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

Introduction

Background

Pectus excavatum (PE), characterized by an inward depression of the sternum, is the most common deformity of the chest wall, with an incidence rate of 8 per 1,000 live births (1). Historically, this sternal defect was treated with the Ravitch procedure, which involved sternal osteotomy and subperichondrial cartilage resection (2). In 1998, Donald Nuss introduced minimally invasive repair of pectus excavatum (MIRPE), which revolutionized the management of this condition and has since become the standard of care (3). The procedure is based on the idea that cartilage is malleable, and reconfiguration of the chest wall can be achieved by applying force with a convex metal bar placed beneath the sternum (4).

A key innovation in the technique was the adoption of thoracoscopy to guide retrosternal dissection and bar placement under direct vision. Video-assisted thoracoscopic surgery (VATS) for PE repair is now performed by about 85% of surgeons performing MIRPE in the United States (5,6). Additionally, various strategies have been proposed to manage postoperative pain. Although less invasive than the Ravitch procedure, MIRPE is still associated with significant postoperative pain due to the tension exerted by the metal bar on cartilage, ribs, muscles, and intercostal nerves, which can cause severe chest pain that may persist for weeks or months, often requiring long-term narcotic medication (7). More recently, thoracoscopic-guided intercostal nerve cryoablation (INC) has been added to the multimodal analgesia approach (8,9).

Despite notable improvements in PE repair outcomes, substantial variability exists with a multitude of permutations that have developed on an individual and institutional basis.

Rationale and knowledge gap

Several reviews have described the evolution of minimally invasive techniques for PE repair and their associated outcomes (4,10,11). However, few have specifically focused on the independent contribution of thoracoscopy to procedural safety and perioperative outcomes, particularly in the context of emerging adjuncts such as INC and enhanced recovery pathways. In addition, the available literature presents conflicting findings regarding the impact of thoracoscopic guidance on complication rates, operative time, and overall outcomes (4-6,12).

A comprehensive synthesis that integrates thoracoscopy’s role in both intraoperative safety and postoperative pain management is therefore needed. Clarifying these aspects is essential to guide clinical decision-making, particularly regarding when thoracoscopy and associated adjunct techniques should be routinely employed versus selectively applied.

Objective

This narrative review aims to complement previous reviews by providing an updated, detailed overview of the technical modifications to the original MIRPE technique, emphasizing their relative benefits and drawbacks, with a focus on how thoracoscopy affects patient safety. Additionally, we evaluate the impact of thoracoscopic-assisted INC as part of multimodal pain management strategies. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-2026-1-0011/rc).

Methods

This manuscript is a narrative review, conducted through the study, analysis, and discussion of previously published articles on technical modifications introduced to the original MIRPE technique described by Donald Nuss in 1998 to improve its safety and effectiveness.

The first electronic search using PubMed was conducted on September 10, 2025. A subsequent search was performed on December 30, 2025. The search strategy examined the use of thoracoscopy for the surgical correction and perioperative pain management of PE in pediatric patients and is summarized in Table 1.

The search was limited to English-language articles published between January 1, 1998, and December 30, 2025.

Articles were screened for relevance based on their focus on thoracoscopic techniques, procedural safety, and perioperative pain management strategies in pediatric patients. The reference study list was also reviewed to identify additional relevant publications. Case reports describing rare or life-threatening complications during retrosternal dissection or bar placement were included to further evaluate the impact of thoracoscopy on these adverse events.

Article selection was conducted by the authors, and discrepancies were resolved by consensus. Given the narrative nature of this review, a formal quality assessment of the included studies was not performed. The findings should be interpreted considering potential selection bias and heterogeneity in study design.

Key innovations in MIRPE

The original technique, described by Donald Nuss, involved creating a blind tunnel to pass the bar across the retrosternal space (3). Creating space between the pericardium and the posterior aspect of the sternum is a critical step in MIRPE, especially in cases of severe defects in which the heart is both compressed and displaced to the left. As the use of this method increased worldwide, life-threatening complications were reported (13); the routine use of right thoracoscopy was introduced to improve safety and optimize bar placement (14,15). Most surgeons adopted thoracoscopy; however, evidence suggests there are no significant differences in outcomes between thoracoscopic-assisted and non-thoracoscopic MIRPE (5,6). More recently, thoracoscopic-assisted INC has been integrated and provides an additional modality for multimodal analgesia in MIRPE. This was used in an effort to reduce length of stay (LOS), decrease opioid consumption, and provide durable pain relief after discharge, but the cost-effectiveness of INC is still being evaluated (16). The timeline of the key innovations to MIRPE is summarized in Figure 1.

