Summary: The aim of the review was to evaluate the routine use of sternal elevation techniques (SETs) during minimally invasive repair of pectus excavatum (MIRPE, the Nuss procedure). We performed a review of the literature between January 1998 and September 2018 with focus on different methods of SET during MIRPE. Reported effects and side effects were evaluated and compared with our own experience concerning the routine use of the vacuum bell for sternal elevation during MIRPE during the last 13 years. SET is more often used in adult patients than in adolescents. SET improves visualization and safety of MIRPE. Advancement of the pectus introducer, retrosternal dissection and placement of the pectus bar are easier. The risk of cardial and/or pericardial lesion is reduced significantly. Different types of retractors, a crane combined with a wire and/or customized hooks are reported to be used as SET. Furthermore, routine use of a subxiphoid incision is reported. However, more technical equipment, and in some SETs additional incisions are necessary. In contrast, no additional skin incision is necessary for the vacuum bell. The routine intraoperative use of the vacuum bell was safe and effective in 131 patients. It facilitates the retrosternal dissection and the insertion of the pectus bar like other SETs. Besides a temporary mild hematoma, no relevant side effect was observed. In conclusion, an increasing number of authors report on the routine use of SET during MIRPE to improve safety of the procedure. We recommend the routine intraoperative use of the vacuum bell during MIRPE.

EXECUTIVE SUMMARY: Pectus defects are a group of congenital conditions found in approximately 1 in 250 people, where the sternum is depressed back towards the spine (excavatum), protrudes forwards (carinatum) or more rarely is a mixture of both (arcuatum or mixed defects). For the majority of patients, it is well tolerated, but some patients are affected psychologically, physiologically or both. The deformity becomes apparent at a young age due to the growth of the ribs and the cartilage that links them to the sternum. The majority of defects are mild and are well tolerated, i.e. they do not affect activity and do not cause psychological harm. However, some young people develop lower self-esteem and depression, causing them to withdraw from activities (such as swimming, dancing) and from interactions that might ‘expose’ them (such as sleepovers, dating, going to the beach and wearing fashionable clothes). This psychological harm occurs at a crucial time during their physical and social development. A small number of patients have more extreme depression of their sternum that impedes their physiological reserve, which can occur when engaging in strenuous exercise (such as running) but can also limit moderate activity such as walking and climbing stairs. The effects can be so extreme that symptoms occur at rest or cause life-threatening compression of the major blood vessels and organs. The group of patients with physiological impairment usually also suffer from low self-esteem and depression. This paper summarizes the current evidence for the different treatment strategies for this condition, including supportive care, psychological support and non-surgical techniques including bracing and vacuum bell therapy. We also consider surgical techniques including the Ravitch procedure, the Nuss procedure (minimally invasive repair of pectus excavatum), pectus implants and other rare procedures such as Pectus Up. For the majority of patients, supportive care is sufficient, but for a minority, a combination of the other techniques may be considered. This paper also outlines best practice guidance for the delivery of such therapies, including standardized assessment, consent to treatment, audit, quality assurance and long-term support. All the interventions have risks and benefits that the patient, parents and clinicians need to carefully consider and discuss when deciding on the most appropriate course. We hope this evidence review of ‘Best Practice for Pectus’ will make a significant contribution to those considerations and help all involved, from patients to national policy makers, to deliver the best possible care.

For decades, open surgical repair was the only available method to treat congenital and acquired chest wall deformities (CWDs). In 1998, D. Nuss described a minimally invasive procedure for surgical repair of Pectus excavatum (PE). Today, the Nuss procedure is performed with increasing frequency worldwide and considered as the “gold standard”. After its introduction, the method experienced numerous modifications such as routine thoracoscopy and/or sternal elevation, increasing safety of the procedure. Placement of multiple bars and/or the so called cross-bar technique were introduced to correct complex CWDs. Standardized pain management, the introduction of cryo-analgesia and a standardized postoperative physiotherapy program including deep breathing exercises facilitate the establishment of an enhanced recovery after surgery (ERAS) process. However, the widespread use of the minimally invasive repair of pectus excavatum (MIRPE) procedure has been associated with a significant number of serious complications. Furthermore, several studies report near-fatal complications, not only during bar placement, but also during bar removal. This review focuses upon the most relevant modifications, including recent published surgical techniques of MIRPE, in order to describe current developments in the field.

Minimally invasive pectus excavatum repair (Nuss procedure, MIRPE) utilizes transthoracic implantation of metal bars for correction of chest wall deformity. Based on family or personal history, metal allergy testing is undertaken prior to operation, as rates of metal allergy in orthopedics are significant. If the patient is found to be allergic to one of the components of the dermal patch test, a titanium bar is used. Otherwise, a stainless steel bar is used. We report an adolescent boy who underwent Nuss procedure. He had neither history of drug allergies nor contact dermatitis. However, he did suffer from seasonal allergies. Preoperative patch test was negative. Twenty-seven days after Nuss procedure the patient noted a slight rash around his right and left chest incision sites. Signs and symptoms of local infection developed, with increases in erythrocyte sedimentation rate (ESR). Opening the wounds and oral antibiotics led to resolution, with only a rash remaining. Due to persistently elevated ESR values and new elevation of C-reactive protein (CRP), repeat allergy testing was performed. The repeat testing showed reaction to chromium, copper, and molybdenum, minor components of the steel bar. Resolution of his complaints was obtained only after removal of the implanted bars

Aim: In childhood, laparoscopy-assisted single-port appendectomy (SPA), including the advantages of open and laparoscopic surgery, is not widely used. However, there is debate whether the retrieval of the infected appendix via the umbilicus results in a higher infection rate compared with other laparoscopic or open techniques. The aim of the study was to determine the postoperative infection rate and possible risk factors for infection after SPA in children. Methods: For this retrospective study, case notes of all children (n = 262) who underwent SPA between August 2005 and December 2008 were reviewed. Those children in whom the preoperative ultrasonography revealed suspected perforation were excluded from SPA and subsequently underwent open surgery. SPA was performed using a 12-mm trocar with one 5-mm working channel, introduced through a sub-umbilical incision. After grasping the appendix with atraumatic forceps, the appendix was exteriorized through the umbilicus and dissected outside the abdominal cavity as in open surgery. Preoperatively, each patient received one dose of Metronidazole and Cefuroxime, and the umbilicus was cleaned in particular. Results: Of the 262 children who underwent SPA, 146 were boys (55.7%) and 116 girls (44.3%). Median age at operation was 11.4 years (range, 1.1–15.9). Six obese (with a body mass index greater than the 95th percentile) children (2.3%) developed intra-abdominal abscess after perforated appendicitis that was treated with a course of antibiotics. One child required revisional surgery and drainage. The median length of antibiotic treatment was 3 days (range, 0–15). Conclusion: In our institution, SPA is the method of choice for appendectomy in children with acute appendicitis, in whom preoperative ultrasound does not reveal signs of perforation. The infection rate (2.7%) after SPA is not increased compared with other laparoscopic or open techniques. Overweight (body mass index greater than the 95th percentile) and perforated appendicitis seem to increase the risk of postoperative infectious complications.