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Nuss Procedure: Pectus Excavatum

Nuss Procedure was invented by Donald Nuss in 1987. It is a minimally invasive procedure. The patient heals faster and the long term outcome of the operation is favourable. It is a widespread method in our present day.

Nuss Surgery - Pectus Excavatum

Before the Surgery;

  • First, physical examination of the patient is conducted.
  • The patient and patient’s relative is informed thoroughly and their questions are answered, in order for them to be able to make an informed decision about the pectus excavatum treatment.
  • To determine the level of chest deformation a two sided chest graphy (front and side-back) and tomography of the chest is taken. According to Haller index, if the proportion of horizontal length of the chest to its vertical length is greater than 2.5 the case is taken into serious consideration. If the proportion is greater than 3.5 the patient may consider surgical treatment.
  • Blood tests and respiratory function tests are conducted to determine whether the patient is fit for general anesthesia.
  • Cardiology consultation is necessary to determine whether the patient has a heart condition. If necessary EKG and EKO tests are conducted to find a possible heart condition, if the patient indeed has a heart condition, it should be treated first in order to proceed with pectus excavatum treatment.
  • For those patients with internal diseases specific consultations are necessary.
Nuss Surgery CT

Image 1 (HALLER INDEX) – In the image, proportion of the length (a) to the length (b) shows whether the patient can have the NUSS surgery. If the proportion is greater than 2.5 the patient can have the surgery

Preparing for the Surgery

Quitting smoking at least 2 months prior to the surgery minimizes all possible problems that may arise after the surgery.

The Surgery

NUSS Surgery Process

  • The surgery is conducted under general anesthesia and it takes 45 – 60 minutes.
  • A steel bar is implanted into the chest to pull up the sunken area.
Steel Pectus Bar

Image 2 – Steel pectus bar (Lorenz bar)

Pectus bar is implanted into the chest through the incisions made in the thoracic wall and it is secured with muscle tissue. A metal stabilizer is also used to stabilize the bar.

Nuss Surgery Bars - Erkan Yildirim, MD.

In certain cases 2 and although very rarely 3 bars can be implanted (Image 3)

NUSS Surgery

Image 4 – Pectus bar is implanted under the sternum as seen in the image.

Following the Surgery

The patient experiences pain in the first 3 days following the surgery. Pain is managed by epidural administration.

Generally after 3 days pain is managed by painkillers taken through the mouth or vein with injections.

Hospital stay is generally 3 – 5 days. Dressing the wound in the first 3 days is enough. The incisions may be left undressed afterwards. Rarely the patient may feel the both sides of the bar under the skin. Massaging the skin lightly prevents the bar to stick the skin. In most cases pectus bar fixes the problem without complications.

The patient can do safe exercises 3 months after the surgery. After 6 months the patient can do regular exercises such as swimming, tennis, jogging etc. Although contact sports such as wrestling, karate, bow are strictly forbidden. The patient should stay away from contact sports for the rest of his life.

Pectus Surgery Before & After

What to do, what not to do after the surgery

In the first month following the surgery the patient;

  • Should not bend her back (She should bend her hips).
  • Should not turn back.
  • Should not roll either way.
  • Should not run or engage in aerobics.
  • Should not engage in physically challenging activities.

In the first 3 months after the surgery the patient;

  • Should not lift anything heavy (including books and back packs)
  • Should not engage in aerobics.

Recommended activities

  • The patient should do posture exercises in order the pectus bar to maintain its place.
  • The patient should take daily walks in order to regain her normal strength.
  • The patient should do deep breathing exercises.
  • Th patient can do more challenging exercises at the end of 6 weeks.
  • The patient should consult her doctor before starting any routine exercises.

Diet;

  • The patient can go back to their normal diet as long as they take their medication.

Removing the bars

Depending on the age and the state of the thoracic wall the pectus bar is removed with a 30 minute operation conducted under general anesthesia within 2 – 4 years.

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