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

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. 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). 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%. 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.