Application of the simplified sternal elevation technique in the Nuss procedure for severe pectus excavatum: A case report_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZENG Zhongyi ^1,2,3 , LIN Haonan ^1,2,3 , SUN Haipeng ^1,3 , GUO Hai ^1,2,3 , ZHANG Jiani ^1,2,3 , LAI Xiaoqin ^1,2,3 ,  LIN Feng ^1,2,3

1. Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;
2. Department of Thoracic Surgery, West China Tianfu Hospital, Sichuan University, Chengdu, 610213, P. R. China;
3. Department of Chest Wall Diseases Center, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;

Corresponding author：

LIN Feng, Email: linfeng0220@aliyun.com

Keywords：

Nuss procedure; sternal elevation technique; pectus excavatum; case report

DOI：

10.7507/1007-4848.202502046

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Pectus excavatum is the most common chest wall deformity. Severe pectus excavatum can significantly impact both the physiological and psychological health of patients, necessitating timely therapeutic intervention. The Nuss procedure is currently the preferred surgical approach for treating moderate to severe pectus excavatum. However, in cases of severe pectus excavatum, the placement of the corrective steel bar through the anterior mediastinum poses a substantial risk of injury to the heart, major blood vessels, and lung tissue. This article reports a case of a 17-year-old patient with severe pectus excavatum combined with Marfan syndrome. CT examination revealed a Haller index of 14.07, with severe sternal depression leading to significant narrowing of the anterior mediastinal space and complete displacement of the heart into the left thoracic cavity, resulting in an extremely high surgical risk. We employed a simplified sternal elevation technique in conjunction with the Nuss procedure for treatment. During the operation, a sternal retractor was used to elevate the sternum, thereby enlarging the retrosternal space and facilitating the successful completion of the Nuss procedure. This approach effectively avoided damage to the heart and major blood vessels, resulted in no surgical complications, and achieved a satisfactory corrective outcome.

1.	Koumbourlis AC. Pectus excavatum: Pathophysiology and clinical characteristics. Paediatr Respir Rev, 2009, 10(1): 3-6.
2.	Janssen N, Coorens NA, Franssen A, et al. Pectus excavatum and carinatum: A narrative review of epidemiology, etiopathogenesis, clinical features, and classification. J Thorac Dis, 2024, 16(2): 1687-1701.
3.	Li H, Wang F, Ji G, et al. Modified Nuss procedure for the treatment of pectus excavatum: Experience of 259 patients. Asian J Surg, 2023, 46(2): 692-697.
4.	Ciriaco P. Surgical treatment of pectus excavatum: The boundary between pathologic and aesthetic need. J Clin Med, 2025, 14(1): 231.
5.	Walsh J, Walsh R, Redmond K. Systematic review of physiological and psychological outcomes of surgery for pectus excavatum supporting commissioning of service in the UK. BMJ Open Respir Res, 2023, 10(1): e001665.
6.	Krasopoulos G, Dusmet M, Ladas G, et al. Nuss procedure improves the quality of life in young male adults with pectus excavatum deformity. Eur J Cardiothorac Surg, 2006, 29(1): 1-5.
7.	Hadolt B, Wallisch A, Egger JW, et al. Body-image, self-concept and mental exposure in patients with pectus excavatum. Pediatr Surg Int, 2011, 27(6): 665-670.
8.	商宏伟, 李强. 漏斗胸外科治疗进展. 中国胸心血管外科临床杂志, 2021, 28(9): 1119-1124.Shang HW, LI Q. Progress in surgical treatment of pectus excavatum, Chin J Clin Thorac Cardiovasc Surg, 2021, 28(9): 1119-1124.
9.	Chu CC, Chang JW, Yang HH, et al. Outcomes of the Nuss procedure in children with pectus excavatum: 14 years of experience. J Chin Med Assoc, 2024, 87(3): 314-319.
10.	Beati F, Frediani S, Pardi V, et al. Case report-every thoracic surgeon's nightmare: Cardiac and lung perforation during placement of Nuss bar for pectus excavatum. Front Pediatr, 2023, 11: 1241273.
11.	Kim DY, Jeong JY. Penetrating lung injury during Nuss procedure for pectus excavatum. J Cardiothorac Surg, 2020, 15(1): 184.
12.	Senica SO, Gasparella P, Soldatenkova K, et al. Cardiac perforation during minimally invasive repair of pectus excavatum: A rare complication. J Surg Case Rep, 2022, 2022(11): rjac538.
13.	Hebra A, Kelly RE, Ferro MM, et al. Life-threatening complications and mortality of minimally invasive pectus surgery. J Pediatr Surg, 2018, 53(4): 728-732.
14.	Sun H, Huang Y, Han Y, et al. Perioperative outcomes of thoracoscopic versus non-thoracoscopic minimally invasive repair of pectus excavatum: A systematic review and meta-analysis. J Cardiothorac Surg, 2024, 19(1): 603.
15.	Aughtman S, Hehman C, Janssen L, et al. Vacuum Bell therapy for pectus excavatum: Long-term experience at a single center. J Pediatr Surg, 2025, 60(3): 162020.
16.	Pawlak K, Gąsiorowski Ł, Gabryel P, et al. Video-assisted-thoracoscopic surgery in left-to-right Nuss procedure for pectus excavatum for prevention of serious complications: Technical aspects based on 1006 patients. Wideochir Inne Tech Maloinwazyjne, 2018, 13(1): 95-101.
17.	Haecker FM, Krebs T, Kocher GJ, et al. Sternal elevation techniques during the minimally invasive repair of pectus excavatum. Interact Cardiovasc Thorac Surg, 2019, 29(4): 497-502.
18.	Park HJ, Kim KS, Lee S, et al. A next-generation pectus excavatum repair technique: New devices make a difference. Ann Thorac Surg, 2015, 99(2): 455-461.
19.	Park HJ, Rim G, Yoon SK. Crane-powered pectus excavatum repair: The NeoPectus surgery. Front Surg, 2023, 10: 1267009.
20.	Rygl M, Vyhnanek M, Kucera A, et al. Technical innovation in minimally invasive repair of pectus excavatum. Pediatr Surg Int, 2014, 30(1): 113-117.
21.	Tedde ML, de Campos JR, Wihlm JM, et al. The Nuss procedure made safer: An effective and simple sternal elevation manoeuvre. Eur J Cardiothorac Surg, 2012, 42(5): 890-891.

