Application of an ultra-minimally invasive incision in reducing incision complications after the Nuss procedure for pectus excavatum_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

CHENG Yinghua ^1,2 , LIANG Xiao ¹ , LI Xing ¹ , YAN Xiaolong ¹ , ZHAO Jinbo ¹ ,  WANG Lei ¹

1. Department of Thoracic Surgery, Tangdu Hospital, Air Force Military Medical University, Xi'an, 710038, P. R. China;
2. Yan'an University School of Medicine, Yan'an, 716000, Shaanxi, P. R. China;

Corresponding?author：

WANG Lei, Email: tuodi1986@126.com

Keywords：

Ultra-minimally invasive; pectus excavatum; Nuss procedure; postoperative incision complications

DOI：

10.7507/1007-4848.202509090

Video：

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Objective To investigate the efficacy and safety of an ultra-minimally invasive incision technique in the Nuss procedure for the correction of pectus excavatum. Methods We retrospectively analyzed the clinical data of patients with pectus excavatum who underwent the Nuss procedure at Tangdu Hospital, Air Force Medical University, from September 2019 to September 2024. Patients were divided into two cohorts: an ultra-minimally invasive incision group and a conventional incision group. Baseline characteristics, efficacy outcomes (e.g., postoperative Haller index), and safety outcomes (e.g., operative time, intraoperative blood loss, postoperative length of stay, and complications) were collected and compared between the two groups. Results A total of 125 patients were included. The ultra-minimally invasive incision group consisted of 49 patients (43 male, 6 female) with a median age of 14 (12.5, 16) years, while the conventional incision group included 76 patients (64 male, 12 female) with a median age of 14 (12, 16) years. Compared to the conventional group, the ultra-minimally invasive incision group had significantly less intraoperative blood loss [10 (5,20) mL vs. 20 (10, 30) mL, P=0.012], a shorter postoperative length of stay [4 (3, 4) d vs. 4 (3, 5) d, P=0.014], a lower incidence of postoperative incision complications [2.04% (1/49) vs. 14.47% (11/76), P=0.027], and a lower visual analogue scale (VAS) score on postoperative day 1 [(3.68±0.62) points vs. (5.37±0.89) points, P<0.001]. There were no statistically significant differences between the two groups in operative time, postoperative Haller index, or the incidence of other complications such as pleural effusion and pneumothorax (all P>0.05). Conclusion The ultra-minimally invasive incision technique can significantly reduce the incidence of incision-related complications and alleviate early postoperative pain in patients undergoing the Nuss procedure. It is a safe and feasible surgical approach for the correction of pectus excavatum.