Figure 1 Timeline of key technical innovations to improve safety and effectiveness of MIRPE. INC, intercostal nerve cryoablation; MIRPE, minimally invasive repair of pectus excavatum; NSQIP-P, National Surgical Quality Improvement Program-Pediatric.

Techniques for retrosternal dissection and bar placement

Right thoracoscopy

The thoracoscopic-assisted MIRPE initially described involved inserting a 3- or 5-mm trocar two interspaces below the right midaxillary skin incision for bar placement (14). The right-sided port entry at the diaphragmatic recess was chosen to improve visualization during dissection, as well as during bar passage and stabilization. However, this low port placement, especially when the diaphragm is elevated, carries a potential risk of diaphragmatic and liver injuries (6,17-22). To mitigate this risk, some advocate positioning the right port above the incision with torso elevation and posterior arm extension, which improves visualization but increases the risk of brachial plexus injury if the arms are overstretched (17,21,23-25). Accordingly, arm abduction to 70°–90° is recommended to minimize nerve injury (17,25,26). Alternative strategies include placing the thoracoscope and introducer through the same incision without compromising visualization (27-29) or positioning the arms alongside the body while inserting the trocar two intercostal spaces cranial to the bar incision (30).

Thoracoscopy may be performed with or without carbon dioxide (CO₂) insufflation. CO₂ insufflation collapses the ipsilateral lung and may eliminate the need for a double-lumen endotracheal tube, reducing operative time and tracheal trauma (31). During capnothorax, insufflation pressures typically range from 4 to 10 mmHg (17,31,32). Although higher pressures improve visualization, pressures above 5 mmHg have been associated with hemodynamic instability, including decreased cardiac index, mean arterial pressure, stroke volume, and left ventricular work index in an animal model (33).

Additionally, after creating the tunnel, positive insufflation pressure may be transferred to the opposite side of the chest, potentially impairing lung ventilation. Given these considerations, it is recommended to keep insufflation pressures at 5 mmHg if ventilation becomes problematic. Risks associated with insufflation pressure are more concerning when the procedure is performed at a younger age. Currently, it is advised that PE repair be performed between the ages of 14 and 15 years (5,7,34). Therefore, an insufflation pressure of 10 mmHg is generally well tolerated in otherwise healthy adolescents.

Furthermore, the thoracoscopic approach has been associated with an increased risk of postoperative capnothorax due to residual entrapped CO₂. The initial reported rate of postoperative capnothorax was 59%; however, most cases resolved spontaneously, and only 2.7% required drainage (14). To reduce this complication at the end of the procedure, before closing the lateral wounds, the residual capnothorax was drained through the insufflation tube, which was cut and placed in a bowl containing saline solution to create a sealed circuit while the anesthesiologist applied 5–6 cmH₂O of positive end-expiratory pressure ventilation (PEEP). PEEP is adjusted until the CO₂ is cleared, as confirmed by the absence of bubbling, and the lung is fully expanded. By evacuating residual CO₂, the rate of capnothorax requiring chest tube placement decreased to 0.4% (35).

Left thoracoscopy

In patients with severe deep sternal depression, the heart, compressed and displaced into the left side of the chest, limits visibility from the right. To overcome this limitation, some surgeons prefer to introduce the thoracoscope from the left side of the patient (23,31,36). Since visualization is affected by the trocar’s position, when using a left thoracoscopic approach, the trocar is best placed along the anterior axillary line in the intercostal space between the second and third ribs (31). Some have also suggested using an endoscopic Kittner introduced through a second trocar placed on the lower part of the left midaxillary skin incision to assist with retrosternal dissection (23).

Bilateral thoracoscopy

Other surgeons perform bilateral thoracoscopy using two 5-mm trocars placed in the intercostal spaces below the midaxillary skin incisions (37-39).

