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.

Background/Objectives: The minimally invasive repair of pectus excavatum (MIRPE) and its modifications represent the gold standard for surgical repair of chest wall deformities. Severe complications during or after MIRPE are rare but likely underreported in the literature. Methods/Results: We report the case of a 14-year-old adolescent who underwent an uneventful repair of an asymmetric pectus excavatum. Six weeks postoperatively, the patient presented with shortness of breath and dizziness. Clinical examination and imaging revealed a spontaneous massive right-sided hemothorax. Following chest tube placement, an initial 600 mL of bloody pleural fluid was drained. CT angiography demonstrated no active bleeding but raised suspicion of an injury to the right-sided internal mammary artery. After a total drainage of 1600 mL, the patient remained hemodynamically stable, and the chest tube was removed within 24 h. During 32 months of follow-up, the further clinical course was uneventful, and imaging demonstrated no secondary displacement of the implants. Discussion/Conclusions: Accidental injury to the internal mammary or intercostal vessels during pectus surgery is a rare but potentially life-threatening complication. Only a few cases of delayed hemorrhage following MIRPE have been reported, and in many a clear source of bleeding could not be identified. Pectus surgeons should be aware of this rare complication and should report such cases to improve understanding of its incidence and management.