How to dissect the retroesternal tunnel in Minimally Invasive Repair of Pectus Excavatum (MIRPE)?
Miguel Tedde
Thoracic and Pectus Surgeon at Instituto do Coracao (InCor) Universidade de Sao Paulo / Sabara Hospital Infantil
The most critical time to perform MIRPE is the creation of the retrosternal tunnel. The literature reports several cases of cardiac perforation during this time. In my opinion, there are two main reasons for this.
The first is that many colleagues dissect the tunnel using the thoracic introducer. This instrument measures 58 cm and acts as a lever, it is dangerous in itself. Since pectus is not operated on every day, it is very difficult to gain expertise with this instrument. In my opinion, the thoracic introducer should be retired, and this proposal is published. You can find the publication here:
The second reason is to dissect the retrosternal tunnel from the right to the left side. It is important to remember that in cases of pectus, the heart is deviated to the left side. Therefore, dissection from right to left side causes the instrument to come against the heart. Because of this, we proposed that the retrosternal tunnel be dissected from the left to the right using regular instruments, usual for the surgeon. The series of cases in which this proposal was based is published here:
Certainly, performing the Crane maneuver minimizes the chance of cardiac injury, but even with Crane I consider that not using the introducer and performing the dissection from left to right makes MIRPE safer.
Chest Wall Surgery Specialist
1moThis is indeed an very important experience, Dear Porf. Miguel.