D E MO
Pectus excavatum repair using a minimally invasive approach. An apprisal.
Dr L.M.Darlong
MS ( AIIMS )
Fellow Thoracic Surg ( Korea Univ Med Centre, Seoul )
Email : lmdarlong@gmail.com, drthoracoscopy@g mail.com
Phone : 91-9436303717.
Abstract
Pectus excavatum (PE) is the most common
congenital chest wall deformity and it has
physiological, cosmetic and intangible
psychosocial implications. Especially with
availability of state of the art minimally
invasive techniques and rising Indian
economy where everyone has the freedom to
Introduction
The most common cong enital chest wall
deformity Pectus ex cavatum (PE), or funnel
chest occurs in approximately 1 in every 400
to 500 births [1], Males are afflicted
approx imately 5 times more often than
females althoug h no data is available in the
Indian context. The deformity usually occurs
as sporadic cases though familial incidence
has also been seen through either parent,
although not clearly as a recessive trait. It is
first recognized by the parents in infancy and
it slowly becomes more prominent until full
skeletal growth is achieved. This is an
important phase during the early ag e as early
repair during childhood brings about the best
results in terms of morphological correction
of the chest wall and thus the development of
the mediastinal and pleural cavity contents. In
the Indian scenario most of the time medical
consultation for such child leaves the majority
of patients and their families poorly informed
about the limiting physiologic effects of the
deformity, or the availability of safe and
highly successful options for surg ical
correction. This leaves the parents with the
impression of it being just a cosmetic
deformity with no implications on the
cardiopulmonary functions, and it is only
during adulthood that the child realizes his
defect. Symptoms are infrequent during early
childhood, apart from a shy awareness of the
abnormality and a typical unwillingness to
V E R S I ON
feel & live healthy and the right to look good,
such patients and their families will be better
informed by the medical community and not
merely neglect it as a cosmetic defect.
Key words: Pectus ex cavatum, Minimally
invasive repair of pectus ex cavatum (
MIRPE).
ex pose the chest while swimming or taking
part in other social or athletic activities. Easy
fatigability, shortness of breath with mild
ex ercise, and decreased stamina and
endurance often become apparent during early
adolescence when children become involved
in competitive sports. Tachycardia and
palpitations are common along with exercise
induced wheezing and also an increased
frequency of respiratory infections or asthma.
The deformity along the sternum displaces the
heart into the left chest with pulmonary
ex pansion during inspiration restricted
resulting in a “restrictive pattern” as noted on
pulmonary function tests. The deformity
clearly places physiologic restrictions on the
patient and thus should not be neglected
merely a cosmetic concern. This trend has
been mainly due to the nonavailabity of
centres or surgeons dealing with this condition
and also where available the conventional
techniques used for such being too radical
with a hig h complication and thus low
acceptance. This condition may also be
noticed because of other anomalies, like
scoliosis (65%), occasionally clubfoot,
syndactylism, Marfan syndrome, or Klippel-
Feil syndrome. The likely pathogenesis of the
deformity results from unbalanced overgrowth
in the costochondral reg ions where the
involved cartilages are often fused, bizarrely
deformed, or rotated. The awareness of this
condition and considering it to be a disease
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and not as cosmetic defect will be a g reat
boon for such patients, this is especially so
Evaluation
Clinical evaluation involves assessment of the
ex ternal morphology along with the CT
thorax findings and measurement of the
various indices. Various classification are
available, and one of them is the
morphological classification by Dr Park (
Table 1, Fig 1,2 ) [2] which guides the
shaping of the stainless steel bar used in
minimally invasive repair. This classification
is of great utility in helping shape the bar for
asymmetrical defects as the orig inal procedure
described by Dr Nuss had limitation for
asymmetrical defects. Various indices are
used to measure the degree of severity and to
evaluate the degree of morpholog ical
Minimally invasive approach
(MIRPE).
The aims of correction of the deformity is to
remove the compressive force on the
mediastinum and pleural cavity by chest wall
remodeling for optimal cardiopulmonary
function with the added advantage of
improved cosmesis and self confidence of the
individual. The optimal age for surg ical
correction of the deformity is the earlier the
better with optimum at 3 years of ag e. This is
due to the bones and cartilage which are more
malleable and remodeling is easier and well
tolerated with lower recurrences. With
increasing age the repair becomes more
difficult and more painful because of the rig id
bones requiring more force and resulting pain,
adults in the age group up to 51 years has
been reported by Dr Park who has the largest
reported series [4]. Minimally invasive repair
was first described by Dr Nuss in 1997 who
used a stainless steel bar placed retrosternally
to lift the deformed chest wall in the desired
chest contour [5]. This procedure has
underg one various modification to place the
bar retrosternally under vision using
thoracoscope or the parks pectoscope (
Perimed Seoul S.Korea ) and also for
Discussion
V E R S I ON
with the introduction of the minimally
