Formosan Journal of Surgery

: 2020  |  Volume : 53  |  Issue : 4  |  Page : 128--134

Modified bilateral thoracoscopy-assisted Nuss procedure for repair of pectus excavatum after previous thoracic procedure

Fu-Jung Lee1, Po-Cheng Lo1, Meng-Yu Wu2, Min-Shiau Hsieh3, Yeung-Leung Cheng4,  
1 Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
2 Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
3 Department of Surgery; Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
4 Department of Surgery; Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City; School of Medicine, Tzu Chi University, Hualien, Taiwan

Correspondence Address:
Yeung-Leung Cheng
Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No 289, Jian-Gao RD, Xindian Dist., New Taipei City 231


Background: Minimally invasive repair of pectus excavatum (PE) (Nuss procedure) was a transmediastinal procedure. Intrathoracic adhesion might increase the risks of this procedure. Patients after previous thoracic surgery might have the problem of intrathoracic adhesion increasing the surgical risks of Nuss procedure. PE after surgical repair was not a rare problem, especially in adults. In this study, we were to investigate the efficacy and safety of a modified Nuss procedure, using bilateral thoracoscopic approach, to repair recurrent or residual PE in adult patients. Materials and Methods: We retrospectively included all adults with PE corrected by modified bilateral thoracoscopy-assisted Nuss repair from January 2015 to December 2016. The clinical and surgical data of patients repaired with primary or secondary Nuss procedure were recorded and analyzed. Results: One hundred and fifty-one adult patients (136 men and 15 women) with a mean age of 26.3 years were included. Eleven patients (9 men and 2 women) were secondarily repaired due to prior failed Ravitch (three patients) or Nuss procedure (eight patients). The pectus repair was done using a single pectus bar (8.6%), 2 bars (81.5%), or 3 bars (9.9%). The rate of postoperative complications (6 months after operation) was significantly higher (P < 0.01) in the secondary repair group (two patients, 18.2%) compared to the primary repair group (seven patients, 9.3%), but it was still lower than most of the previous reports in the world (around 40%). Conclusion: All patients with PE had excellent postoperative outcomes in both the groups, even if with a slightly higher postoperative complication rate in the secondary repair group. The number of bar insertions was higher than previous data but with a lower complication rate. The modified bilateral thoracoscopy-assisted Nuss repair for adult patients after failed Ravitch or Nuss procedure was a safe and effective method and could have good early results.

How to cite this article:
Lee FJ, Lo PC, Wu MY, Hsieh MS, Cheng YL. Modified bilateral thoracoscopy-assisted Nuss procedure for repair of pectus excavatum after previous thoracic procedure.Formos J Surg 2020;53:128-134

How to cite this URL:
Lee FJ, Lo PC, Wu MY, Hsieh MS, Cheng YL. Modified bilateral thoracoscopy-assisted Nuss procedure for repair of pectus excavatum after previous thoracic procedure. Formos J Surg [serial online] 2020 [cited 2020 Oct 22 ];53:128-134
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Pectus excavatum (PE) is the most frequent congenital chest wall anomaly. The depression in the anterior chest wall and/or sternum may be decreased the self-esteem and caused the social limitation. Furthermore, it could also impair the cardiac and respiratory function after puberty. Surgical correction was considered as the definitive treatment for PE, and multiple techniques for correction have been reported. The Ravitch procedure was regarded as traditional surgical repairs for PE and generally applied until mid-1990. The Ravitch procedure was an open approach by the subperichondrial resection of costal cartilages.[1] In 1998, Nuss et al.[2] published a minimally invasive repair of PE for remodeling the depressed chest deformity using placement of substernal stainless steel bar (s). Compared to Ravitch procedure, the Nuss procedure became more and more popular due to the small incision sites, significantly less estimated blood loss, and shorter operative time.[3],[4] Although both procedures are considered safe and still commonly used up to now, a 2%–37% recurrence rate is still documented in recent studies.[5],[6],[7],[8],[9],[10]

In 2005, Croitoru et al.[5] firstly reported successfully using modified Nuss procedure repaired recurrent or failed PE repair. After then, several studies documented the results of undergoing Nuss procedure for repairing the recurrent PE.[9],[11],[12],[13] However, the reoperation for failed PE repair has a higher complication rate in most reports due to extensively dissecting severe adhesions between the sternum and mediastinal structures.[5],[6],[7],[8],[9],[10],[14]

In 2008, we performed a modified Nuss procedure, using bilateral thoracoscope assisted for increasing the efficacy and safety, in more than 400 patients and had demonstrated before.[12] The modified Nuss procedure seems to be an excellent method for PE repair. In the present study, the aim was to investigate the efficacy and safety of the failed PE repair using the modified Nuss procedure in adults.

