Key Points

• Since its introduction by Nuss et al. in 1997, the minimally invasive repair of pectus excavatum (MIRPE) has been gaining acceptance worldwide among surgeons and patients.
• The main indication for surgery is cosmetic impairment and associated psychosocial problems regardless of the degree of the deformity. Haller Index (Pectus Index) has been used in order to make a more objective decision.
• MIRPE is formally indicated if two or more of the criteria below are present in a PE patient :
  • Pectus Index > 3.25,
  • Cardiac compression/ cardiac malrotation and/or pulmonary compression,
  • Mitral valve prolapse, bundle branch block or other cardiac pathologies related to cardiac compression,
  • Restrictive pattern in PFTs,
  • History of unsuccessful repair
• As the experiences of the surgeons increased, new modifications were developed according to the necessity for specific groups of patients. Sandwich and Cross-Bar Techniques are the two examples of these modifications.
• MIRPE is the treatment of choice in pectus excavatum patients as it is minimally invasive, has low morbidity rates and provides short length of hospital stay. It may be performed with high patient satisfaction in experienced hands

Pectus excavatum (PE), funnel chest, is the most common chest wall deformity ccurring with an incidence of 1 in 300 - 400 live births. Although manubrium and first two ribs are in their normal location, PE is generally charactarized by the posterior deppression of sternum together with costal cartilages[1],[2].

PE is more common in white race having a male to female ratio of 5:1. The degree of the deformity varies and it is quite common to detect asymmetry in the patients. Depression of the right side is present in the majority of the cases and sometimes accompanied by the malrotation of the sternum. Even though the deformity regresses with adolescence in some patients, it progresses in the majority of the patients with puberty. The most common accompaying anomaly of PE is scoliosis with the incidence of 25%[3]. Congenital cardiac anomalies and asthma also can be associated with the deformity less frequently. It is quite common to have a positive familial history which is presented as 40 % in some of the series[4]. It is also common to detect Marfan Syndrome in PE patients which is generally seen with scoliosis[1].

PE patients are generally asymptomatic but shorthess of breath, rapid fatigue, chest pain and palpitation may occur in severe cases. In general, there are no objective cardiovascular or respiratory problems in most of the patients, but cosmetic and psycho-social problems are prominent. As a result the most common indication for surgical repair is ‘cosmetic disfigurement’. By the absence of an absolute indication criterion, the decision for the surgery is made by the joint opinion of patient and surgeon[1],[2].

The standard repair for PE has been an open procedure described by Ravitch in 1949[5]. Through the years, minor modifications have been applied, but the main idea of the method remained the same and the Ravitch repair was the treatment of choice until the mid-1990s. The Ravitch technique consists of an 8-12 cm incision which basicly involves the complete resection of the cartilage, xiphoid excision and osteotomy of the sternum when first described. Since its initial introduction, modifications of this procedure have been developed including placement of a metal strut, to support the sternum, that is removed after six months. Many surgeons think that a 10 cm large incision does not match with the idea of cosmesis in a surgery that is performed mostly with cosmetic purposes. This belief made them to search for alternatives and develop new techniques. Since its introduction by Nuss et al. in 1997, the minimally invasive repair of pectus excavatum (MIRPE) has been gaining acceptance worldwide among surgeons and patients. MIRPE has been first performed by Dr.Donald Nuss at Children’s Hospital of the King’s Daughters ,Norfolk, Virginia, U.S.A. in 1987. Dr.Nuss published his data in Journal of Pediatric Surgery in 1998 which includes 10 years of experience with MIRPE in 42 cases[6]. It became the treatment of choice for pectus excavatum patients in many centers all over the world over following two decades[7],[8],[9],[10],[11],[12].

MIRPE is a thoracoscopy-assisted intervention based on the remodeling of the anterior chest wall by employing a nickel-steel retrosternal metal bar and correction of the defomity by its chronic compression effect. Stabilisers are developed to prevent malrotation of the bar which is dislocating of the bar through ribs and intercostal spaces[10]. The best results are obtained in symmetric deformities, but the results are satisfying also in the asymmetric ones. The best age to perform MIRPE is between 10 and 16, but satisfying results are reported in adults as well . The main advantages of this technique are: smaller incisions on lateral chest wall resulting in better cosmesis, no cartilage resections, minimal blood loss, shorter operation time and early return to full activity. Modifications and succesfull results are reported in many centers ever since the widespread acceptance and application of MIRPE [6],[7],[8],[9],[10],[11],[12],[13].