1.	Westphal FL, Lima LC, Lima NJ, et al. Prevalence of pectus carinatum and pectus excavatum in students in the city of Manaus, Brazil. J Bras Pneumol, 2009, 35(3): 221-226.
2.	Zou X, Lin Y, Jin H, et al. Screening for pectus excavatum among primary students and establishment of a pectus excavatum screening program in Dongguan, China. J Thorac Dis, 2015, 7(5): 868-874.
3.	Coskun ZK, Turgut HB, Demirsoy S, et al. The prevalence and effects of pectus excavatum and pectus carinatum on the respiratory function in children between 7-14 years old. Indian J Pediatr, 2010, 77(9): 1017-1019.
4.	Nuss D, Kelly RE Jr, Croitoru DP, et al. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg, 1998, 33(4): 545-552.
5.	Protopapas AD, Athanasiou T. Peri-operative data on the Nuss procedure in children with pectus excavatum: independent survey of the first 20 years' data. J Cardiothorac Surg, 2008, 3(1): 40.
6.	徐芬, 周成偉, 毛勇, 等. 胸腔鏡輔助下微創漏斗胸矯形術治療小兒先天性漏斗胸切口愈合情況及危險因素分析. 中國婦幼保健, 2021, 36(8): 1930-1933.Xu F, Zhou CW, Mao Y, et al. Analysis of incision healing and risk factors for pediatric congenital pectus excavatum after minimally invasive repair. Matern Child Health Care China, 2021, 36(8): 1930-1933.
7.	喬貴賓, 莫緒明, 曾騏. 漏斗胸外科治療中國專家共識. 中華小兒外科雜志, 2020, 41(1): 7-12.Qiao GB, Mo XM, Zeng Q. Chinese expert consensus on surgical treatment for pectus excavatum. Chin J Pediatr Surg, 2020, 41(1): 7-12.
8.	劉文英. 關于漏斗胸手術治療的若干問題. 臨床小兒外科雜志, 2016, 15(2): 110-113.Liu WY. Several issues concerning the surgical treatment of pectus excavatum. J Clin Pediatr Surg, 2016, 15(2): 110-113.
9.	Kelly RE Jr, Obermeyer RJ, Goretsky MJ, et al. Recent modifications of the Nuss procedure: the pursuit of safety during the minimally invasive repair of pectus excavatum. Ann Surg, 2022, 275(2): e496-e502.
10.	Abid I, Ewais MM, Marranca J, et al. Pectus excavatum: a review of diagnosis and current treatment options. J Am Osteopath Assoc, 2017, 117(2): 106-113.
11.	Rshaidat H, Gorgov E, Collins ML, et al. Complication rate of the Nuss procedure in adults and pediatric patients: national database analysis. Ann Thorac Surg Short Rep, 2024, 2(3): 364-368.
12.	Obermeyer RJ, Godbout E, Goretsky MJ, et al. Risk factors and management of Nuss bar infections in 1717 patients over 25 years. J Pediatr Surg, 2016, 51(1): 154-158.
13.	Pio L, Carlucci M, Leonelli L, et al. Minimally invasive repair of pectus excavatum without bar stabilizers using Endo Close. J Laparoendosc Adv Surg Tech A, 2016, 26(2): 148-152.
14.	Ochoa B, Lai K, Eldredge RS, et al. Preoperative metal allergy testing for pectus excavatum repair does not effectively identify patients who develop metal bar allergy. J Pediatr Surg, 2024, 59(5): 956-961.
15.	徐冰, 劉文英. 漏斗胸Nuss術后切口反應21例分析. 中華小兒外科雜志, 2015, 36(11): 863-865.Xu B, Liu WY. Incision reaction after Nuss procedure in 21 patients. Chin J Pediatr Surg, 2015, 36(11): 863-865.
16.	Huerta CT, Alligood DM, Davis JK, et al. Outcomes after pectus excavatum repair: a nationwide comparison of Nuss versus Ravitch operations. J Surg Res, 2024, 303: 381-389.
17.	周天駿, 田單, 施瑞卿, 等. 交叉鋼板技術在漏斗胸矯形手術中的應用. 中國胸心血管外科臨床雜志, 2025, 32(11): 1572-1578.Zhou TJ, Tian D, Shi RQ, et al. Application of the cross-bar technique in the correction of pectus excavatum. Chin J Clin Thorac Cardiovasc Surg, 2025, 32(11): 1572-1578.
18.	Difiore JW, Heitsman CG, Robertson JO. Parks bridging bar pectus procedure: techniques to optimize functional and aesthetic results in 72 cases. J Pediatr Surg, 2025: 162661.
19.	van Braak H, de Beer SA, Al Ghouch Y, et al. 15 years of vacuum bell therapy for pectus excavatum: long-term outcomes and influencing factors. J Pediatr Surg, 2025, 60(2): 161891.
20.	扶劍, 吳春, 李勇剛, 等. 負壓吸盤在低齡漏斗胸患兒中的初步應用. 中國胸心血管外科臨床雜志, 2025, 32(11): 1610-1614.Fu J, Wu C, Li YG, et al. Preliminary application of vacuum bell therapy in young children with pectus excavatum. Chin J Clin Thorac Cardiovasc Surg, 2025, 32(11): 1610-1614.
21.	Wang W, Wang W, Long W, et al. Experience of the Wang procedure in treating pectus excavatum in two hundred fifty-six paediatric patients. Int Orthop, 2022, 46(10): 2307-2313.
22.	田東, 鄧志強, 林浩楠, 等. 經皮懸吊拉鉤輔助漏斗胸矯治術的臨床應用及技術優勢. 中國胸心血管外科臨床雜志, 2024, 31(2): 234-239.Tian D, Deng ZQ, Lin HN, et al. Clinical application and technical advantages of percutaneous suspension retractor-assisted pectus excavatum repair. Chin J Clin Thorac Cardiovasc Surg, 2024, 31(2): 234-239.
