Nuss procedure

The Nuss procedure is a non-invasive procedure, invented by Dr. Donald Nuss for treating pectus excavatum. He developed it at Children's Hospital of The King's Daughters, in Norfolk, Virginia. The operation typically takes 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 may receive two bars, and hence, four incisions. 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 but is usually only used for operations requiring two bars. The stabilizer fits around the bar and into the ribcage. The bar and stabilizer are secured with sutures that dissolve in about six months. Eventually, the bar is secured with muscle tissue that regrows during the recovery time.

Recovery
Recovery time includes between four and five days in the hospital typically, depending upon the patient and how the operation went, followed by time at home to overcome the pain and to let the bar settle into place. Patients younger than fifteen often require only two to four weeks at home after being discharged from the hospital for recovery, but older children and adults typically require a much longer recovery period due to the decreased flexibility of their bones. Fully grown adults may require many months before they can resume normal activities, including work. For six to twenty-four hours after the operation, the patient will have a Foley catheter to minimize risk of movement that could displace bar. The patient also receives an epidural in the back for two to five days depending on patient recovery.

For six weeks, there should be no running or strenuous physical activity, and lifting is limited to ten pounds or less. Walking for exercise is encouraged. It is sometimes suggested that weight-training should be limited or eliminated for up to three months. Also, it is generally accepted to not play sports where impact to the chest is likely, such as hockey or boxing. If the bar slips out of position, surgery is required to place it back into position.

Bar removal
After a period of six months to five years, the stainless steel bar is removed from the patient's chest. This outpatient procedure lasts approximately thirty minutes. Pain relief only requires over-the-counter painkillers. The patient stays at the hospital for a few hours.

Complications
There is concern to the heart and lungs when the bar is being placed. Surgeons use cameras to prevent damage to organs, but there is still an extremely minor risk of abrasion.

Air in the chest (pneumothorax) is one of the more frequent complications. It is easily cured by aggressive breathing exercises and close monitoring.

Bar displacement rarely occurs a month or so after surgery, most common among people who have one bar. This necessitates a repeat of the surgery and if the patient only has one bar, the next surgery often uses two. High impact trauma, such as car accidents can dislodge the bars, causing extreme pain. This is the reason for the restriction on driving, because a sudden defensive maneuver, such as a jerk of the steering wheel, could dislodge the bar up to six weeks directly after the surgery.

If the guidelines are followed, complications are rare.