Pectoscopy – Nuss procedure for

minimally invasive repair of pectus

excavatum (MIRPE)

Dr LM.Darlong“Chest wall deformity clinic”Consultant Thoracic Surgery & Thoracic OncologyFortis Hospital NOIDA

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• Funnel chest

• Depression chest wall

• Symmetric defect

• Asymmetric defect

• Overgrowth of cartilage

• 1 in 500 to 1000

• Males 3-4 times

Pectus excavatum

Funnel chest

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Facts

• M.C congenital chest wall deformity

• Effects on the individual-Physiological

-Psychosocial

-Cosmetic

• Medical community –Neglect

feels -Not a Disease, only Cosmetic

Fact-DISEASE www.pectusindia.com

Parks* morphologic classification

Morphologic type Features

Type 1: Symmetric Centre of sternum and depression are in the midline.

1 A: Prototype (Deep, focal) Typical deep focal symmetric sternal depression

1 B: Broad, flat Broad flat symmetric sternal depression

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 right

2A1:Focal Deep focal asymmetric depression

2A2:Broad flat Broad flat asymmetric depression

2A3:Long canal, Grand canyon Extreme 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 axis are different ( alpha <

beta )

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

Symmetrical

Type 1 A Type 1B

Type 2A1 Type 2A2 Type 2A3

Type 2B Type 2C

Type 1A Type 1B

Asymmetrical

Type 1AType 1A

Type 2A1 Type 2A2

Asymmetrical

Grand Canyon / Type 2 A3

Asymmetrical

Type 2B Type 2C

MIRPE principle

MIRPE

• Stainless steel bars placed under sternum

• Forcing the chest to remodel

• No cutting/removal of cartilage

• 2 cm incision on each side of chest

Repair techniques

• Bar bending – Based on morphology type

• Retrosternal tunnel – Crucial for safety

• Bar fixation / stabilization

Bar bending

• Morphology based

• Correct length of bar

• Creation of mirror image

• Multiple bending and reinsertion

Bar bending

Symmetrical Asymmetrical

Bar benders

Bar benders

Retrosternal tunnel

• Crucial - Avoid cardiac injuries

• Crane technique – Sternal lift

• Pectoscopy – Direct endoscopic vision

• Thoracoscopy - limitations

Retrosternal tunnel creation

Pectoscopy Thoracoscopy

View both side of chest View of right side of chest only

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Crane Tech – Sternal lift

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Crane lift

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Pectoscope

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Pectoscopy

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Right to left under vision

Bar stability

• Hinge point stabilization – Hinge plate

• Bar fixation – Claw fixators

• Crucial to prevent

Hinge disruption

Lateral displacement

Flipping

Bar exit site stabilization

Claw Fixators

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Postop images

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Postop images

CT before and after

Before and after surgery

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Indications for repair

• Physiological- Improve heart and lung

function

• Psychosocial – Improves self image/esteem

• Cosmetic

Time of repair

• No consensus

• Early repair- Bone softer/malleable

• Adults – Strong bones/less

malleable/multiple bars

• Best at 3yrs age – at 5 yrs Bar removed

and child ready to join school

MIRPE

• Remodeling of Chest wall

• Truly minimally invasive

• Cosmetic – 2 incision, 2 cm size

1.Morpho tailored-Asymmtrc defects

2.Crane technique – Sternal lift

3.Pectoscope – Endoscopic Guidance

Conclusion

• Medical community–Indentify as Disease

• Not neglect it as Cosmetic defects

• Minimally Invasive Techniques

Look good / Feel good

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