23.	Masai K, Okubo Y, Kaseda K, et al. Combined Ravitch and Nuss procedure for patients with severe pectus excavatum: technique and initial results. J Surg Case Rep, 2023, 2023(10): rjad571.
24.	謝曉, 梅舉, 李國慶, 等. 免翻轉鋼板矯治成人復發性漏斗胸的臨床研究. 中國胸心血管外科臨床雜志, 2021, 28(10): 1212-1215.Xie X, Mei J, Li GQ, et al. Clinical study of a non-turnover bar for correction of recurrent pectus excavatum in adults. Chin J Clin Thorac Cardiovasc Surg, 2021, 28(10): 1212-1215.
25.	Rocco R, Morris J, Wentworth A, et al. Customized three-dimensional printed Nuss bar molds for repair of pectus excavatum. Ann Thorac Surg Short Rep, 2023, 1(4): 713-717.
26.	Obermeyer RJ, Cohen NS, Gaffar S, et al. Multivariate analysis of risk factors for Nuss bar infections: a single center study. J Pediatr Surg, 2018, 53(6): 1226-1229.
27.	Rushing GD, Goretsky MJ, Gustin T, et al. When it is not an infection: metal allergy after the Nuss procedure for repair of pectus excavatum. J Pediatr Surg, 2007, 42(1): 93-97.
28.	劉一為, 劉彩霞. 漏斗胸微創Nuss矯治術后金屬過敏反應的研究進展. 中華小兒外科雜志, 2023, 44(4): 366-370.Liu YW, Liu CX. Research progress on postoperative metal allergy after the minimally invasive Nuss procedure for pectus excavatum. Chin J Pediatr Surg, 2023, 44(4): 366-370.
29.	Shah B, Cohee A, Deyerle A, et al. High rates of metal allergy amongst Nuss procedure patients dictate broader pre-operative testing. J Pediatr Surg, 2014, 49(3): 451-454.
30.	Cruz-Centeno N, Fraser JA, Stewart S, et al. Determining the optimal technique for bar fixation in the repair of pectus excavatum. J Laparoendosc Adv Surg Tech A, 2024, 34(4): 368-370.
31.	Nonnemacher C, Elman M, Saylors S, et al. Minimally invasive repair of pectus excavatum without stabilizers does not result in increased bar displacement or other postoperative complications. J Laparoendosc Adv Surg Tech A, 2025, 35(7): 570-573.
32.	Weinhandl AC, Ermerak NO, Yüksel M, et al. 'Short bars crossed' to remodel the entire chest wall in children and adolescents with pectus excavatum. J Pediatr Surg, 2024, 59(10): 161590.
33.	de Vivo A, Mancuso A, Giacobbe A, et al. Wound length and corticosteroid administration as risk factors for surgical-site complications following cesarean section. Acta Obstet Gynecol Scand, 2010, 89(3): 355-359.
34.	Skrzypczak PJ, Rozmiarek M, Dobiecki T, et al. A large single-center propensity score-matched cohort study on outcomes and complications based on the number of corrective bars used in the Nuss procedure. Sci Rep, 2024, 14(1): 28285.
35.	Laven IEWG, Franssen AJPM, van Dijk DPJ, et al. A no-chest-drain policy after video-assisted thoracoscopic surgery wedge resection in selected patients: our 12-year experience. Ann Thorac Surg, 2023, 115(4): 835-843.
36.	Rai RH, Fiza M, Saher T, et al. Synergistic effects of physiotherapy and diaphragmatic stretching in post-tuberculosis pleural effusion management: a case report. J Bodyw Mov Ther, 2025, 43: 210-213.
37.	Yan K, Chu L, Zhang Z, et al. Comparative study of total thoracoscopic and traditional incision internal fixation for the treatment of multiple rib fractures. Eur J Trauma Emerg Surg, 2025, 51(1): 339.
38.	Liu G, Dong P, Hu H, et al. Modified 2-cm super single port vs. the traditional 3-cm single port for video-assisted thoracoscopic surgery lobectomy. Surg Today, 2021, 51(11): 1805-1812.
39.	張雪偉, 張亮, 吳積民, 等. 小切口闌尾炎切除術在治療闌尾炎中的臨床效果. 系統醫學, 2024, 9(5): 135-138.Zhang XW, Zhang L, Wu JM, et al. Clinical efficacy of small-incision appendectomy in the treatment of appendicitis. Syst Med, 2024, 9(5): 135-138.
40.	Chiu MZ, Li R, Koka A, et al. Pain management after pediatric minimally invasive repair of pectus excavatum: a narrative review. Transl Pediatr, 2024, 13(12): 2267-2281.
41.	石翔, 趙杰, 李文壯. 單孔胸腔鏡手術在肺結節臨床治療中的應用價值. 世界復合醫學, 2023, 9(11): 181-183.Shi X, Zhao J, Li WZ. Application value of single-port thoracoscopic surgery in the clinical treatment of pulmonary nodules. World J Complex Med, 2023, 9(11): 181-183.
42.	Zheng W, Wang P, Cao Z. Clinical study on the role of modified chest drainage tube in enhanced recovery after uniportal VATS radical surgery for lung cancer. BMC Pulm Med, 2025, 25(1): 369.