 Materials and Methods

We retrospectively reviewed all adult patients with PE who had undergone Nuss procedure as their primary repair (Group A) or secondary repair (Group B) at the Division of Thoracic Surgery, Taipei Tzu-Chi Hospital, New Taipei City, Taiwan, from January 2015 to December 2016. The complete history, physical examination, chest radiographs, electrocardiogram, pulmonary function test, echocardiogram, and computerized tomography (CT) of the chest were evaluated. The demographic data, clinical data, surgical indications, complications, operative time, estimated blood loss (subjective estimation of the approximate amount of bleeding perioperatively by the surgeon),[2],[5],[7],[8],[12],[13] and surgical outcome were collected and analyzed. This study was approved by the Ethics Committee and the Institutional Review Board (IRB) of the Taipei Tzu-Chi Hospital, Taipei, Taiwan, ROC (IRB No: 05-X14–045). Patient consent was waived by the Institutional Review Board on account of the retrospective nature of the study.

Surgical preparation and technique

A modified bilateral thoracoscopy-assisted Nuss procedure was demonstrated in 2008.[12] Before the modified Nuss procedure performed, all patients received a thoracic epidural for intraoperative anesthesia and postoperative pain control. The patient was placed in the supine position after general anesthesia. In patients undertaking the first Nuss procedure or redo Nuss procedure for patients having Ravitch repair, one vertical skin incision (3 cm–5 cm) was made in the bilateral midaxillary line. In patients undertaking redo Nuss procedure for patients having previous Nuss procedure, the skin incisions were through the previous surgical incisions. After subcutaneous or submuscular dissections, the pleural cavities were entered through the bilateral hinge points. Each hinge point is an intercostal space located at the crest of the depression on either side and is the point where the bar penetrates the pleural cavity.[12],[13] A right thoracoscopy with a 10-mm, 0° scope entering the pleural cavity through the right surgical wound for direct inspection of the mediastinal structures was done. The left side was the same. A right-to-left mediastinal dissection by the introducer was undergone under direct left thoracoscopic visualization. For patients undergoing the second operation, if there were intrapleural or mediastinal adhesion, an endoscopic electrocautery or harmonic scalpel (Ethicon-Johnson and Johnson, US, LLC) was used to lysis the adhesion under ipsilateral lung hypoventilation. After the substernal tunnel achieved, a 28-Fr chest tube was connected on the tip of an introducer. After the introducer was pulled back, the chest tube was retained in the thorax. A prebent Lorenz pectus bar (Lorenz Surgical Inc., Jacksonville, FL) was tightly connected to the tip of the one side of a chest tube. After the chest tube was pulled out, the pectus bar was across the mediastinum. The pectus bar was rotated and anchored into the position. It was fixed with either a 1.0-mm stainless wire or heavy nonabsorbable sutures at the end holes of the pectus bar and the right hinge point.[15] For wider and/or more severe chest deformity, an additional pectus bar was introduced and fixed for another substernal tunnel which was made under the direct left thoracoscopic viewing. Two small-caliber close drainage tubes were inserted into the pleural spaces for drainage of air and fluid. After extubation, all patients received a postoperative radiograph and intensive monitored for 24 h.

Postoperative pain was controlled epidural patient-controlled analgesics with fentanyl. Nonsteroidal anti-inflammatory drugs were provided in patients of severe pain episodes. If there is no air leakage from the drainage tube and the drainage volume is <20 ml/day, we will remove the drainage tube.[12],[13] The patients were discharged from the hospital when pain control was replaced by oral analgesics. The chest plain film was following at 2 weeks, 1 month, 3 months after operation, and then twice annually.

If the progressive dyspnea and/or pleural effusion on chest plain film was noted, the procedures of aspiration or drainage and/or medication with a low dose of oral steroid were made depending on the condition of patients.[16]

The early postoperative results (before removal the bar) were used the criteria:[5] excellent if preoperative symptoms were resolved and gross appearance was normal, good if symptoms were resolved and gross appearance was improved after operation, and fair if symptoms were improved but chest appearance had no improvement after operation.