invasive repair of pectus ex cavatum
correction [3].Hallers CT index is the most
widely used index, which is the ratio of the
transverse diameter of the rib cage and the
anteroposterior distance between the sternum
and vertebra (fig3). Normal hallers index is
considered upto 2.5 and severity can reach up
to 5.5 . Standard pulmonary function tests at
rest are either within normal limits or show a
mild restrictive defect, however it is difficult
to obtain reliable measurements in children’s
and limits its use. Electrocardiographic
abnormalities are common in PE patients,
consisting primarily of right-axis deviation
and depressed ST segments, which reflect
rotation of the heart within the thorax rather
than an intrinsic abnormality.
correction of asymmetrical defects [4,5,6,7].
The technique described by Dr Park has as
spectrum covering repair of symmetric,
asymmetric and also adult patients with a
problem seeking approach [6]. It involves the
placement of stainless steel bar placed
retrosternally from one end of the lateral chest
wall to the other end through a retrosternal
tunnel made under vision using Parks
pectoscope, which is very crucial to avoid life
threatening cardiac injury in the narrow
compressed mediastinum [7]. Following this
the bars which have been shaped to exactly
duplicate the chest wall morphology with
elevation at depressed site and depression at
elevated site is introduced in the retrosternal
space and fixed at the lateral chest wall
leaving behind two small incisions each of 2
cm (fig 4,5). In defects involving long
seg ments as in Grand canyon ( Type 2A3 ) or
adults two bars are usually placed at the level
of the target sites (fig6).
Following the procedure pain control is
achieved using injectable narcotics initially
which can be converted to oral analgesics
from day 4 of surgery and may be continued
for a period of 2-3 weeks. The bars are
removed after 2 years in paediatric cases, 2-3
years in teenager and 3–4 years in adults.
The management of pectus excavatum is done
D E MO
by paediatric surgeon, plastic surgeon, general
surgeon and the thoracic surgeons thoug h at
times such cases are often referred to
orthopaedic surg eon in view of it being a bony
and cartilage deformity.The minimally
invasive repair of pectus excavtum (MIRPE)
as initiated by Dr Nuss in 1997 has found
greater acceptance to the surg eons doing the
procedure and also higher acceptance among
patients. This is truly a minimally invasive
procedure unlike the Ravitch, as it does not
involve the resection of the cartilages but
preservation of the cartilag e for remodeling of
the chest wall along the rig id bars contour. As
the MIRPE does not involve resection of the
cartilage as in other procedure physical
activity can be resumed as soon as possible
with adequate pain control. However
following the resection of the cartilage it takes
about 6 months for the ribs to g row again and
during this period the chest wall is unstable
thus restricting physical activity. Besides this
aesthetically the scar of MIRPE is minimal
about 2cm only compared to the long scar for
References
1. Boas SR. Skeletal diseases influencing
pulmonary function. In: Klieg man RM, et al.
Nelson Textbook of Pediatrics. 18th ed.
Philadelphia, Pa.: Saunders Elsevier; 2007.
2. Park HJ, Lee SY, Lee CS, et al. The Nuss
procedure for pectus excavatum: an evolution
of techniques and results on 322 patients. Ann
Thorac Surg . 2004;77:289–295.
3. Lee CS, Park HJ, Lee SY. New
computerized tomogram (CT) indices for
pectus excavatum: tools for assessing
modified techniques for asymmetry in Nuss
repair. Chest.2004; 126 (suppl): 777S .
4.Park HJ, Jeong JY, Jo WM, Shin JS, Lee IS,
kim KT, Choi YH.Minimally invasive repair
Table 1
Parks morphological classification of Pectus excavatum.
Morphologic type
Type 1: Symmetric
1 A: Prototype (Deep,focal)
1 B: Broad, flat
V E R S I ON
ravitch procedure making it also a minimally
access procedure. The complications seen
with the procedure are usually pneumothorax,
wound infection, pericarditis, pleural and
pericardial effusion, bar displacement or
dislocation, hemothorax and rarely life
threatening cardiac injuries which can be
avoided if retrosternal space is created under
vision using a thoracoscope or more
preferably a pectoscope [7].
Recurrence rate less then 5% following bar
removal in MIRPE [5] is similar to the ravitch
procedure of 2% and thus with surgeons
performing more procedure a further
reduction is likely.
Conclusion
With a knowledge of the chest wall anomaly
and development of centres in India such
patients and their families will be better
informed by the medical community and not
merely neglected as a cosmetic defects
especially with the rising Indian economy
where everyone ones to feel healthy and look
good.
of pectus excavatum: A novel morphology-
tailored, patient-specific approach. J Thorac
Cardiovasc Surg 2010;139:379-386.
5. Nuss D, Kelly RE, Croitoru DP, et al. A
10-year review of a minimally invasive
technique for the correction of pectus
ex cavatum. J Pediatr Surg. 1998;33:545–552.
6. Park HJ. Technical innovations in
minimally invasive approach for pectus
ex cavatum: a paradigm shift throug h 630
patients. Innovations. 2007;2:25-8.
7. Park HJ, Jeong JY, Kim KT, Choi YH. A
new videoscopic device to avoid cardiac injury
in minimally invasive pectus ex cavatum
repair. J Paediatr Surg 2010 ( In Press ).
Features
Centre of sternum and depression are in the
midline
Typical deep focal symmetric sternal depression
Broad flat symmetric sternal depression
D E MO V E R S I ON
Type 2: Asymmetric Centre of depression not in the centre of the
sternum but found laterally to the left or
right

