stabilizer to the bar on the left side.
yses were performed using IBM SPSS Statistics, ver-
The bar was also secured on the right side using one
sion 20.0 (IBM Corp., Armonk, N.Y.). Values of p < 0.05
no. 1 polydioxanone (PDS) (No. 1 Pedesente Doğsan,
were considered statistically significant.
Trabzon, Turkey) suture around the ribs. Using ad-
ditional absorbable 2-0 vicryl sutures, the bar was
fixed to the adjacent tissue.
Results
Additional bars were implanted as a  single bar The modified Nuss operation was performed in
did not provide satisfactory cosmetic correction and all 236 adult patients. The median length of the bars
the HI was greater than 5. We also placed the bars was 11 inches (range: 9–14 inches) for adults and
asymmetrically in patients with asymmetric defor- 10 inches (range: 7–14 inches) for younger patients.
mity. The average operative time was 44.4 min (range:
Later, a slim 14 Fr silicone tube was inserted into 25–90 min).
the pleural cavity through the trocar site. The prox- The median postoperative stay was 4.92 ±2.81
imal end of the silicone tube was placed in a small days (range: 3–21 days) in adults and 4.64 ±1.58
cup of saline solution in order to form a  modified (2–13) in younger patients. The difference was not
underwater seal device. The lung was reinflated, statistically significant (p = 0.637). Two or more
intrathoracic air was evacuated and lung re-expan- bars were used in 36 (15.8%) adult patients and
sion was controlled with the videothoracoscope at 44 (7.5%) younger patients. These figures were not
the end of the procedure. The tube was withdrawn, statistically significant either (p = 0.068). Intraopera-
while the anesthesiologist applied positive end-expi- tive variables and characteristics of hospital stay are
ratory pressure. summarized in Table II.
A chest X-ray was taken on the same day of the There were no perioperative deaths. Cardiac inju-
surgery in order to evaluate the presence of pneu- ry developed in one case where a small ventricular
mothorax. All patients took antibiotics intravenously defect was repaired rapidly with anterior thoracot-
for 3 days. omy. One patient developed aspiration pneumonia
Pain management was the most important issue which was treated with antibiotics. Seven (2%) pa-
following the surgery. It was managed with an epi- tients had asymptomatic residual pneumothorax
dural catheter for the first 2 days. On the third day,
the catheter was removed and nonsteroidal anti-in- Table II. Intraoperative variables and character-
flammatory drugs (NSAID) and myorelaxant drugs istics of hospital stay (adult patients, n = 236)
were administered orally for 5 weeks postoperative-
Characteristic Result
ly. The patient was monitored in the outpatient clinic
1 week after surgery for clinical evaluation with an Operative time [min] 44.2 (25–90)
X-ray and 1 month after surgery for general evalua- Estimated blood loss [ml] 25 (5–500)
tion. After 2.5–3 years, we called the patients back
Bars placed, n (%):
for removal of the implanted system.
For the first 6 weeks, we did not allow the patient 1 200 (84)
to carry a heavy weight (more than 2 kg in front of 2 or more 36 (15)
the body or more than 5 kg on the shoulders). Cy-
cling and rotation of the upper body of more than Mortality, n (%)
15° were also prohibited. The patient was also re- Intraoperative death 0 (0.0)
quested to sleep in the supine position without turn-
30-day mortality 0 (0.0)
ing to either side. In addition, heavy contact sports
(e.g. boxing, hockey, and self-defense sports such as Length of hospital stay, mean 4.92 ±2.81 (3–21 days)

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Ezel Erşen, Ahmet Demirkaya, Burcu Kılıç, Hasan Volkan Kara, Osman Yakşi, Nurlan Alizade, Özkan Demirhan, Cem Sayılgan, Akif Turna, Kamil Kaynak