Statistical analysis

The Kolmogorov–Smirnov and Shapiro–Wilk tests were used to assess the normality of distribution of investigated parameters. Continuous data were summarized as median interquartile range (IQR) and categorical data were summarized as n (%). Differences between the two groups were compared using the Mann–Whitney U-test for continuous data and the Chi-square test or Fisher's exact test for categorical data. All statistical assessment was two-tailed and considered significantly as P < 0.05. Statistical analyses were performed using SPSS 22 software (SPSS Inc, Chicago, IL).


A total of 151 consecutive patients (male: 136 and female: 15) with PE repaired by Nuss procedure were included retrospectively. These patients were with a median age of 26.3 years (range: 20–49 years) at the time of surgery. The median Haller index was 4.5 (IQR: 3–8) in Group A and 5.1 (IQR: 3.4–8) in Group B. There was no statistically significant in Haller index between the two groups. In Group B, the median preoperative sternovertebral distance (SVD) was 6.8 cm (IQR: 2.9–10.8 cm) and had significantly narrower compared to Group A (median: 7.8 cm; IQR: 4.6–11.7 cm) (PP = 0.026). The postoperative SVD showed a significant improvement in both Group A (median ratio of difference: 31.3%; IQR: 19.6%–41.2%; P < 0.01) and Group B (median ratio of difference: 28.4%; IQR: 17.8%–38.8%; P < 0.01). In the secondary repair group, three patients received secondary repair after initial repaired by Ravitch procedure and eight patients after Nuss procedure. Three patients had bar flipping and eight patients had residual chest wall deformity after initial repair.

The recorded surgical data revealed that the median operative time is 78.2 min, with a significance between the two groups (Group A: 74.8 min; Group B: 101.8 min, P < 0.01). The median estimated blood loss during operation was 14.5 ml in Group A and a median of 25.9 ml in Group B with significant P < 0.01. One hundred and thirty-eight patients (91.4%) received two or three bars for PE repair. In both the groups, patients received that two bars were major population (Group A: 82.1%; Group B: 72.7%). The duration of drainage tube placement in Group B had significantly longer than Group A (median: 4 days and 2 days, respectively; P < 0.01). The median length of hospital stay was 7.4 days and significant between Groups A and B (7.2 days and 7.7 days, respectively; P = 0.023). No blood transfusion was needed in any patient during and after operation. The demographic features and surgical results of these patients are shown in [Table 1]. Both the initial preoperative and postoperative results after modified bilateral thoracoscopy-assisted Nuss procedure are presented in [Figure 1], [Figure 2], [Figure 3].{Table 1}{Figure 1}{Figure 2}{Figure 3}

Surgical complications

The perioperative complications were divided into lung laceration, heart injury, transient cardiac arrest, and active bleeding. No perioperative complication was recorded in both the groups. The incidence rate of postoperative complications, including pneumothorax, hemothorax, seroma, pneumonia, empyema, pleural effusion, pericardial effusion, bar displacement, and mortality, was significantly higher in Group B (two patients, 18.2%) compared to Group A (seven patients, 9.3%).

In Group A, seven cases of postoperative complication were identified. The bar displacement was 6 cases and accounted for most complications, requiring surgical revision. Two patients presented with dyspnea due to pleural effusion after Nuss procedure. There were three patients with seroma and two patients diagnosed with pneumonia. In Group B, one patient with pneumonia and another patient with bar displacement were noted. No pneumothorax, empyema, hemothorax, pericardial effusion, bar displacement, and mortality were recorded in both the groups. The surgical complications and outcomes of 11 patients after Nuss procedure are summarized in [Table 2].{Table 2}


Regardless of which procedure was initially used, the recurrence of PE is not a rare complication. Shamberger and Welch[17] analyzed 704 patients with PE and revealed a total recurrence rate of 5.7%. A similar result was reported from Janusz Kowalewski,[18] with a recurrent rate of 8.82% (6/68 patients). After Croitoru et al.[5] successfully using modified Nuss procedure for repair recurrent PE, the modified Nuss procedure became an alternative method for secondary repair, but the complication rate was higher. In 2008, we performed a modified bilateral thoracoscope-assisted Nuss procedure for primary repair of PE.[12] Compared to previous standard procedure, bilateral thoracoscope-assisted Nuss procedure provided a direct left visualization for right-to-left mediastinal dissection without an additional wound for thoracoscope. The complication easily occurred during mediastinal dissection because severe adhesions were mostly found between lung and chest wall or sternum and mediastinal structures. The direct left visualization helps surgeons prevent the vascular and cardiopulmonary injuries and decreases the complication rate during bar insertion and lysis of adhesion. The early result showed that 91.6% of the patients have been satisfied the primary repair of PE.[12]