Type 2A:Eccentric Centre of sternum in midline but maximal

depression located laterally in cartilage to the
left or rig ht

2A1:Focal Deep focal asymmetric depression

2A2:Broad flat Broad flat asymmetric depression
2A3:Long canal, Grand canyon Ex treme form with deep longitudinal groove
from clavicle to lower chest

Type 2 B:Unbalanced Centre of depression in midline but one of the

walls of the depression is more severely
depressed than other, angles formed by each
wall and vertical ax is are different ( alpha < beta
)

Type 2 C:Combined Combination of 2A and 2B

classification of Petus ex cavatum

Fig 1. Illustration of Parks morphologic

Fig 2 . CT reconstruction of pectus ex cavatum.

D E MO V E R S I ON

Fig 3. CT measurement of Hallers Index .

Fig 4. Lateral CXR showing steel bar placed

retrosternally.
D E MO V E R S I ON

Fig 5. CT thorax post MIRPE showing corrected deformity and bar on lateral aspect.

Fig 6. CXR showing double bar for g rand canyon type defect.
Legends
D E MO V E R S I ON
Fig 1. Illustration of Parks morphologic classification of Petus ex cavatum.
Fig 2 . CT reconstruction of pectus ex cavatum.
Fig 3. CT measurement of Hallers Index .
Fig 4. Lateral CXR showing steel bar placed retrosternally.
Fig 5. CT thorax post MIRPE showing corrected deformity and bar on lateral aspect.
Fig 6. CXR showing double bar for g rand canyon type defect.