The Nuss Procedure; A Detailed Explanation

1. The first step will be a course of antibiotics at the time of surgery to prevent infection and reduce the development of pneumonia. This surgery is performed under general anesthesia with a muscle relaxant and epidural block for both operation and pain control purposes.

2. The patient is then positioned with both arms extended out sideways to allow better access to chest wall. Padding under the arms will prevent any neurologic injury.

3. The patient is then draped, and the chest is marked and sterilized. The deepest section of the pectus is marked. If the deepest point of the pectus is inferiro to the sternum, then mark the lower end of the sternum. Using this point, establish a horizontal plane across the pectus area. Extend the horizontal plane to the lateral chest wall and mark between the anterior and midaxillary lines for transverse lateral incisions.

4. The preop chest measurements are then double chcked. And the proper bar is then selected for beind into the desired chest wall curvature. A bar will be chosen specifically for your chest that will give you maximum stability and correction.

5. Using the pectus bender, the bar is shaped from the center outward making small gradual bends. It may be necessary to exaggerate the curvature slightly to allow for chest wall pressure downward force on the sternum. Avoid bending the lateral ends of the bar.

6. 2.5cm incisions are then made at the marks previously made. A skin tunnel is raised from both incisions to the top of the pectus ridge at previously selected space. The pectus bar then enters the chest slightly elevated from the pectus ridge.

7. A thoracoscope is used during the procedure to get an idea of where all the surrounding organs are in order not to damage them. The pectus bar is then entered from the patients right side with the proper pectus introducer in order to make a tunnel for the implant. Small introducers are used for patients 4 to 12 years old and the longer one for patients 13 – 20 or older.

8. The introducer is slowly eased in through the side of chest and pushed through to the other side of the chest. From here the surgeons can begin elevating the sternum.

9. The sternum is then lifted into place from both sides. Pressure is applied above and below the sternum to obtain the desired curvature of the sternum. This process may be repeated a few times in order to stretch the connective tissue and correct the deformity prior to inserting the main bar. Two strangs of umbilical tape are then tied through each end of the hole this will be later used to guide the bar through the hole.

The bar is then inserted and flipped into a position that will push the sternum outwards to the desired position.

10. At this point the stability of the bar is checked. Depending on how stable the bar is, will dictate if any stabilization need take place. Patients typically require one bar to achieve correction but some may have 2 or 3 for more severe deformities.

A stabalizer bar is then fitted to each end of the pectus bar. Patients 4 to 13 years have one stabilizer per bar , and 14 to 18 years of age have one or two depending on patients muscular development and activity level (sports , gym e,g)

11. The bar and stabilizer are then secured to each other and to the chest wall and the bar and stabilizer are covered up. The incisions are then closed up and a chest radiograph is obtained postop to check for pneumothorax and is an excellent way to see final bar placement.

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