In our studies, all patients were successfully repaired using modified bilateral thoracoscopy-assisted Nuss repair. Compared to primary repair, the patients of recurrent PE had severe chest wall deformity with narrower preoperative SVD (6.8 cm vs. 7.8 cm). The duration of operative time was significantly prolonged in the secondary repair group (74.8 min vs. 101.8 min), and the estimated blood loss was more (14.5 ml vs. 25.9 ml). The duration of drainage tube placement in Group B was also significantly longer than Group A (4 days vs. 2 days). The secondary repair is more challenging, especially in additional dissection of severe adhesions. Kocher et al.[14] reported similar data as our operative results and found the severe adhesions also increased the risk of early complications.

Our postoperative complication rate was 9.3% (seven patients) in primary repair and 18.2% (two patients) in secondary repair. In detail analysis of postoperative complications, seroma, pneumonia, and pleural effusion were common early complications in the primary repair group. The most common late complication was displacement of the bar, occurring in six patients in primary repair and in one patient in secondary repair. A similar result was reported by Kelly in 7.1% of the patients.[19] In the secondary repair group, only two patients had complications: one patient had pneumonia and another one had shifts. The postoperative complication rate of secondary repair was significantly lower than primary repair as previous studies.[5],[9],[10] Wang et al.[10] analyzed 12 cases of secondary repair and revealed hemothorax in 16.7% of the patients, pleural effusion requiring drainage in 25.0% of the patients, and bar shifts in 16.7% of the patients. Croitoru et al. reported[5] that the complication rates of “redo” patients were as follows: pneumothorax was in 70%, bar shifts were in 14%, and 8% of the patients were requiring revision. In our experience, the most common problem during redo surgery is the intrathoracic adhesion, which will affect the field of vision during the operation and cause surgical complications, bleeding, or increase the surgical time. The results of secondary Nuss repair for failed or recurrent PE in adults are summarized in [Table 3].[5],[8],[9],[10],[14],[20] Although some studies revealed a high complication rate, most of the complications were not life-threatening and overall results demonstrated well.{Table 3}

Although our complication rate was lower than previous data, it also had 18.2%. There were some reasons for slightly higher complication rate. First, the preoperative SVD, reflecting the severity of chest wall deformity, was significantly lower in secondary repair patients. Second, the rate of using 2 bars was higher in our studies (82.1% in primary repair and 72.7% in secondary repair). A second bar was usually added in wider chest wall deformity patients, taller patients, and redo patients due to severe abnormal ossification. One of the secondary repair patients with severe chest wall deformity is described in [Figure 2]. The wider chest wall deformity due to malunion and abnormal calcification was revealed in the preoperative lateral chest radiograph and the preoperative CT scan. A second bar provided an additional force to overcome the underlying deformity and shared the forces from the chest wall. In previous reports, the rate of PE patients who received 2 bars was lower than 50%.[9],[21] Finally, the sample size was small in our study.

In our analysis, the modified bilateral thoracoscopy-assisted Nuss repair decreased the complication rate because the substernal tunnel formation from mediastinal dissection can be directly visualized under the thoracoscopy. Many studies had confirmed the safety and efficacy of using thoracoscopy to assist the bar passage.[22],[23],[24] The thoracoscope is used preferentially from the right side because the heart obscures the view in the left thorax. The distal end of the substernal tunnel cannot be directly visualized during mediastinal dissection. In our cases, all flelds of dissection can be visualized using bilateral thoracoscopy. The higher rate of number of bar insertion reflected the limitation of surgical technique, and clinical condition overcame using modified Nuss procedure. All patients with PE had excellent postoperative outcomes in both the groups, even if with a slightly higher postoperative complication rate in the secondary repair group. However, the long-term results were needed to be followed.


The modified bilateral thoracoscopy-assisted Nuss repair is safe and effective for failed or recurrent PE. Although the patients in the secondary repair group had severe chest wall deformity with narrower preoperative SVD, longer operative time, and more blood loss, all patients with PE had excellent postoperative outcomes in both the groups. The postoperative complication rate was lower than in previous studies, even if the number of bar insertion was higher. However, the long-term results were needed to be followed. We believe that the modified bilateral thoracoscopy-assisted Nuss is a promising alternative for secondary repair in failed or recurrent patients.

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Conflicts of interest

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