The current role of video-assisted thoracoscopy in managing pectus excavatum in pediatric patients: a narrative review

Background and Objective: Minimally invasive repair of pectus excavatum (MIRPE) has undergone significant technical evolution to improve safety and perioperative outcomes. Thoracoscopy has emerged as a key adjunct, enabling direct visualization during retrosternal dissection and facilitating additional innovations such as intercostal nerve cryoablation (INC). However, variability in its application and unclear impact on outcomes necessitate a focused evaluation. This narrative review aims to critically assess the role of thoracoscopy in enhancing procedural safety and its role in the expansion of multimodal pain management strategies in pediatric patients.

Methods: A literature search was conducted in PubMed for English-language studies published from January 1998 through December 2025. Search terms included “pectus excavatum”, “MIRPE”, “Nuss procedure”, “thoracoscopy”, “cryoablation”, “enhanced recovery after surgery (ERAS)”, and “children”.

Key Content and Findings: Thoracoscopy provides direct visualization during retrosternal dissection and bar placement, contributing to improved intraoperative safety, particularly in complex or severe deformities. While large database studies show comparable overall complication rates between thoracoscopic and non-thoracoscopic approaches, more recent analyses suggest reduced specific complications with thoracoscopic guidance. In addition, thoracoscopy has enabled the widespread adoption of INC, which is associated with decreased opioid use, shorter hospital stay, and improved postoperative recovery. Adjunct techniques such as sternal elevation and bilateral visualization may further optimize safety in select patients.

Conclusions: Thoracoscopy plays a central role in modern MIRPE by improving intraoperative visualization and enabling advanced adjuncts, particularly cryoablation for pain control. Its integration with complementary techniques, such as sternal elevation, can optimize patient outcomes. Ongoing standardization and higher-quality comparative studies are needed to define its routine versus selective use.