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Nuss Procedure

pectus bar on x-ray

What is Nuss Procedure ?

Nuss Procedure is minimally invasive surgery, invented and developed by Dr. Donald Nuss in 1987. Considered as an upgraded and more advanced method of the originally performed Ravitch procedure, it has become the number one surgical method for correction of pectus excavatum deformity. Unlike the Ravitch procedure in which the costal cartilage is removed and the sternal bone is cut in order to get a flatten chest wall appearance, this process is considered less aggressive and invasive to the chest wall area and to some degree, easier to execute. Because of this, since it’s invention and further perfection of the method, it was instantly approved and accepted by surgeons and patients worldwide and gained the reputation as the best option for pectus excavatum repair.

Before the surgery the patient has to take some preoperative measurement, where the overall health and the level and shape of the deformity is measured. This is critical for successful outcome of the operation as the length and shape of the nuss bar is determined. After the surgery the patient is given a program of postoperative care and is scheduled for apointment after some initial period, usually month or two, to see if there are some complications with the incisions or the inserted bar. If everything is fine, the patient resumes with his everyday activities and slowly regaining full health, with an safety appointment every six months. 

 

Developement of the Nuss Procedure

Although there have been written documentations about pectus excavatum deformity in as early as the 1500’s, thoracic surgery and practises remained a very grey area until the beginning of the 20th century. Lack of medical knowledge and expertise prevented doctors and surgeons around the world from dwelling deeper and trying to correct a deformity as complex as pectus excavatum. First official attempt at fixing pectus excavatum has been recorded in 1911, performed by removing the second and third cartilages of the right side of a patient, without any success. The ravitch procedure, first widely accepted method as a pectus excavatum repair intervention, began to take shape in the 1920’s, constantly polishing and upgrading as more surgeries were performed and more expertise was gained in the area. The idea about the nuss procedure came when doctor Donald Nuss was working on a pectus excavatum operation in Children’s Hospital Of The Kings Daughter, in 1987. While performing the Ravitch procedure on a patient, doctor Nuss took notice of the flexibility of the rib cartilages and thought if it is possible to take advantage of that instead of removing them completely (there have been previous connections made between rib cartilages removal and development of asphyxiating chondrodystrophy in young patients). This is where the idea was born.

How is it performed ?

The idea was to reduce the invasive technique of the ravitch and take out the unnecessary removal of the rib cartilages if possible (there are extreme cases where this is mandatory). This is achieved by opening two small incisions on each side of the chest, where the dent is at it’s deepest point. Then, an introducer is inserted along posterior to the sternum and ribs, and anterior close to the heart and lungs. Another small incision is made for the use of thoracoscope, an instrument vital for succesfull outcome for this type of surgery. The thoracoscope is used so surgeons can have an inside look while placing the metal bar, thus massively decreasing the risk of the bar colliding or damaging with any vital organ. Then a concave steel stainless bar, made prior to the operation and according to the patient level of deformity and characteristics, is pushed under the sternum, throughout the incisions made on each side of the chest. The main moment is when the bar is fliped for 180 degrees, instantly poping the sternum out and in correct position. In order to keep the bar in correct position and not come to some post-op displacement, a metal plate called stabilizer is hooked at the end of the bar, connecting it together with the muscles and giving it the much-needed firmness.

 

 

This type of correction using braces for correcting skeletal deformities has been proven successful many times before with skeletal structures more firm and dense than the anterior chest wall and although much more complex and harder to execute, many surgeons view it in the same manner as putting braces to straighten out the teeth.

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