1. Koumbourlis AC. Pectus excavatum: Pathophysiology and clinical characteristics. Paediatr Respir Rev, 2009, 10(1): 3-6.
2. Janssen N, Coorens NA, Franssen A, et al. Pectus excavatum and carinatum: A narrative review of epidemiology, etiopathogenesis, clinical features, and classification. J Thorac Dis, 2024, 16(2): 1687-1701.
3. Li H, Wang F, Ji G, et al. Modified Nuss procedure for the treatment of pectus excavatum: Experience of 259 patients. Asian J Surg, 2023, 46(2): 692-697.
4. Ciriaco P. Surgical treatment of pectus excavatum: The boundary between pathologic and aesthetic need. J Clin Med, 2025, 14(1): 231.
5. Walsh J, Walsh R, Redmond K. Systematic review of physiological and psychological outcomes of surgery for pectus excavatum supporting commissioning of service in the UK. BMJ Open Respir Res, 2023, 10(1): e001665.
6. Krasopoulos G, Dusmet M, Ladas G, et al. Nuss procedure improves the quality of life in young male adults with pectus excavatum deformity. Eur J Cardiothorac Surg, 2006, 29(1): 1-5.
7. Hadolt B, Wallisch A, Egger JW, et al. Body-image, self-concept and mental exposure in patients with pectus excavatum. Pediatr Surg Int, 2011, 27(6): 665-670.
8. 商宏伟, 李强. 漏斗胸外科治疗进展. 中国胸心血管外科临床杂志, 2021, 28(9): 1119-1124.Shang HW, LI Q. Progress in surgical treatment of pectus excavatum, Chin J Clin Thorac Cardiovasc Surg, 2021, 28(9): 1119-1124.
9. Chu CC, Chang JW, Yang HH, et al. Outcomes of the Nuss procedure in children with pectus excavatum: 14 years of experience. J Chin Med Assoc, 2024, 87(3): 314-319.
10. Beati F, Frediani S, Pardi V, et al. Case report-every thoracic surgeon's nightmare: Cardiac and lung perforation during placement of Nuss bar for pectus excavatum. Front Pediatr, 2023, 11: 1241273.
11. Kim DY, Jeong JY. Penetrating lung injury during Nuss procedure for pectus excavatum. J Cardiothorac Surg, 2020, 15(1): 184.
12. Senica SO, Gasparella P, Soldatenkova K, et al. Cardiac perforation during minimally invasive repair of pectus excavatum: A rare complication. J Surg Case Rep, 2022, 2022(11): rjac538.
13. Hebra A, Kelly RE, Ferro MM, et al. Life-threatening complications and mortality of minimally invasive pectus surgery. J Pediatr Surg, 2018, 53(4): 728-732.
14. Sun H, Huang Y, Han Y, et al. Perioperative outcomes of thoracoscopic versus non-thoracoscopic minimally invasive repair of pectus excavatum: A systematic review and meta-analysis. J Cardiothorac Surg, 2024, 19(1): 603.
15. Aughtman S, Hehman C, Janssen L, et al. Vacuum Bell therapy for pectus excavatum: Long-term experience at a single center. J Pediatr Surg, 2025, 60(3): 162020.
16. Pawlak K, Gąsiorowski Ł, Gabryel P, et al. Video-assisted-thoracoscopic surgery in left-to-right Nuss procedure for pectus excavatum for prevention of serious complications: Technical aspects based on 1006 patients. Wideochir Inne Tech Maloinwazyjne, 2018, 13(1): 95-101.
17. Haecker FM, Krebs T, Kocher GJ, et al. Sternal elevation techniques during the minimally invasive repair of pectus excavatum. Interact Cardiovasc Thorac Surg, 2019, 29(4): 497-502.
18. Park HJ, Kim KS, Lee S, et al. A next-generation pectus excavatum repair technique: New devices make a difference. Ann Thorac Surg, 2015, 99(2): 455-461.
19. Park HJ, Rim G, Yoon SK. Crane-powered pectus excavatum repair: The NeoPectus surgery. Front Surg, 2023, 10: 1267009.
20. Rygl M, Vyhnanek M, Kucera A, et al. Technical innovation in minimally invasive repair of pectus excavatum. Pediatr Surg Int, 2014, 30(1): 113-117.
21. Tedde ML, de Campos JR, Wihlm JM, et al. The Nuss procedure made safer: An effective and simple sternal elevation manoeuvre. Eur J Cardiothorac Surg, 2012, 42(5): 890-891.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

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