Minimally Invasive Repair of Pectus Carinatum

The Presentation

Two 16-year-old boys presented with pectus carinatum that developed at adolescence 0:00. Preoperative assessment measured correction pressures between 6 and 7 pounds per square inch, indicating moderate stiffness of the chest wall 0:27. After discussion of all available surgical and non-surgical options, both patients elected to proceed with minimally invasive repair [c1, c2].

The Technical Decision

The central question in pectus carinatum repair is whether cartilage resection is necessary to achieve durable correction. Traditional open techniques rely on resecting deformed costal cartilages — a more invasive approach with longer recovery. The alternative is the Abramson technique, also called the reverse Nuss procedure, which uses a compressive bar to remodel the chest wall without cartilage resection 0:08.

The decision hinges on chest wall stiffness. Correction pressures in the 6-7 PSI range occupy a middle zone — stiff enough that bracing alone might fail, but potentially compliant enough for bar-based remodeling if the fixation is robust. The discussant chose the minimally invasive approach, accepting that success would depend on achieving secure four-point fixation to resist the outward spring of the deformed cartilages.

What Was Done

The procedure was performed under general anesthesia with epidural catheter for analgesia 0:58. Prophylactic antibiotics were administered and a Foley catheter placed for 24 hours 1:05.

Bar length was determined by measuring the distance between mid-axillary lines at the carinatum's apex after manual correction 1:19. The bar ends were positioned to correspond with the intercostal spaces where stabilizers would anchor 1:33. Bilateral incisions exposed two ribs on each side, cleared of muscle attachments for approximately 3 centimeters 1:57.

The fixation technique departed from standard bar placement. A 1-inch periosteal incision was made in each rib, and the periosteum separated anteriorly and posteriorly to create a subperiosteal tunnel 2:13. Bendable rib protectors, sized to match the measured subperiosteal space, were contoured to each rib's shape and threaded with cable 2:37. A small piece of dental wire was attached to each protector to facilitate later removal at 2 to 3 years 2:58. The cable-protector assemblies were passed through the subperiosteal space 2:44.

A subcutaneous tunnel was created across the anterior chest using curved clamps and finger dissection from both sides 3:27. The pre-bent pectus bar was passed through this tunnel and its ends inserted into stabilizers on each side. Sternal wire was placed around a notch in the bar just distal to each stabilizer to lock the bar-stabilizer interface 3:52. The cables were adjusted to equal length and crimped under compression to achieve corrected chest position. This created four-point fixation — the bar was tightly anchored to 4 ribs, 2 on each side 4:24. The rib protectors prevented the cables from cutting through bone 4:32.

The Outcome

One year postoperatively, excellent correction was achieved and maintained in both patients 4:48. Notably, in addition to correction of the pectus deformity itself, lateral chest wall expansion occurred 4:55.

What This Case Changes

The one-year result demonstrates that cartilage resection is not obligatory for durable pectus carinatum correction, even in adolescents with moderately stiff chest walls. The key technical innovation is the subperiosteal cable-and-protector system, which distributes compressive force across four ribs rather than relying on stabilizer-to-rib interface alone. This fixation was sufficient to resist the outward recoil of unremodeled cartilages long enough for chest wall remodeling to occur.

The lateral expansion is mechanically interesting — it suggests the bar does not simply compress the protrusion but redistributes growth forces across the anterior chest. Whether this expansion is cosmetically favorable or represents overcorrection was not discussed.

The 2-to-3-year bar removal timeline is longer than typical Nuss bar retention for excavatum, reflecting the different mechanical challenge: the bar must resist outward rather than inward forces. The dental wire markers on the rib protectors acknowledge that subperiosteal hardware retrieval will be technically demanding.

For the adolescent with moderate-stiffness carinatum who wants to avoid cartilage resection, this technique offers a minimally invasive alternative — provided the surgeon is prepared to execute meticulous four-point subperiosteal fixation and the patient accepts a multi-year bar retention period.

Presentation

Two 16-year-old boys presented with pectus carinatum that had developed at adolescence 0:00. Preoperative assessment measured correction pressures between 6 and 7 pounds per square inch, indicating moderate stiffness of the chest wall 0:27. After discussion of all available surgical and non-surgical options, both patients and their families elected to proceed with minimally invasive repair [c1, c2].

The Decision Point

Pectus carinatum can be managed through multiple approaches, including bracing, traditional open repair with cartilage resection, or minimally invasive techniques 0:00. The central question in these cases was whether the chest wall stiffness — moderate by pressure measurement — would allow adequate correction without cartilage removal. The Abramson procedure, also called the reverse Nuss, uses a compressive bar anchored to ribs via subperiosteal cables to reshape the chest wall 0:08. Success depends on sufficient chest wall flexibility to accept the new contour and maintain it during the remodeling period.

The correction pressure measurements provided the key data. At 6 to 7 PSI, these chest walls were stiff enough to require secure fixation but not so rigid as to preclude non-resectional correction 0:27. The patients' age — 16 years, with onset at adolescence — suggested the deformity was still actively developing rather than fully ossified. This combination made them candidates for the minimally invasive approach.

What Was Done

Both patients underwent the procedure under general anesthesia with epidural catheter placement for intraoperative and postoperative analgesia 0:58. Prophylactic antibiotics were administered and a Foley catheter inserted for 24 hours 1:05.

Bar length was determined by measuring the distance between the mid-axillary lines at the highest point of the carinatum after manual correction 1:19. The bar ends were positioned to correspond with the intercostal spaces where stabilizers would anchor to ribs 1:33. Bilateral incisions exposed multiple ribs on each side, which were cleared of muscle attachments 1:57.

The fixation technique centered on subperiosteal cable placement. A periosteal incision was made in each rib, and the periosteum separated from underlying bone both anteriorly and posteriorly 2:13. Bendable rib protectors, sized to match the measured subperiosteal space, were shaped to the rib contour and threaded with cable 2:37. Each protector was marked with a small piece of dental wire to facilitate removal at 2 to 3 years 2:58. The cable and protector assembly was then passed under each rib within the subperiosteal space 2:44.

A subcutaneous tunnel was created between the muscles and chest wall using long curved clamps and finger dissection from both sides, meeting at the midpoint 3:27. The pre-bent pectus bar was passed through this tunnel and its ends inserted into stabilizers on each side. Sternal wire was placed around a notch in the bar just distal to each stabilizer to lock the bar-stabilizer connection 3:52. The cables were adjusted to equal length and crimped under pressure to achieve corrected chest position. The bar was ultimately anchored to four ribs, two on each side 4:24. The rib protectors served to prevent the cables from cutting through bone 4:32.

Outcome

One year postoperatively, both patients demonstrated excellent correction that had been maintained 4:48. Beyond the intended correction of the pectus deformity, lateral chest wall expansion had occurred 4:55.

What This Case Changes

The outcome was not discussed beyond the one-year mark, so durability past that point remains unstated. What the case demonstrates is that moderate chest wall stiffness — quantified by correction pressure measurement — does not preclude non-resectional repair. The subperiosteal cable-and-protector system provided sufficient fixation to maintain correction through the remodeling period without requiring cartilage excision. The lateral chest wall expansion was an additional benefit not always achieved with other techniques 4:55.

For the trainee selecting among pectus carinatum repair options, this case establishes that correction pressure in the 6 to 7 PSI range can be managed with the Abramson approach 0:27. The technical emphasis on subperiosteal dissection, rib protector sizing, and secure four-point fixation reflects what the procedure requires to succeed 4:24. The one-year result supports the approach; longer follow-up would be needed to assess permanence of correction and timing of hardware removal.