Pectoscopy Nuss procedure for

minimally invasive repair of pectus excavatum (MIRPE)

Dr LM.Darlong Chest wall deformity clinic Consultant Thoracic Surgery & Thoracic Oncology Fortis Hospital NOIDA
www.pectusindia.com

Pectus excavatum
Funnel chest
Depression chest wall

Symmetric defect Asymmetric defect Overgrowth of cartilage 1 in 500 to 1000

Males 3-4 times

Funnel chest

www.pectusindia.com

Facts
M.C congenital chest wall deformity
Effects on the individual -Physiological

-Psychosocial -Cosmetic Medical community Neglect

Cosmetic
www.pectusindia.com

feels -Not a Disease, only

Fact-DISEASE

Parks* morphologic classification

Morphologic type
Type 1: Symmetric 1 A: Prototype (Deep, focal) 1 B: Broad, flat Type 2: Asymmetric

Features
Centre of sternum and depression are in the midline. Typical deep focal symmetric sternal depression Broad flat symmetric sternal depression Centre of depression not in the centre of the sternum but found laterally to the left or right

Type 2A:Eccentric
2A1:Focal 2A2:Broad flat 2A3:Long canal, Grand canyon

Centre of sternum in midline but maximal depression located laterally in cartilage to the left or right
Deep focal asymmetric depression Broad flat asymmetric depression Extreme form with deep longitudinal groove from clavicle to lower chest 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 ) Combination of 2A and 2B

Type 2 B:Unbalanced

Type 2 C:Combined

Symmetrical

Type 1A

Type 1B

Asymmetrical

Type 2A1 Type 1A Type 1A

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

www.pectusindia.com

Crane Tech Sternal lift

www.pectusindia.com

Crane lift

www.pectusindia.com

Pectoscope

www.pectusindia.com

Pectoscopy

Right to left under vision

www.pectusindia.com

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

www.pectusindia.com

Postop images

www.pectusindia.com

Postop images

CT before and after

Before and after surgery

www.pectusindia.com

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 communityIndentify as Disease
Not neglect it as Cosmetic defects

Minimally Invasive Techniques Look good / Feel good

www.pectusindia.com