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Nuss procedure for pectus excavatum

Authors

Abstract

This video demonstrates the Nuss procedure done with thoracoscopic assistance in an adolescent. It is a highly specialized technique, suitable for pediatric and thoracic surgeons.

Keywords

pectus excavatum, Nuss

Media type

Duration

06'15''

Publication

2007-06

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E-publication

WeBSurg.com, Jun 2007;7(06).
URL: http://www.websurg.com/doi-vd01en2140.htm

Nuss procedure for pectus excavatum

1. Preoperative evaluation 00'15''

The Nuss procedure for the correction of chest wall defects known as pectus excavatum (or sternal depression) is available to adolescents who clearly express the need for it. The preoperative workup includes a chest X-ray, cardiac echography and pulmonary function tests. As you can see here, CT-scanning shows the pectus excavatum. On the operating table, the defect is obvious. At the time of the consultation, concave adjustable bars also called Nuss bars are used. The Nuss bar should either be a size lower or higher than what is initially anticipated.

2. Creation of tunnel 01'09''

Identification of the convex apex of both right and left hemithorax is critical on each part of the sternal depression because both landmarks correspond to the points of entry and exit of the bar into the thoracic cavity. The Nuss bar enables us to model the patient’s thorax and helps us to adapt the bar to an almost perfect fit. A few adjustments may be done at the end of the procedure once the bar is placed. As you can see, the entry and exit points are placed in a sub-axillary incision The thoracoscopic equipment is installed on the right-hand side and allows the operator to follow the progression of dissection and progress of the bar. The dissection instrument that you can see is a kind of sabre or introducer that helps to prepare the passage of the bar and to model the pectus in order to correct the deformity. You can see at this stage that we are very close to the pericardium. It can be expected that there may be some ECG changes, which can be monitored by the anesthetist.

3. Passage of bar 02'52''

Once the dissecting instruments have been passed through, a loop is placed in order to guide the passage of the bar. The bar is placed upside down in order to ensure that it is going to fit correctly with the concave part facing upwards. The loop must not be pulled. It is merely used as a guide under thoracoscopic control in order to deform the pectus. Once again, when it nears the pericardiac area, potential disorders of the recordings of the ECG may occur.

4. Adjustment of bar 03'36''

The bar is then positioned and tests are performed in order to check that it is well positioned. And also at times this is a good moment in order to ensure that the bar is correctly modelled. The first attempt as you can see to rotate the bar at 180 degrees is not satisfactory. Therefore you need to remodel the bar in order to accentuate the limbs on the other side so that they fit correctly. The bar is turned through a 180 degrees, and this time the result is perfect and correction of the pectus excavatum has been achieved. A stabilizer is placed on the bar so that a rivet can be anchored there.

5. Stabilization and fixation 04'40''

Bar movement is still possible at this stage as the rivet and the associated metal work act as a stabilizer like a sliding rail that will allow respiratory movements. The stabilizer is then fixed onto the thoracic cage using a non-absorbable wire. It is preferable to carry out fixation on both sides to avoid any secondary movements of the stabilizer in the first postoperative period.

6. Postoperative evaluation 05'30''

Major analgesics are advised in the first 24 hours and a locoregional anesthesia may also be given. Thoracic radiography and postoperative CT-scanning confirm that there has been a good clinical outcome. And the pain relief felt by the adolescent is truly rewarding for the surgeon.

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