Intercostal nerve cryoablation as an adjunct to the Nuss procedure for pectus excavatum: surgical technique and practical considerations

Thoracoscopic intercostal nerve cryoablation is increasingly used as an adjunct to the Nuss procedure for pectus excavatum to reduce postoperative pain, yet detailed stepwise descriptions remain limited. This video tutorial presents a practical, structured description of the operative technique with emphasis on reproducible procedural steps. The patient is placed supine with both arms elevated, and single lung ventilation is established, commencing with the left-sided procedure. Thoracoscopic access is obtained through small lateral ports, followed by carbon dioxide insufflation to improve visualization. The thoracoscope is introduced to identify the third to eighth intercostal spaces. A cryoprobe is inserted through a lateral intercostal access point and positioned directly onto the intercostal nerve along the inferior border of each rib. A palpation instrument is used to retract the lung and facilitate safe exposure of the target nerve. Once correct positioning is confirmed, a controlled freezing cycle is initiated to achieve targeted nerve ablation, after which complete thawing is ensured before probe repositioning. The process is repeated sequentially for each intercostal level. After completion of cryoablation, an adjunctive intercostal block may be administered, followed by reinflation of the lung under thoracoscopic visualization. After the left-sided procedure is completed, it may be reproduced on the right. Once the right-sided procedure is completed, standard Nuss bar placement is performed. Technical pitfalls related to probe positioning, rib level identification, and tissue protection are highlighted to support safe and consistent application of the technique.