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724 Cases with the Submuscular Nuss Procedure; Safe & Secure

Yashushi Kasagi, Machiko Saito, Akihiro Matsuoka, Hideo Teraoka

Matsuyama Cardiovascular Medical Center, Matsuyama, Japan


Purpose: Nuss’s MIRPE is a superior operative procedure in releasing compression upon the heart and lung.  However, as found in Nuss's earlier literature, the bar displacement occurred at a high rate (6.8%).  Thus, we have developed submuscular MIRPE.

Review: Skin incision was made at the both sides of the chest, or infero-laterally around the areolas in a semi-circular manner. By peeling off the pectoralis and serratus anterior muscles under the muscles, the intercostal muscle was resected to open the chest.  The anterior mediastinal tissue was dissected by using the operator’s 3rd finger in the bilateral pleural space.  A bar for elevation was led to the intercostal space, connecting it to an engine jack by a shackle for yacht, chains and a carabiner for rock climbing, and the anterior chest wall was elevated, causing the bilateral sternum-cartilage joint and cartilage-rib connection to fracture.  In every case since 2013, at least two bars have been used.  Another bar was inserted for rib elevation by resecting the inferior intercostal muscles. The anterior chest wall was elevated similarly.  A pre-bent bar, inserted into the inferior inter-costal space, turned by 180 degrees and inserted under the muscle layer, was fixated to the two bilateral ribs by ligation, and so was the other upper bar.  3 bars were used for some severe depression cases.

Results: No post-operative bar displacement was observed among 739 cases (July 2000 – Feb. 2016).  The bars have been removed after more than 1.5 postoperative years for children and 3 years for adults.  There was no recurrent depression after bar removal.  We performed 52 re-operations by submuscular MIRPE.  Areola incision was employed for 56 cases with severe depression in the upper chest.

Conclusion: Good post-operative shape was achieved while no postoperative bar displacement was observed. Submuscular MIRPE is a well recommended procedure.