Nuss Procedure for Pectus Excavatum - An early Experience Lt Col Bipin Puri*, Brig SK Kaul,
+
VSM
, Lt Col MM Harjai#
Abstract The technique of minimally invasive repair of pectus excavatum is a new operation that allows for repair of this deformity without any cartilage resection or sternal osteotomy. The procedure has revolutionized the management of pectus excavatum. Six cases of pectus excavatum were referred to our centre for surgical correction. However, based on Haller’s CT index 2 merited surgery. Our results suggest that the minimally invasive repair of pectus excavatum is an exciting operation with minimal morbidity and excellent results. The innovative incorporation of thoracoscopic techniques and small but important modifications to the techniques will make this operation very effective and safe. MJAFI 2003; 59 : 316-319 Key Words : Minimally invasive surgery; Pectus excavatum
Introduction he repair of Pectus Excavatum (PE) defect in childhood has over the years gained wide acceptance. The development of restrictive lung disease after repair of PE by the somewhat extensive Ravitch procedure [1] is unusual, but may result in pulmonary symptoms that may vary from mild to severe. Poor growth of the bony thorax after pectus repair combined with increasing rigidity of the chest wall can severely limit vital capacity and air flow characteristics. This iatrogenically acquired morbidity stimulated the search for lesser surgical procedures with similar or better postoperative cosmetic results. It was in this backdrop then, the minimally invasive technique for PE correction was described by Donald Nuss in 1998 [2], which has rapidly achieved wide acceptance. This report presents our early experience of the minimally invasive technique utilized over a period of two years.
T
Material and Methods Six children with PE defects were seen in the Paediatric Surgery OPD of our hospital from May 1998 to date. There were 4 boys and 2 girls. All patients presented with a significant cosmetic defect and all of them were subjected to an initial exercise and posture programme in an attempt to halt / improve their deformity. Patients underwent history evaluation, physical examination, chest X-ray, CBC, PT, PTT, CT Chest (Fig 1 & 2), echocardiography and a cardiology and pulmonary consultation. All children were evaluated to assess nutritional or syndromic causes of this defect. There was this one child with florid Rickets with asymmetrical defect, who is on medical treatment and follow up. Of the 6 patients, only 2 were judged to warrant reconstructive surgery based on the severity of *
the defect. Haller’s CT index was 7.3 and 8 respectively in the operated patients and Pulmonary Function Tests (PFT) were severely affected in one of the operated patients. Surgical Technique The patient’s chest was measured before surgery and the correct length steel bar selected and bent using anvil bar benders. The operation was performed under general anaesthesia with muscle relaxation. The patient was positioned with both arms abducted at the shoulder to allow access to the lateral chest wall. After draping the patient, the selected steel bar was placed on the patient’s chest and bent into its final convex shape to conform to the desired anterior chest wall curvature. The stainless steel bar was given a slightly exaggerated convex curvature to allow for anterior chest wall pressure. A transverse incision 2.5 cm long was made in each lateral chest wall between the anterior and posterior axillary line. A skin tunnel was negotiated anteriorly and the previously selected intercostal space was entered with a Roberts clamp (Fig 3). The clamp was slowly advanced across the mediastinum immediately under the sternum, until it emerged on the opposite side. Two strands of No 1 silk were pulled through the tract, by a small incision over the contralateral corresponding intercostal space. Another Roberts clamp was negotiated through a skin tunnel entered from the opposite mid-axillary line to the midline and the silk suture were thus pulled across. After adequate widening of the tract, the previously prepared 1.5 cm wide and 2 mm thick surgical stainless steel bar was pulled beneath the sternum using the silk suture for traction. The bar was initially passed under the sternum with the convexity facing posteriorly. When the bar was in position, it was turned over so that the convexity of the bar now faced anteriorly, thereby raising the sternum to the desired position. The bar was secured with No 1 prolene sutures to the lateral chest wall muscles and
Classified Specialist (Surgery & Paediatric Surgery), Command Hospital (Southern Command), Pune - 411 040, +Commandant, Military Hospital, Namkum, #Classified Specialist (Surgery and Paediatric Surgery), 166 Military Hospital, C/o 56 APO.
