The Nuss procedure is a minimally invasive procedure, invented in 1987 by Dr. Donald Nuss and his colleagues, Dr. Daniel Croitoru and Dr. Robert Kelly, for treating pectus excavatum. He developed it at Children's Hospital of The King's Daughters, in Norfolk, Virginia. The operation typically takes approximately two hours. Through two small incisions in the side of the chest, an introducer is pushed along posterior to the sternum and ribs, and anterior to the heart and lungs. Then a concave stainless steel bar is slipped under the sternum, through the incisions in the side of the chest. A third, smaller incision is made to insert a thoracoscope (small camera) used to help guide the bar. Taller patients, older patients, or patients requiring extensive correction may receive two or more bars. All bars may be placed through two incisions or additional incisions may be made. The bar is then flipped, and the sternum pops 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 sutures may also be used in addition to the stabilizer. The stabilizer fits around the bar and into the ribcage. The bar and stabilizer are secured with sutures that dissolve in about six months. Kevlar strings may also be attached to the lower ribcage to prevent costal flaring. This option is often not preferred by surgeons as it can cause extreme amounts of additional pain during recovery and up until the strings are removed. Some surgeons have achieved excellent results using only pericostal sutures, without the use of stabilizers. For older children who have more ossified bones, an additional option the surgeon has is to make an incision across the sternum so the bar is attached with a wire to the sternum to avoid bar displacement. Older children's bones do not conform as easily to the bar, thus increasing the risk of bar displacement, so the wire attaching the bar directly to the sternum may help avoid a second surgery to correct bar displacement. Eventually, the bar is secured with muscle tissue that regrows during the recovery time. Although initially recommended only for younger patients, the Nuss procedure is now commonly used on patients in their thirties and forties with excellent results. 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. Although this procedure is categorized as "minimally invasive", post-operative pain control can be quite challenging, thus requiring multi-modal pain management including epidural anesthetics. Nurses who attend these patients post operation generally concur that this operation is one of the more difficult recoveries of any operations for children.
Sternal elevation The retrosternal passage performed in the Nuss procedure carries a high risk of damaging the heart. This is why multiple sternal elevation systems have been developed to increase the space between the heart and the sternum in order to pass the thoracoplasty rod more safely.
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