With bilateral thoracoscopy, dissection can be performed with a single dissector by moving from the right to the left or vice versa, while advancing a second dissector from the opposite side until it crosses the mediastinum (37). When the two instruments cross, one dissector is gradually retracted while the introducer is advanced, maintaining continuous contact between the instruments until the introducer emerges from the intercostal entry point. Generally, in bilateral thoracoscopy, surgeons use only one thoracoscope, which is moved to the opposite side when the introducer crosses the midline of the chest (38,40). More recently, bilateral simultaneous thoracoscopy using two endoscopic towers, two 5-mm 30-degree scopes, two insufflation systems, and video monitors has been proposed (39). When the introducer/bar can no longer be seen from the right side, the left camera, already in place, allows visualization of their entry into the chest away from the pericardium (39).

Technical adjuncts

Diagonal mediastinal tunnel under bilateral thoracoscopic guidance

Since the displaced heart can obscure the view during both right- and left-sided thoracoscopy, a diagonal mediastinal tunnel has been proposed (41). Under thoracoscopic guidance, the dissector is introduced through the right incision and advanced obliquely into the mediastinal pleura beneath the upper sternum and caudal to the thymus. Once the tip of the dissector is palpated and visualized under the skin, the scope is moved to the left to assist its exit from the left incision. With anterior mediastinal dissection, there is no need for CO₂ insufflation and one-lung ventilation (41). However, it requires extensive dissection of the anterior mediastinum, which increases operative time and the risks of pleural effusion and pneumothorax.

Sternal elevation technique (SET)

Regardless of which side is used for thoracoscopy, visualizing the chest cavity does not eliminate risks of life-threatening complications (19,21,42-48). Fatal cases of cardiac perforation have been reported even with the use of bilateral thoracoscopy (49,50). Fifteen cases of lung injuries due to port placement, a case of lung entrapment between the bar and the chest wall with persistent air leak, and two cases of lung perforation during bar passage guided by a vascular tape have been reported, despite being performed under thoracoscopic visualization (45,46).

A 2.3% rate of lung parenchymal injury during VATS bar placement has been reported (21).

Cases of pericarditis, pericardial tears, hemopericardium without cardiac perforation, and mammary artery laceration during thoracoscopic bar placement have also been described (14,15,17,22,51,52). The heart can obstruct the view of the introducer and/or the bar crossing the mediastinum. Therefore, several techniques have been proposed to elevate the sternum and facilitate identification of the correct plane of dissection. Among sternal elevation methods, the crane elevator and the Rultract^® retractor are the most commonly used (53-56) (Figure 2A,2B). Transsternal wire sutures, or a bone clamp, are placed through the anterior cortex of the sternum and attached to a retractor device mounted on the left side of the operating table to generate the sternal lift. The sternum is gradually lifted and aligned, allowing the initial correction of the deformity. Forced sternal elevation with the crane or Rultract system can also be achieved using two crossbars and rail clamps mounted on each side of the table. The latest system is considered more stable and provides greater elevation of the deepest part of the sternal depression (57). The crane system reduces sternal depression by 78%, creating space to improve visualization and enable safe passage of the bar (57). It also assists in remodeling the chest wall, eliminating the need to apply force with the bar to lift the chest into the desired position and lowering the risk of stripping the intercostal nerves during bar flipping (55,58,59).

Figure 2 Crane systems used to elevate the sternum to facilitate the retrosternal dissection. (A) Crane retractor device mounted on one side of the operating table. (B) Sternal elevator with two crossbars and rail clamps mounted on both sides of the operating table.

A crane elevation technique includes placing 10- to 15-mm screws, with screw sizes preoperatively selected based on computed tomography (CT) measurements of sternal thickness, with a spiral section to provide better support for the sternum (60). In selected cases when the surgeon wants to use more than one bar to correct the sternal deformity, multiple wires and screws may be used to achieve full elevation of the chest wall (54). Manual sternal elevators have also been used during MIRPE, including the Volkmann bone hook (61), the Langebeck retractor (62), and the horseshoe elevator, which is characterized by a horseshoe shape connecting the handle and the elevator part. Thanks to the shape of the connection part, the curvature of the elevator and the introducer are the same and do not interfere with each other during insertion (63). The elevation of the sternum and the expansion of the retrosternal space depend on the surgeon's individual strength; therefore, this technique results in less consistent results. The application of the sternal elevation system is variable, with some surgeons using it for all cases regardless of defect severity, while others reserve its use for severe sternal depression (Haller index >5.6) (54,57,64,65). The crane sternal pre-lifting method has become an integral part of the procedure at centers using multiple bars (parallel, cross bar, and XI bar) stabilized with bridge plates or multiple bar fixators, including claw fixators and hinge plate fixators (55). The SET may introduce additional complexity and necessitate a dedicated learning curve (64). Additionally, it increases overall procedure time and cost. Although complications are rare, potential risks include sternal bleeding, fractures, and infections (65,66). Use of SET has been associated with a pinpoint perforation of the heart and delayed hemothorax caused by a needle during wire placement (67). A single-institution study found higher rates of pleural effusion and surgical site infections, leading to increased hospital readmissions when SET was used (68). However, other studies did not confirm these findings (64). As an alternative to these sternal elevators, the vacuum bell device has been used more recently to elevate the sternum during MIRPE (66,69). This silicone device, featuring a plexiglass dome, creates negative pressure to lift the sternum and has recently gained acceptance as a first-line treatment for PE in young children in Europe (70).