1. Westphal FL, Lima LC, Lima NJ, et al. Prevalence of pectus carinatum and pectus excavatum in students in the city of Manaus, Brazil. J Bras Pneumol, 2009, 35(3): 221-226.
2. Zou X, Lin Y, Jin H, et al. Screening for pectus excavatum among primary students and establishment of a pectus excavatum screening program in Dongguan, China. J Thorac Dis, 2015, 7(5): 868-874.
3. Coskun ZK, Turgut HB, Demirsoy S, et al. The prevalence and effects of pectus excavatum and pectus carinatum on the respiratory function in children between 7-14 years old. Indian J Pediatr, 2010, 77(9): 1017-1019.
4. Nuss D, Kelly RE Jr, Croitoru DP, et al. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg, 1998, 33(4): 545-552.
5. Protopapas AD, Athanasiou T. Peri-operative data on the Nuss procedure in children with pectus excavatum: independent survey of the first 20 years' data. J Cardiothorac Surg, 2008, 3(1): 40.
6. 徐芬, 周成偉, 毛勇, 等. 胸腔鏡輔助下微創漏斗胸矯形術治療小兒先天性漏斗胸切口愈合情況及危險因素分析. 中國婦幼保健, 2021, 36(8): 1930-1933.Xu F, Zhou CW, Mao Y, et al. Analysis of incision healing and risk factors for pediatric congenital pectus excavatum after minimally invasive repair. Matern Child Health Care China, 2021, 36(8): 1930-1933.
7. 喬貴賓, 莫緒明, 曾騏. 漏斗胸外科治療中國專家共識. 中華小兒外科雜志, 2020, 41(1): 7-12.Qiao GB, Mo XM, Zeng Q. Chinese expert consensus on surgical treatment for pectus excavatum. Chin J Pediatr Surg, 2020, 41(1): 7-12.
8. 劉文英. 關于漏斗胸手術治療的若干問題. 臨床小兒外科雜志, 2016, 15(2): 110-113.Liu WY. Several issues concerning the surgical treatment of pectus excavatum. J Clin Pediatr Surg, 2016, 15(2): 110-113.
9. Kelly RE Jr, Obermeyer RJ, Goretsky MJ, et al. Recent modifications of the Nuss procedure: the pursuit of safety during the minimally invasive repair of pectus excavatum. Ann Surg, 2022, 275(2): e496-e502.
10. Abid I, Ewais MM, Marranca J, et al. Pectus excavatum: a review of diagnosis and current treatment options. J Am Osteopath Assoc, 2017, 117(2): 106-113.
11. Rshaidat H, Gorgov E, Collins ML, et al. Complication rate of the Nuss procedure in adults and pediatric patients: national database analysis. Ann Thorac Surg Short Rep, 2024, 2(3): 364-368.
12. Obermeyer RJ, Godbout E, Goretsky MJ, et al. Risk factors and management of Nuss bar infections in 1717 patients over 25 years. J Pediatr Surg, 2016, 51(1): 154-158.
13. Pio L, Carlucci M, Leonelli L, et al. Minimally invasive repair of pectus excavatum without bar stabilizers using Endo Close. J Laparoendosc Adv Surg Tech A, 2016, 26(2): 148-152.
14. Ochoa B, Lai K, Eldredge RS, et al. Preoperative metal allergy testing for pectus excavatum repair does not effectively identify patients who develop metal bar allergy. J Pediatr Surg, 2024, 59(5): 956-961.
15. 徐冰, 劉文英. 漏斗胸Nuss術后切口反應21例分析. 中華小兒外科雜志, 2015, 36(11): 863-865.Xu B, Liu WY. Incision reaction after Nuss procedure in 21 patients. Chin J Pediatr Surg, 2015, 36(11): 863-865.
