Modified minimally invasive pectus repair in children, adolescents and adults: an analysis of 262 patients

Abstract

BACKGROUND: In order to achieve safe and successful funnel chest treatment even in older patients and reduce postoperative complications, we modified the procedure of minimally invasive pectus repair using the single-piece pectus bar (PSI® Hofer Medical, Austria) with no metal abrasion. METHODS: The features of modified minimally invasive funnel chest correction (MMIPR) are the following: (a) additional subxiphoidal incision, (b) anterior mediastinal-mediastinoscopic mobilization, (c) mediastinoscopy, (d) elevation of the funnel during pectus bar placement, and (e) fixation of the implant ends in a latissimus dorsi muscle bag, below the anterior margin of the muscle. In older funnel chest patients with a stiff thorax, a curved sternum, marked asymmetry or a mixed pigeon/funnel chest, the minimally invasive correction method has to be supplemented by additional surgical measures (MEMIPR) such as partial sternotomy (23%), slit-rib chondrotomy under thoracoscopic guidance (Rokitansky method; 48%), rib resection (5%), and occasionally rib osteotomy. In 8 patients with residual minor deformities we administered an ultrasound-guided Macrolane® injection (5 to 20 cc). RESULTS: 262 patients (mean age, 17.7 ± 7 years) were eligible for analysis. The large majority of them underwent MIPR between the age of 14 and 20 years; 6 patients were older than 40 years. The pectus bar implant was left in the chest for a period of 1.4 to 6.5 years. Modified minimally invasive pectus repair (MMIPR) was performed in 121 patients (mean age, 15.2 ± 5 years). The majority of patients received one pectus bar; 13.2% received two bars. Modified extended minimally invasive pectus repair (MEMIPR) was performed in 141 patients (mean age, 22.5 ± 8 years); two pectus bars were used in 58.1% of cases. We observed no bar dislocation. Minimal bar movements were noted in 1.6% (MEMIPR) and 4.9% (MMIPR) of cases. With the MEMIPR technique, subcutaneous hematoma was observed in 4.1% of patients. No re-thoracotomy was required in the 262 patients who underwent MMIPR or MEMIPR. After a mean period of 3.4 years the implants were removed surgically in 103 patients; recurrences were observed 0.9%. CONCLUSIONS: Our procedures of MMIPR and MEMIPR with a single-piece pectus bar permitted safe and successful surgery in patients who required complex funnel chest correction.