Subxiphoid incision

A safe way to pass the bar without thoracoscopic assistance can be accomplished using a 3-cm subxiphoid incision (71,72). After locating the xiphoid, manual blunt retrosternal dissection is performed with a finger, as performed to prepare for sternotomy. The finger is then advanced into the extra-pleural retrosternal space until it reaches the desired intercostal space for bar placement (Figure 3A,3B). The finger pointing under the sternum serves as a landmark for the entry point in the corresponding intercostal space on both sides and is marked on the skin. At this stage, two lateral incisions are made 1 inch lateral to the lateral border of the areola. A subcutaneous plane of dissection is then carried out with a large clamp from the lateral incision to the appropriate intercostal space on both sides and popped into the chest onto the internal finger. The introducer is placed under finger guidance from the selected side of the chest until it exits through the subxiphoid incision. This approach ensures the introducer’s tip remains in contact with the posterior aspect of the sternum during this critical passage, keeping it away from the pericardium. The tip of the introducer is then attached to a chest tube or umbilical tape and pulled to exit through the lateral incision. The same process is repeated contralaterally. The chest tube or umbilical tape guides the insertion of the bar. With this method, no major complications have been reported (71,72).

Figure 3 Subxiphoid incision and digital creation of a retrosternal tunnel. (A) A 3-cm vertical incision is made inferior to the sternum to expose the subxiphoid process. (B) The subxiphoid process is dissected and elevated to allow insertion of a finger to create a substernal pocket, gently displacing the pericardium on the left and the pleura bilaterally away from the chest wall. The finger, acting as a protective guide, ensures safe advancement of the dissector/introducer.

Additionally, a technique combining a subxiphoid incision, blunt retrosternal dissection to position the Langenbach retractor, and sternal lift with a crane system, followed by right thoracoscopic retrosternal dissection and bar placement under thoracoscopic guidance, has been described and recommended for patients with severe sternal depression (42,73).

Type of thoracoscope

The type of scope used has not been reported uniformly. Most surgeons use the 30-degree scope, which provides a satisfactory view of the operative field if the port site is properly selected.

Semiflexible fiberoptic thoracoscopes have been proposed, offering optimal visualization from multiple angles through single-site insertion and proving particularly useful in patients with severe deformity or marked cardiac displacement, where the retrosternal space is narrow and rigid scopes may obstruct bar passage (61). A 70-degree scope has been reported to aid wire placement for bar stabilization (31). More recently, a thoracoscope specifically designed for MIRPE—the “Pectoscope”—has been introduced; it features a curved shaft with an integrated camera, enabling direct visualization of the chest wall and heart during dissection without the need for a separate introducer (26,74). Additionally, using a 32F chest tube to guide bar passage across the retrosternal tunnel, instead of umbilical tape, has been shown to reduce off-track advancement and is increasingly adopted (59,75). The thoracoscope can also be passed through the hollow chest tube to inspect retrosternal blind spots and minimize complications, a technique termed pectus tunneloscopy (76).

Effect of different operative techniques on outcomes

Safety profile of technical variations in the Nuss procedure

Thoracoscopic-assisted MIRPE is the most common surgical approach for PE repair (5,6,77). As the use of VATS became more widespread, the overall complication rate decreased and now ranges from 2% to 20%, with an estimated rate of life-threatening complications at 0.1% (32). Most of these serious complications were reported by many surgeons during the learning curve (6,78) (Table 2). Over time, awareness of the potential for severe cardiothoracic complications has led to the development of several technical innovations to make the procedure safer.