16. Huerta CT, Alligood DM, Davis JK, et al. Outcomes after pectus excavatum repair: a nationwide comparison of Nuss versus Ravitch operations. J Surg Res, 2024, 303: 381-389.
17. 周天駿, 田單, 施瑞卿, 等. 交叉鋼板技術在漏斗胸矯形手術中的應用. 中國胸心血管外科臨床雜志, 2025, 32(11): 1572-1578.Zhou TJ, Tian D, Shi RQ, et al. Application of the cross-bar technique in the correction of pectus excavatum. Chin J Clin Thorac Cardiovasc Surg, 2025, 32(11): 1572-1578.
18. Difiore JW, Heitsman CG, Robertson JO. Parks bridging bar pectus procedure: techniques to optimize functional and aesthetic results in 72 cases. J Pediatr Surg, 2025: 162661.
19. van Braak H, de Beer SA, Al Ghouch Y, et al. 15 years of vacuum bell therapy for pectus excavatum: long-term outcomes and influencing factors. J Pediatr Surg, 2025, 60(2): 161891.
20. 扶劍, 吳春, 李勇剛, 等. 負壓吸盤在低齡漏斗胸患兒中的初步應用. 中國胸心血管外科臨床雜志, 2025, 32(11): 1610-1614.Fu J, Wu C, Li YG, et al. Preliminary application of vacuum bell therapy in young children with pectus excavatum. Chin J Clin Thorac Cardiovasc Surg, 2025, 32(11): 1610-1614.
21. Wang W, Wang W, Long W, et al. Experience of the Wang procedure in treating pectus excavatum in two hundred fifty-six paediatric patients. Int Orthop, 2022, 46(10): 2307-2313.
22. 田東, 鄧志強, 林浩楠, 等. 經皮懸吊拉鉤輔助漏斗胸矯治術的臨床應用及技術優勢. 中國胸心血管外科臨床雜志, 2024, 31(2): 234-239.Tian D, Deng ZQ, Lin HN, et al. Clinical application and technical advantages of percutaneous suspension retractor-assisted pectus excavatum repair. Chin J Clin Thorac Cardiovasc Surg, 2024, 31(2): 234-239.
23. Masai K, Okubo Y, Kaseda K, et al. Combined Ravitch and Nuss procedure for patients with severe pectus excavatum: technique and initial results. J Surg Case Rep, 2023, 2023(10): rjad571.
24. 謝曉, 梅舉, 李國慶, 等. 免翻轉鋼板矯治成人復發性漏斗胸的臨床研究. 中國胸心血管外科臨床雜志, 2021, 28(10): 1212-1215.Xie X, Mei J, Li GQ, et al. Clinical study of a non-turnover bar for correction of recurrent pectus excavatum in adults. Chin J Clin Thorac Cardiovasc Surg, 2021, 28(10): 1212-1215.
25. Rocco R, Morris J, Wentworth A, et al. Customized three-dimensional printed Nuss bar molds for repair of pectus excavatum. Ann Thorac Surg Short Rep, 2023, 1(4): 713-717.
26. Obermeyer RJ, Cohen NS, Gaffar S, et al. Multivariate analysis of risk factors for Nuss bar infections: a single center study. J Pediatr Surg, 2018, 53(6): 1226-1229.
27. Rushing GD, Goretsky MJ, Gustin T, et al. When it is not an infection: metal allergy after the Nuss procedure for repair of pectus excavatum. J Pediatr Surg, 2007, 42(1): 93-97.
28. 劉一為, 劉彩霞. 漏斗胸微創Nuss矯治術后金屬過敏反應的研究進展. 中華小兒外科雜志, 2023, 44(4): 366-370.Liu YW, Liu CX. Research progress on postoperative metal allergy after the minimally invasive Nuss procedure for pectus excavatum. Chin J Pediatr Surg, 2023, 44(4): 366-370.
29. Shah B, Cohee A, Deyerle A, et al. High rates of metal allergy amongst Nuss procedure patients dictate broader pre-operative testing. J Pediatr Surg, 2014, 49(3): 451-454.