which was resolved without chest tube placement. Discussion

Postoperative pleural effusion was detected in 2 pa-
The surgical treatment of pectus excavatum
tients. The effusions were minimal and they were
has changed in the last few decades. Although the
resolved spontaneously. Wound infection developed
Ravitch procedure is still a  widely used approach
in 4 patients. Wound care and antibiotics were suf-
for adult patients with pectus excavatum, there is
ficient for recovery in this group. One patient devel-
an increasing trend for using the minimally invasive
oped thoracic outlet syndrome after the correction
technique also known as the Nuss procedure. There
of the deformity. The first rib caused severe obstruc-
are sufficient data regarding the use of the Ravitch
tion of the right subclavian artery. The resection of
repair in adult patients [12–16], although the treat-
the first rib and the division of the anterior scalene
ment of pectus excavatum with the minimally inva-
muscle and fibrous bands provided complete relief
sive technique in adults is still controversial. Many
in this case. Bar displacement developed in 12 (5%)
surgeons still recommend the use of the Ravitch
adult patients, while it was observed in 5 (0.8%)
approach, since there are problems such as the fre-
younger patients. The difference between the two
quent need for multiple bars and higher rate of com-
groups was statistically significant (p < 0.05). All
plications that accompany the minimally invasive
complications related to the surgical procedure are
approach.
provided in Table III.
The minimally invasive technique has been used
Regarding the overall complications, the compli-
for pectus excavatum repair since 1998 [6], although
cation rates among the adult patients and younger
only a  limited number of studies have been pub-
patients were 26.2% and 11.8% respectively. The dif-
lished on this topic.
ference was statistically significant (p = 0.007).
In 2002, Coln et al. reported their early expe-
rience with the minimally invasive technique in
Table III. Complications adults. Eight patients (5 male and 3 female), aged
Complications N (%) between 19 and 32 years, underwent the minimal-
ly invasive Nuss repair [17]. They used one bar with
Bar displacement 12 (5)
one or two stabilizers. The mean operative time was
Cardiac injury 1 (0.4) 1.32 h, while the mean hospital stay was 4 days.
Thoracic outlet syndrome 1 (0.4) There were no early complications, although in one
case the separation of a  stabilizer required reoper-
Wound infection 4 (1)
ation, while in another case bar displacement was
Pneumonia 1 (0.4) reported as a late complication. Although the short
Removal of stabilizer pain 0
time results were encouraging, this was a small se-
ries with a short follow-up period.
Sternotomy/thoracotomy 1 (0.4) Kim et al. [18] reported their experience with the
One more bar 2 (0.8) minimally invasive pectus repair with 51 patients.
They assigned the patients to three different age
Removal before time due to pain 0
groups. Twelve patients were older than 20 years,
Pneumothorax 7 (2) and 12 patients were aged between 12 and 20 years.
Pneumothorax which needed drainage 0 Two bars and lateral stabilizers were used routinely
in the adult patients, while two bars were used only
Pleural effusion 2 (0.8)
in 9 adolescents. The mean operative times were
Pleural effusion which needed drainage 0 longer in the adult group (127.3 ±44.9 min). The
Prolonged pain 4 (1)
mean hospital stay was 10 ±8.5 days for adult pa-
tients. These values are very high compared with our
Readmission for pain 0 results. In our study, the operative time was 44.4 min
Recurrence 0 and the mean hospital stay was 4.92 ±2.81 days.
The postoperative complication rate in the ado-
Respiratory distress 0
lescent and adult groups was 58.3%, and bar rota-
Bleeding requiring transfusion or reoper- 0 tion was reported in 8.3% of adolescents and 33.3%
ation
of adults.

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 Minimally invasive repair of pectus excavatum (MIRPE) in adults: is it a proper choice?