However, due to wide variability in operative technique, it is difficult to evaluate which intervention is most effective in reducing complications. Additionally, since some technical modifications lack specific procedural codes, it is not possible to assess their impact using studies based on large database analysis that rely on diagnostic and procedural codes. Since information on the occurrence of cardiothoracic injuries relies on case reports and single-institution experiences, which may be underreported, their true incidence is likely higher, and they can still occur under a thoracoscopic view (48,78).

There are essentially two critical points in the technique where a limited view of the operating field may result in cardiac or other major organ injuries. First, the tip of the dissector creating the plane between the sternum and pericardium may not always be seen, even with bilateral thoracoscopy. Additionally, the view of the exit site through the intercostal muscle is not always clear without using a sternal elevator or, alternatively, digitally confirming it with a subxiphoid dissection/lift (48,71).

Therefore, a combination of multiple technical approaches, including thoracoscopy, SET, and subxiphoid incision, may be necessary in selected cases. Notably, even SET cannot prevent cardiac injuries in patients with previous sternotomies, where dense mediastinal adhesions increase the risk of major mediastinal injuries, ranging from 3.3% to 7% (80,81). In such cases, it is recommended to work with cardiothoracic surgeons to create the retrosternal plane and to have a cardiopulmonary bypass team readily available (35,81). Additionally, a subxiphoid incision, used by cardiothoracic surgeons in cases of redo sternotomy, is also recommended to facilitate the dissection of adhesions in the retrosternal space (12,79,82).

Finally, another technical innovation manufactured in China is a pre-bent steel bar with a fixed end on one side, which eliminates the need for rotation and therefore reduces the need for a more extensive substernal dissection. In addition, the bar is attached to the introducer with a screw, allowing only one passage through the anterior mediastinum. When the bar exits the wound on the opposite side, it is disconnected from the introducer, and this end is secured with a lateral stabilizer (80). The bar was specifically designed for patients with a previous median sternotomy to reduce trauma during retrosternal dissection. With this novel bar used in 27 patients, the authors reported one case of cardiac perforation requiring unplanned sternotomy and repair of the right atrium (80).

Studies comparing outcomes of VATS MIRPE and blind bar placement have shown inconsistent results. Data from large, multicenter national databases show no differences in outcomes between the two approaches regarding safety, organ space, and superficial site infections (5,6). Contrary to these findings, a recent meta-analysis found that VATS MIRPE was associated with fewer postoperative complications. When examining specific complications, the authors noted that non-thoracoscopic surgery was linked to poor wound healing (12) (Table 3).

Impact of technical variations on operating time

VATS MIRPE is associated with longer surgery and anesthesia times (5,6,12,71,77) (Table 4).

In a recent analysis of over 5,000 MIRPE procedures performed at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program Pediatrics (ACS NSQIP-P), longer operating times were found to be an independent predictor of longer hospital stays and 30-day readmission rates (77). Extended exposure to anesthetic medications may influence discharge timing. However, the severity of PE, a major confounder, could not be controlled for because imaging findings are not available in databases such as NSQIP-P or the Pediatric Health Information System (PHIS). Furthermore, discharge policies vary between hospitals, with some institutions having in place pathways for same-day discharge (83,84). Therefore, differences in outcomes may result from variations in surgeon experience, hospital discharge pathways, the type of analgesia used for postoperative pain management, standardized definitions of complications, and temporal bias when single-institution studies within meta-analyses include the learning curve period.

Multimodal pain management

MIRPE, although less invasive than the Ravitch procedure, is associated with severe postoperative pain due to the pressure of bending the chest. Postoperative pain perception can be influenced by several factors, including the severity of the defect, multiple bar placements, and age. Differences in cartilage flexibility represent a biomechanical disadvantage when performing MIRPE in older patients, as the stress from the bar is distributed across a wider range of ribs (85). Consequently, a linear relationship exists between age and morphine consumption (86-88). Effective post-surgery pain management is crucial for promoting a quick recovery, reducing hospital stay, and minimizing complications such as lung atelectasis and pneumonia.

