The Nuss procedure is a minimally-invasive procedure, when compared to the Ravitch technique. The procedure was invented by Dr. Donald Nuss for the treatment of Pectus Excavatum. Dr. Nuss developed the procedure at the King’s Daughters children’s hospital, in Norfolk, Virginia, US. Although, the uss procedure was initially only recommended for younger patients, it has become commonly used on much older patients, with excellent results.
The Nuss procedure typically takes approximately two hours to complete. An introducer is pushed along posterior to the sternum and ribs, anterior to the heart and lungs, through two small incisions in either side of the chest. Subsequently, a concave stainless steel bar is slipped under the sternum, through the incisions in the side of the chest. A third, much smaller incision is made to insert a thoracoscope into the patient which is used to help the surgeon guide the bar into place. Taller patients, older patients, or patients requiring extensive correction may receive two or more bars to ensure the bar is effective and does not become deformed as well. All bars are placed through the two incisions though additional incisions may be necessary in some circumstances. The bar is then flipped, which forces the sternum out. To support the bar and keep it in place, a metal plate called a stabilizer may be inserted with the bar on one side of the torso. PDS internal sutures may also be used, in addition to the stabilizer, to ensure the bar remains in its correct position. Essentially, the stabilizer fits around the bar and into the ribcage and is secured with sutures that dissolve in about six months.However, many surgeons have achieved excellent results using only pericostal sutures, without the use of a stabilizer.
For older patients with more ossified bones, an additional step the surgeon may need to make is an incision across the sternum so the bar can be attached to the sternum using a wire in order to avoid bar displacement. Older patients bones do not conform as easily to the bar, and thus the risk of bar displacement is higher; this step helps to mitigate this risk.
Eventually, the bar is properly secured with muscle tissue that regrows during the recovery period. Postoperative evaluation indicates a significant improvement in pulmonary function studies and a high proportion of patients report improvements in well being and an increase in exercise tolerance as well.
Although this procedure is categorized as being minimally invasive, the postoperative recovery cannot be considered minimal. Postoperative pain control can be extremely challenging, requiring multi-modal pain management such as an epidural.
Recovery from the Nuss Procedure
Recovery time typically involves four to five days as an in hospital patient, depending on the patient age, activity level, and complications. This initial period is followed by time at home to overcome the pain and to let the bar settle into place. Younger patients often require two to four weeks at home after being discharged from the hospital, but older patients typically require a greater recovery time due to the increased ossification and flexibility of their bones.
Clearly therefore, the difficulty and length of recovery should be a factor which is carefully considered before making the decision to undergo the operation, as the limitations to lifestyle, functionality and comfort can be significant for a number of months. Because of this, doctors generally tend not to recommend surgery for older patients (i.e. not for purely cosmetic reasons); adult patients may require many months before they are able to resume normal daily activities, such as work. For the first day after the operation, the patient will generally have a Foley catheter to minimize the risk of movement that could displace bar, and because the epidural can interfere with normal urination. The patient may also receive thoracic epidural analgesia in the back depending on patient recovery.
For two months, physical activity should be limited (i.e. no running or strenuous physical activity). Walking for exercise and breathing exercises aid in recovery. It is sometimes suggested that weight-training should be avoided for up to three months. It is also recommended that any sports where contact may occur should be avoided, however, aerobic sports are encouraged. After a period of six to ten months, the athletic skills of the patient should be mostly recovered.
After a period of two to four years, the surgical stainless steel bar needs to be removed from the patient’s chest. This outpatient procedure lasts approximately ninety minutes, and the patient should only need to stay in hospital for a few hours at most.