In our study, bar displacement developed in 5% ±2.81 days in our study, which was not significantly
of the adult patients, whereas the complication rate different in comparison with the younger patients,
in the same group was 26.2%. who had a mean hospital stay of 4.64 ±1.58 days.
Recent reports have demonstrated more promis- They detected pneumothorax in 86 (48%) cases,
ing outcomes in adults [19–21]. Pilegaard published while 4 patients required tube drainage. In our study,
his experience with 52 adult patients who were there were only 7 (5%) patients with pneumothorax,
over 30 years of age [21]. The median age of the which resolved spontaneously. Other complications
patients was 37 (range: 30–53). One bar was used included pneumonia in 4 patients, pleural effusion
in 15 (29%) patients, while two bars were used in in 4 patients, empyema in 1 patient, seroma in 1 pa-
35 patients, and three bars were used in 2 patients. tient and deep infection in 5 patients. Three (2%)
Two stabilizers were used in 10% of the bars. The patients underwent reoperation because of the dis-
median duration of surgery was 60 min and medi- location of the bar.
an postoperative hospital stay was 4 days. Although In 13 (7%) patients, the stabilizer was removed
25 patients had pneumothorax, only 1 of them re- early due to intolerable pain. In our study, we did
quired a chest tube. There was no bar rotation, while not remove any bars or stabilizers due to pain. Yet,
1 patient with lateral migration of the bar was reop- 12 (5%) patients underwent reoperation for bar dis-
erated. The bars were removed early because reop- placement.
eration caused infection and the patient refused to Absorbable stabilizers were used in 8 patients.
take antibiotics for a long time. We did not experience any displacement or rotation
In another study, Teh et al. evaluated the results in the last 3 years. The mean duration of bar appli-
of 19 patients aged 17 years or above [22]. The cation was 36 ±4.6 months (30–48 months). One
mean operative time was 2.1 ±0.2 h. Twelve patients hundred and thirty-six (57%) patients had their bars
required two bars, while one bar was used in 7 pa- removed, while there was no recurrence.
tients. We used two or more bars in 36 (15.8%) pa- Pain appears to be the major problem following
tients in adults. The mean hospital stay was 5.8 days, the minimally invasive pectus repair. It is believed
which was similar to our result. One patient de- that there is greater stress in all ribs in adults com-
veloped pneumonia and 6 patients had residual pared to children after the Nuss procedure [23].
pneumothorax which resolved without chest tube On the other hand, force distribution in adults
placement. Pneumothorax rates were quite high in is more diffuse and often frequently located in the
comparison with our study. We believe this is mainly posterior part of the chest wall. Moreover, there are
due to our evacuation technique, where we used an papers which report the increasing use of analgesics
underwater seal mechanism. and narcotics in older patients [24].
In 2008, Pilegaard and Licht published a  larger We managed the pain in adult patients with the
study including 180 adult patients [11]. The patients same amount of analgesics that we used in younger
were aged 18 years or above (mean: 22 years). One patients. As also reported in the literature [25], we
hyndred and sixty of them were male patients. They found that patients with more than one bar had less
used two bars in 57 patients and three bars in 2 pa- pain in the adult group.
tients. They found that more than one bar was used We also experienced a very rare problem in one
in adults compared with younger patients and re- of the patients. The patient developed vascular tho-
ported it as statistically significant. In our study, we racic outlet syndrome after the correction of the de-
also found that more than one bar was used fre- formity. The first rib caused severe obstruction of the
quently in adults, but we found that this was not right subclavian artery. The patient was treated with
statistically significant. resection of the first rib and division of the anterior
The median duration of the procedure was scalene muscle and fibrous bands [26].
41 min, which was very similar to our operative time,
since we performed the same modified technique as
Conclusions
described by Pilegaard. The median hospital stay –
5 days (3 to 29 days) – was also similar. The hospital Data from our present clinical experience indicate
stay was not significantly longer compared with the that many adults with pectus deformities can be op-
younger patients. The mean hospital stay was 4.92 erated on using the minimally invasive technique.

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Ezel Erşen, Ahmet Demirkaya, Burcu Kılıç, Hasan Volkan Kara, Osman Yakşi, Nurlan Alizade, Özkan Demirhan, Cem Sayılgan, Akif Turna, Kamil Kaynak

We can achieve the same good results as the 14. Mansour KA, Thourani VH, Odessey EA, et al. Thirty-year expe-
younger patients with the same operative time as rience with repair of pectus deformities in adults. Ann Thorac
Surg 2003; 76: 391-5.
well as the same number of bars. Although complica-
15. Genc O, Gurkok S, Gozubuyuk A, et al. Repair of pectus defor-
tions are quite high in comparison with the younger mities: experience and outcome in 317 cases. Ann Saudi Med
patients, patients do not have to stay longer after 2006; 26: 370-4.
the operation compared with the younger patients. 16. Fonkalsrud EW, De Ugarte D, Choi E. Repair of pectus excava-
In conclusion, minimally invasive pectus repair tum and carinatum deformities in 116 adults. Ann Surg 2002;
for the treatment of pectus excavatum is feasible 236: 304-14.
and provides good long-term results in adult pa- 17. Coln D, Gunning T, Ramsay M, et al. Early experience with the
Nuss minimally invasive correction of pectus excavatum in
tients. As surgeons become more experienced, com-
adults. World J Surg 2002; 26: 1217-21.
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can be achieved. for pectus excavatum in different age groups. Ann Thorac Surg
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pectus excavatum in the adult population: should it be done?
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