Traditionally, postoperative pain has been managed with patient-controlled analgesia (PCA) or thoracic epidural analgesia (TEA). Thoracic epidural blockade is effective for pain control, resulting in fewer respiratory side effects than PCA, and was the most common analgesia used before the introduction of cryoanalgesia (89). However, neurologic complications, although temporary, such as Horner syndrome, have been documented in 15.5% of cases treated with TEA, with a risk of permanent neurologic damage estimated at 0.07% (90,91). Additionally, TEA is associated with a high rate of failed placements, catheter displacements, calls for anesthesia providers, and potential site infections. Hospital stays may also be longer because transitioning from epidural catheter removal to oral pain medications can still require intravenous (IV) opioid medications (92). The enhanced recovery after surgery (ERAS) pathway has been adopted by many centers performing MIRPE, emphasizing multimodal pain management that combines regional anesthesia before incision with a mix of opioids and non-opioid medications (83,84,93-97). This approach enables the use of lower doses of each drug, thereby reducing side effects while maintaining effectiveness. In response to the opioid epidemic, many efforts have been made to decrease their use in postoperative MIRPE management.

Recently, INC has been introduced as an additional method for postoperative pain management (98). The cryoprobe can be applied to the intercostal nerve via an extra-thoracic approach guided by ultrasound or through an intrathoracic approach under thoracoscopic visualization (99). Currently, 90% of surgeons performing INC during MIRPE use thoracoscopy (99).

Positive outcomes with cryoanalgesia led to increased use in the USA. An analysis of the PHIS database showed a trend toward more frequent use of INC, rising from 33% in 2016 to 61% of MIRPE cases in 2023 (16,99). A significant predictor of INC utilization was treatment at a high-volume hospital (100).

Thoracoscopic INC technique and approaches

Cryotherapy has been used for the management of chest pain in patients who underwent thoracotomy since the 1970s (101). However, its application to MIRPE was only adopted in 2015, following the Food and Drug Administration (FDA) approval of the first commercially available cryoablation probe manufactured in the USA, the CryoICE^® (AtriCure, Mason, OH, USA) (8,9).

Another commercially available cryoprobe system used in Europe and South America is the Cryo-S painless (^®METRUM Cryoflex, Blizne Laszczyn-skiego, Stare Babice, Poland) (102,103). Brief exposure to hypothermia at temperatures ranging from −60 to −80 ℃ induces ice crystal formation and Wallerian degeneration, resulting in a temporary sensory deficit that lasts approximately 4 to 6 weeks until the axon regenerates (9,104-106). The INC is usually performed before bar placement.

The technique involves using a 5-mm, 30- or 45-degree thoracoscope inserted into the chest for direct visualization of the intercostal spaces. The trocar for the scope and the probe is typically placed in the same incision for bar entry. Partial lung collapse is achieved through CO₂ insufflation without lung isolation. The cryoprobe then enters the chest cavity, and its position is confirmed thoracoscopically. The probe is cooled to approximately −60 ℃ for two minutes per nerve and applied to the intercostal nerves from the 3rd to the 8th on both sides. The T3–8 ablation results in temporary loss of sensation from the manubrium of the sternum to just below the xiphoid (16). However, the ablation limited to T4–7 level also provides satisfying analgesia (107). Alternatively, some surgeons use a thoracoscopic transthoracic approach (8). The cryoprobe is introduced from the opposite incision and crosses the mediastinum to freeze the intercostal nerve on the other side (8). However, the transthoracic approach is less commonly used and has not gained widespread adoption.

Cryoablation vs. traditional pain management modalities: strengths and limitations

Short-term outcomes

(I) Operating time

One drawback of the cryoablation technique is that it tends to increase both the procedure duration and overall operating room time. Cryoablation involves additional steps, including accessing the thoracic cavity, deflating the ipsilateral lung, applying cryoablation for about 2 minutes per nerve, and a 10- to 40-second rewarming period between ablations. Reported operating times in the literature range from 20 to 68 minutes, with total operating room times from 18 to 46 minutes (9,95,106-111). Variations in operating time among surgeons may be due to the learning curve, the number of nerves ablated, and technical differences aimed at streamlining the procedure (9,105,107,112). Data from multicenter studies show that when cryoablation replaces other nerve blocks or epidural catheter placement, differences in total operating room time are not statistically significant (108,113). However, since the full effect of cryoanalgesia develops after 12–24 hours, using thoracoscopic-assisted intercostal nerve block (INB) or other peripheral nerve blocks, such as the erector spine plane block (ESPB), as a bridge until cryoanalgesia reaches full effect may also increase overall operating room time (84,94,95,97,114) (Table 5).

