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.
Download ReportTranscript 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