30. Cruz-Centeno N, Fraser JA, Stewart S, et al. Determining the optimal technique for bar fixation in the repair of pectus excavatum. J Laparoendosc Adv Surg Tech A, 2024, 34(4): 368-370.
31. Nonnemacher C, Elman M, Saylors S, et al. Minimally invasive repair of pectus excavatum without stabilizers does not result in increased bar displacement or other postoperative complications. J Laparoendosc Adv Surg Tech A, 2025, 35(7): 570-573.
32. Weinhandl AC, Ermerak NO, Yüksel M, et al. 'Short bars crossed' to remodel the entire chest wall in children and adolescents with pectus excavatum. J Pediatr Surg, 2024, 59(10): 161590.
33. de Vivo A, Mancuso A, Giacobbe A, et al. Wound length and corticosteroid administration as risk factors for surgical-site complications following cesarean section. Acta Obstet Gynecol Scand, 2010, 89(3): 355-359.
34. Skrzypczak PJ, Rozmiarek M, Dobiecki T, et al. A large single-center propensity score-matched cohort study on outcomes and complications based on the number of corrective bars used in the Nuss procedure. Sci Rep, 2024, 14(1): 28285.
35. Laven IEWG, Franssen AJPM, van Dijk DPJ, et al. A no-chest-drain policy after video-assisted thoracoscopic surgery wedge resection in selected patients: our 12-year experience. Ann Thorac Surg, 2023, 115(4): 835-843.
36. Rai RH, Fiza M, Saher T, et al. Synergistic effects of physiotherapy and diaphragmatic stretching in post-tuberculosis pleural effusion management: a case report. J Bodyw Mov Ther, 2025, 43: 210-213.
37. Yan K, Chu L, Zhang Z, et al. Comparative study of total thoracoscopic and traditional incision internal fixation for the treatment of multiple rib fractures. Eur J Trauma Emerg Surg, 2025, 51(1): 339.
38. Liu G, Dong P, Hu H, et al. Modified 2-cm super single port vs. the traditional 3-cm single port for video-assisted thoracoscopic surgery lobectomy. Surg Today, 2021, 51(11): 1805-1812.
39. 張雪偉, 張亮, 吳積民, 等. 小切口闌尾炎切除術在治療闌尾炎中的臨床效果. 系統醫學, 2024, 9(5): 135-138.Zhang XW, Zhang L, Wu JM, et al. Clinical efficacy of small-incision appendectomy in the treatment of appendicitis. Syst Med, 2024, 9(5): 135-138.
40. Chiu MZ, Li R, Koka A, et al. Pain management after pediatric minimally invasive repair of pectus excavatum: a narrative review. Transl Pediatr, 2024, 13(12): 2267-2281.
41. 石翔, 趙杰, 李文壯. 單孔胸腔鏡手術在肺結節臨床治療中的應用價值. 世界復合醫學, 2023, 9(11): 181-183.Shi X, Zhao J, Li WZ. Application value of single-port thoracoscopic surgery in the clinical treatment of pulmonary nodules. World J Complex Med, 2023, 9(11): 181-183.
42. Zheng W, Wang P, Cao Z. Clinical study on the role of modified chest drainage tube in enhanced recovery after uniportal VATS radical surgery for lung cancer. BMC Pulm Med, 2025, 25(1): 369.

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Latest ArticlesApplication of an ultra-minimally invasive incision in reducing incision complications after the Nuss procedure for pectus excavatum

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