An effective way to shorten operative time, as used at our institution, is the simultaneous execution of cryoablation and tunneling (Figure 4A,4B). Once the retrosternal space is created manually through the subxiphoid incision, since tunneling doesn’t require thoracoscopic guidance, one surgeon can perform the thoracoscopic-assisted cryoablation on the right side while the assistant surgeon simultaneously completes the retrosternal tunnel and passes the introducer on the left side. By the time cryoablation is finished on the right, the introducer emerges from the xiphoid incision and is connected to a polyvinyl chloride suction tube or umbilical tape to guide the bar later; it is then retracted until it exits through the left incision. The scope is then moved to the left, while tunneling on the right side is completed, and cryoablation continues on the left. The operation is effectively cryoablation followed by flip-and-close (Figure 5A,5B). This simultaneous approach shortens the overall procedure time by about 20–30 minutes. Others suggest shortening the freezing time to 1 minute per nerve, which provides an equivalent analgesic effect while adding only 10 minutes to the overall procedure (115).

Figure 4 Simultaneous execution of right thoracoscopic intercostal cryoablation and left tunneling. (A) Following the placement of the thoracoscope on the right side of the chest and the creation of a subxiphoid incision, the two surgeons execute the right INC and the left retrosternal tunneling simultaneously. (B) Once the INC is completed on the right side, the chest tube used to guide the bar passage is in place in the left retrosternal space, exiting from the subxiphoid incision. The retrosternal tunnel is created on the right side, while at the same time, the left intercostal nerves are ablated. INC, intercostal nerve cryoablation.

Figure 5 Ready to flip-and-close following cryoablation. (A) The bar is secured to the suction tube. The tube is pulled, and the bar is passed through the chest. (B) The bar is flipped into the correct position and secured to the adjacent rib with one stabilizer.

(II) Opioid consumption and LOS

Most studies comparing different pain management options have found no significant differences in postoperative complications, hospital readmissions, or reoperations between INC and other pain management methods, except for reduced postoperative constipation, nausea, and vomiting, as well as urinary retention (107,113,116-118). This reduction is attributed to a general decrease in opioid use and the complete elimination of thoracic epidural in patients treated with cryoablation (107,113,116,118). Not only does the INC decrease the IV need for opioids and shorten the time to discontinue IV pain medications, but it also reduces the overall use of oral morphine equivalent (OME) per kg by about two-fold during the hospital stay and to 2.6- to 5.6-fold after discharge, with approximately 28% to 50% of patients off narcotic medications at 2–4 weeks follow-up (9,16,115,119-121). Moreover, better pain control results in a shorter LOS of 1 to 5.4 days, with an average reduction of about 1.7 days (83,98,100,106-108,118,122). The use of INC enabled same-day discharge for PE repair, with rates reaching 61% (77,83,123) (Table 6).

(III) Health care costs

Studies analyzing hospital costs related to different pain management strategies have found the primary driver of higher costs with INC is operating room supply (100,116). Another factor that significantly affects hospital care costs is LOS. Some studies found that although INC was linked to shorter LOS, it decreased patient charges but was associated with higher overall hospital expenses (100,118,124). Conversely, others found that reductions in analgesic use and labor in patient care, as well as shorter LOS, offset the additional costs associated with INC (114,115).

Differences in hospital costs may be attributed to different cost measures used, such as charges, cost-to-charge ratios, and reimbursements. In addition, other factors influencing operating time and equipment costs include the use of thoracoscopy during retrosternal dissection, the use of sternal elevator systems, the number of bars placed, the number of stabilizers used, and the methods of bar fixation, as well as the use of peripheral nerve blocks and the placement of analgesic pumps. Ultimately, individual institutional practice pathways designed to implement same-day discharge may significantly affect LOS and overall hospital costs (Table 7).

Intermediate and long-term outcomes

Some authors reported a higher rate of bar displacements in patients treated with INC, suggesting that these cases were likely due to the absence of pain, which could have allowed an earlier return to full activity despite recommended restrictions (9,68,116,120). However, this data has not been confirmed by multicenter studies or large national database analyses (108,118). Thermal injuries to the lung are a rare potential complication. To date, only one case of thermal lung injury causing pneumothorax has been reported in the literature (125).

