Pectus excavatum: Out of Africa – evolution, outcomes, and global implications of minimally invasive repair

Pectus excavatum is the most common congenital deformity of the anterior chest wall and, although historically regarded primarily as a cosmetic abnormality, is now recognised to produce significant cardiopulmonary and psychosocial impairment in moderate to severe cases. Surgical correction has evolved substantially over the past three decades, progressing from radical open chest wall resection techniques to minimally invasive repair. This narrative review examines the development and evolution of surgical management for pectus excavatum, with particular emphasis on the introduction, refinement, and outcomes of the minimally invasive Nuss procedure. Historical background, indications for surgery, operative modifications, pain management strategies, complications, and functional outcomes are reviewed with reference to major institutional series. Minimally invasive repair has become the contemporary gold standard, with objective studies demonstrating improvements in cardiac compression, pulmonary mechanics, exercise tolerance, and quality of life following repair. Large published series report excellent or good outcomes in more than 90% of patients, with low complication rates when performed in experienced centres. Advances in perioperative pain management, particularly the adoption of intercostal cryo-analgesia, have further reduced postoperative morbidity and shortened hospital stay. The minimally invasive correction of pectus excavatum represents a major paradigm shift in thoracic surgery. Importantly, the originator of the technique, Donald Nuss, was African-born and trained in Cape Town. The procedure is safe, effective, reproducible, and should be accessible wherever appropriately trained thoracic surgeons practice, including throughout the African continent.