Extension of the minimally invasive pectus repair to adult patients: strategies for success

Pectus excavatum (PE) is the most common congenital deformity of the anterior chest wall and is increasingly recognized as a clinically relevant condition in adult patients. While minimally invasive repair of pectus excavatum (MIRPE) is well established in pediatric and adolescent populations, early attempts to apply this technique in adults were associated with higher complication rates. These challenges were largely attributed to increased chest wall rigidity, more severe and asymmetric deformities, and greater mechanical forces acting on intrathoracic support bars. Over the past two decades, however, progressive refinements in surgical technique, bar stabilization, and perioperative management have enabled the safe expansion of MIRPE to adult populations. This review summarizes the contemporary literature on MIRPE in adults, focusing on patient selection, technical considerations, perioperative strategies, and reported outcomes. Adult MIRPE presents distinct technical challenges and frequently requires modifications such as routine thoracoscopic guidance, forced sternal elevation, reinforcement of intercostal spaces, use of multiple bars, cross-bar configurations, and enhanced bar fixation techniques to achieve durable correction. These technical adaptations have contributed to reductions in bar displacement, recurrence, and major complications in more recent series. Postoperative pain management remains a critical component of adult repair, and the adoption of multimodal analgesic protocols, including intercostal nerve cryoablation, has been associated with reduced opioid requirements and shorter hospital length of stay. Contemporary reports from experienced, high-volume centers demonstrate consistent improvements in patient-reported quality of life (QoL), symptom burden, and cosmetic satisfaction following adult MIRPE. Improvements in cardiopulmonary function have been described in selected patients, particularly when complete anatomic correction is achieved, although objective physiologic benefits remain variable across studies. Adult MIRPE is technically demanding, and outcomes appear closely linked to surgeon experience and institutional volume. With careful patient selection and modern surgical strategies, MIRPE can be performed safely and effectively in adult patients, including those over 30 years of age. Further prospective studies focused on adult populations are needed to better define long-term outcomes and durability following bar removal.