One concern with the use of INC is the potential risk of long-term sensory change of the chest wall and neuropathic pain. Studies evaluating the long-term effects of INC found that transitory hypersensitivity lasted a median of 1 month in 20.7% of cases. Additionally, 1.7% to 3.3% of patients experienced persistent numbness in the lower central sternum at the 12-month follow-up (126-128). On dermatomal neurosensory examination, the area of hypoesthesia at the time of bar removal is generally limited to one or two dermatomes (T4–6), which correspond to the intercostal level of bar placement; therefore, it is most likely the effect of intercostal nerve compression by the bar (129,130). Overall, 86% of patients treated with cryoablation regain normal chest wall sensitivity 2 months after bar removal (129). Chronic neuropathic pain is uncommon, and full recovery was obtained with the administration of gabapentin.

The prophylactic use of pregabalin and/or gabapentin to reduce the risk of neuropathic pain is controversial. A retrospective study comparing outcomes of patients who received two weeks of preoperative gabapentin and up to two months postoperatively with those who did not found that the gabapentin cohort experienced less neuropathic pain on postoperative day (POD) one than the control group; however, this did not translate into lower pain scores, reduced opioid use, shorter LOS, and differences in hyperesthesia at 2-week follow-up (104).

Overall, thoracoscopic-guided INC has been associated with reduced opioid consumption, shorter hospital LOS, and improved postoperative recovery. While it may increase operative time and has variable cost implications, its integration into multimodal analgesia pathways represents a significant advancement in perioperative care for patients undergoing MIRPE.

Limitations of evidence

This narrative review is subject to limitations inherent to its non-systematic design, which may introduce selection bias into the curated literature. Unlike a meta-analysis, these findings provide a qualitative synthesis of expert perspectives rather than a statistical evaluation. Despite these limitations, this narrative review offers a novel perspective that complements existing literature and provides clinically relevant insights for surgeons adopting evolving, multimodal approaches to MIRPE.

Several limitations should be considered when interpreting the available evidence from the growing literature on thoracoscopic-assisted MIRPE. Most studies are retrospective or based on single-institution experiences, which may limit generalizability and introduce selection bias. In addition, significant heterogeneity exists in patient populations, deformity severity, operative techniques, and perioperative management protocols, making direct comparisons across studies challenging.

Large database analyses, such as those derived from NSQIP-P or PHIS, provide valuable population-level insights but lack detailed information on operative techniques, intraoperative decision-making, and deformity severity. As a result, the independent contribution of specific technical modifications, such as thoracoscopy, SETs, or subxiphoid approaches, is difficult to determine.

Furthermore, many reported complications, particularly rare but life-threatening events such as cardiac injury, are derived from case reports or small series and may be underreported. Variability in the definition and reporting of complications also limits the ability to draw definitive conclusions regarding safety outcomes.

Finally, comparative studies evaluating different pain management strategies, including INC, are often limited by non-randomized design, small sample sizes, and institutional practice patterns, which may influence both outcomes and cost analysis.

Taken together, these limitations underscore the need for standardized reporting, prospective multicenter studies, and higher-quality comparative data to clarify the role of thoracoscopy and associated adjuncts in MIRPE.

Clinical implications and future directions

Current literature supports the use of technical adjuncts to thoracoscopy, including sternal elevation and a subxiphoid incision, to improve safety during retrosternal dissection and bar placement in patients with limited visualization due to severe deformity or prior surgery. Prospective comparative studies are needed to clarify the impact of selective versus routine use of these adjuncts on outcomes and to support standardized decision-making based on anatomic complexity, chest wall flexibility, and surgical history. Despite increasing evidence supporting INC as part of multimodal pain management, its use remains largely limited to high-volume centers. Expanding adoption will require standardized training, multicenter outcome studies, and cost-effectiveness analyses to promote broader and more equitable access.

Conclusions

MIRPE is a well-established procedure; however, variability in operative techniques and predominantly retrospective data limit direct comparisons of safety outcomes. Despite these challenges, literature supports thoracoscopic guidance as a key component of modern MIRPE, enhancing visualization and improving safety, particularly in complex deformities. Thoracoscopy has also facilitated the adoption of INC, which improves postoperative recovery despite increasing operative time. Future progress will depend on standardizing surgical techniques, improving outcome reporting, and conducting prospective multicenter studies to better define best practices.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-2026-1-0011/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-2026-1-0011/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-2026-1-0011/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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