Modified Nuss procedure to prevent myocardial injury

The Nuss procedure is a minimally invasive procedure for treating pectus excavatum. The onset of intraoperative complications during the placement of a Nuss bar used in the treatment of pectus excavatum has been recently reported and discussed in the literature. In order to avoid any pericardial and myocardial injury, a double thoracoscopy along with a very short substernal access allowing for a finger dissection of the space separating the sternum from the anterior mediastinum is demonstrated.

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Modified Nuss procedure to prevent myocardial injury

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Abstract

The Nuss procedure is a minimally invasive procedure for treating pectus excavatum. The onset of intraoperative complications during the placement of a Nuss bar used in the treatment of pectus excavatum has been recently reported and discussed in the literature.
In order to avoid any pericardial and myocardial injury, a double thoracoscopy along with a very short substernal access allowing for a finger dissection of the space separating the sternum from the anterior mediastinum is demonstrated.

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contribution

Keywords

Modified Nuss procedure, myocardial injury

Media type

Surgical video

Duration

04'08''

Publication

2011-12

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E-publication

WeBSurg.com, Dec 2011;11(12).
URL: http://www.websurg.com/doi-vd01en3482.htm

Modified Nuss procedure to prevent myocardial injury

1. Introduction 00'19''

The onset of intraoperative complications during the placement of a Nuss bar used in the treatment of pectus excavatum has been recently reported and discussed in the literature. In order to avoid any pericardial and myocardial injury, we decided to perform a double thoracoscopy along with a very short substernal access allowing for a finger dissection of the space separating the sternum from the anterior mediastinum. Such technical precautions contribute to safely prepare the passage of the Nuss bar. The operative indication is dependent on the following data: the results of clinical examination, the patient’s demands, and measurements for the Haller index as well as any findings bearing out the absence of any other cardiothoracic anomaly.

2. Introduction of thoracoscope 01'08''

Two access routes on the mid-axillary line to the right and to the left are necessary. The thoracoscope to the right is placed on the most posterior and superior portion of the axillary incision. The thoracoscope to the left is placed on the most anterior and inferior portion of the axillary route.

3. Incision on xiphoid process 01'28''

A short incision over 1.5 to 2cm is carried out underneath the xiphoid process of the sternum. It will allow for a digital dissection of the precardial space and for the pleural opening on the midline. The videoscope controlling the passage of the Nuss bar into the freed anterior premediastinal space then becomes possible.

4. Substernal dissection 01'49''

Here the digital substernal dissection controlled by a right thoracoscopy is visible. A peanut swab can be used to help the surgeon complete the dissection. Under left thoracoscopic control, the visibility is not so good considering the cardiac mass. The dissection must be performed with the same quality as carried out on the right side and the pleural opening allows to complete the dissection at the lowermost point of the sternum. A lateral subcutaneous detachment gives access to enter the bar into the right hemithorax. The dissector is brought until the surgeon’s finger. It is placed substernally. The operator’s finger is placed between the cardiac mass and the dissector. A retractor allows to suspend the sternum temporarily, which enlarges the space to allow for the dissector’s passage. The dissector’s passage into the left hemithorax is carried out under left thoracoscopic control. The exit of the dissector is achieved once again under thoracoscopic control. The videoscopic control of the dissection through a small median and substernal incision demonstrates the future exit site of the bar, the precardial dissection area, and the right hemithorax.

5. Bar insertion 03'29''

A tape will be used to replace the dissector. It will help to guide the passage of the bar into the right, then left hemithorax until its exit at the level of the left subcutaneous tunnel. This procedure is undertaken under right, then left videoscopic control. Once the bar has been positioned, it is turned upside down over 180 degrees as indicated by the Nuss technique and stabilized on each side. The subcutaneous drainage is sufficient to treat the residual pneumothorax and subcutaneous emphysema that may still occur following the intrathoracic insufflation. The drain is left in place during 24 hours. The procedure has been performed under general anesthesia with an epidural catheter to maintain adequate analgesia during the first postoperative 48 hours.