The Nuss Procedure Correcting Pectus Excavatum Zach Warriner The most common congenital chest wall abnormality Posterior depression of the inferior portion of the sternum with.
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Transcript The Nuss Procedure Correcting Pectus Excavatum Zach Warriner The most common congenital chest wall abnormality Posterior depression of the inferior portion of the sternum with.
The Nuss Procedure
Correcting Pectus Excavatum
Zach Warriner
The most common congenital chest wall
abnormality
Posterior depression of the inferior portion of
the sternum with posterior curving of attaches
ribs at affected levels
Normally affects ribs 4 – 7
Deepest point usually just above junction of xyphoid
Incidence: 1:400 and 3 – 5x more common in
boys
Affects patients both physiologically and
psychosocially
Physiologic symptomatology
Easy fatigability/decreased exercise tolerance
Chest pains
Palpitations
Psychosocial implications
Poor self-image
Low self esteem
Patient presents with obvious anterior chest
wall deformity
Chest CT performed to analyze and quantify
severity of defect, and for surgical planning
Severity graded using Haller index (>3.2 = severe)
CXR
Pulmonary function tests
Cardiology exam
Auscultation
ECG
Decreased anteroposterior diameter of the
chest
Decreased lung expansion
Restrictive pulmonary dysfunction
Compression/displacement of the heart
Decreased stroke volume
Mitral valve prolapse
The only way to correct pectus excavatum is
with surgery
Invasive
Ravitch method
Minimally invasive
Nuss procedure
Basis for developing procedure:
Anatomical
Malleability of pediatric chest wall
Pathological
Potential for remodeling of chest wall
Orthopedic surgery
Implantable fixation device
General anesthesia equipment
Two monitors for visualization
Image displayed on both monitors from single 30°
scope
Patient is placed under general anesthesia for pain
control and immobilization during procedure
Prophylactic antibiotic therapy for infection prevention
Thoracic epidural for post-operative pain control
Pectus bar (Lorenz)
Bar passer (Lorenz pectus introducer)
Bar bender (Zimmer)
Handheld bar bender
Bar template
Bar flipper (Lorenz pectus bar rotational instrument)
Bar stabilizer
Sternal wire
2-0 vicryl
Electrocautery
Scalpel
Army-Navy retractor
Kelly clamp
Veress needle
5mm trocar
30 scope
Umbilical tape
Mold bar template
Bend pectus bar with bar
bender
Introduce scope and induce
pneumothorax
Port placement
Creation of pilot hole
Pass bar passer between
pericardium and subxyphoid fat
Create contralateral exit
Bar passer insertion
complete
Tie umbilical tape to bar
passer and retract
Tie umbilical tape to pectus
bar to guide entry
Introduce pectus bar into
chest cavity
Finalize bar bending once
pectus bar is in place
Stabilize pectus bar with
unilateral bar stabilizer
Pectus bar with bar
stabilizer
Day of operation, patient should remain in bed
at 30 with catheter and epidural still in place
ingesting only clear liquids
The next day, patient is allowed out of bed
with assistance to use the restroom and diet is
slowly increased
On day 3, patient is switched to outpatient pain
meds and discharged if appropriate
Recovery time is generally one month
Increases with patient age
Exercise restriction should be imposed for 6
weeks
After 3 months, patients may return to regular
sports activities
Deformity prior to
correction with pectus bar
Corrected deformity after
implantation of pectus bar
Pre-operative
Post-operative
After 2 years, the bar is removed during an
outpatient procedure
A single unilateral incision is made over the
bar stabilizer to remove both the pectus bar
and bar stabilizer
The patient is discharged and pain is controlled
with OTC pain meds
Intraoperative heart perforation
Pericardial tearing
Piercing of liver with trocar
Infection
Bar displacement
Pleural effusion
Pneumothorax
Intercostal muscle rupture
Laceration of internal thoracic artery
Decreased operating time
Minimal blood loss
Minimal operative chest trauma
No breaking or cutting of cartilage
Three small incisions vs one large incision
Minimal visible scarring and reduced healing time