Nuss Procedure
Fig. 1 : Pre-operative and post-operative CT scan of case No. 1
Fig. 2 : Pre-operative and post-operative CT scan of case No. 2
317
secured to another vertically disposed lateral stabilizing stainless steel bar. Before closing the incisions,positive end expiratory pressure of 4 to 5 cm of water was added to prevent pleural air trapping. A chest radiograph was obtained in operation theatre to check for pneumothorax (Fig 4). Liberal use of post-operative analgesia was instituted in the initial 3 to 5 days after surgery. The patients were discharged from hospital on the 10th and 12th postoperative days. Regular activity was permitted by the 30th day post operatively. Results Of the 2 patients selected for surgery, the first had been operated by the Ravitch procedure prior to this presentation and presented with a recurrent severe defect. The operation time was 95 and 75 minutes respectively. Blood loss in both our minimally invasive procedures ranged between 10 to 25 ml and length of hospitalization varied between 10 to 12 days. We had no complications in both the operated cases except for prolonged postoperative pain, which was adequately treated with opiates and NSAIDs. Postoperative cosmetic result was excellent and both the children continue to be on 3 monthly regular follow-up and await removal of their bars 2 years after the procedure.
Fig. 3 : Operative photograph showing technique
Fig. 4 : Post-operative X-ray showing SS bar in situ MJAFI, Vol. 59, No. 4, 2003
Discussion The technique for minimally invasive repair of PE was introduced to the American Paediatric Surgery Association in 1997, and the first report describing the experience and results with 42 patients was reported by Donald Nuss in 1998 [2]. The acceptance and popularity of this technique developed quickly among patients and surgeons mainly because of its less radical approach and excellent results. The principal advantage of the minimally invasive repair for pectus excavatum (MIRPE) technique was based on the fact that there was no need for an anterior chest wall incision, pectoralis muscle flap resection of rib cartilage or to perform sternal osteotomy. This resulted in a shorter operating time, minimal blood
318
Puri, Kaul and Harjai
Fig. 7 : Case No. 2 preoperatively
Fig. 5 : Case No. 1 preoperatively
Fig. 6 : Case No. 1 postoperatively
Fig. 8 : Case No. 2 postoperatively MJAFI, Vol. 59, No. 4, 2003
Nuss Procedure
loss and early return to full activity. The long term cosmetic result was considered excellent with normal long term chest expansion, flexibility and elasticity. The apparent simplicity of the technique combined with the good results reported, probably led to early enthusiasm and widespread use of this operation among Paediatric surgeons. The common complications observed in literature include displacement of the stainless steel bar, postoperative pneumothorax and postoperative infection [3]. Other less common complications included thoracic outlet syndrome, cardiac injury and anterior thoracic artery pseudoaneurysm. Though our follow-up is small (14 and 12 months) respectively, we have had no complications till now. Most surgeons performing MIRPE consider their results and patient satisfaction excellent or good. The overall incidence of complications and problems with this new technique is reportedly high (21%). It is believed that this may be related to the learning curve associated with a new operation. To improve results, strict
319
adherence to technique, careful patient selection, use of lateral stabilizing bars, and use of thoracoscopy are all considered essential. The minimally invasive repair for PE is soon emerging as a suitable alternative to the hitherto standard Ravitch procedure. Ours is a small study with a limited follow up. We feel that results of MIRPE would be suboptimal in asymmetrical defects due to difficulty in contouring of the stainless steel bar to the sternal curvature. Notwithstanding the above, this minimally invasive technique for correction of PE has produced encouraging results. References 1. Ravitch MM. The operative treatment of pectus excavatum. Ann Surg 1949;129:429-44. 2. Nuss D, Kelly RE Jr, Croitoru DP, Katz ME. A 10 year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545-52. 3. Engum S, Rescorla F, West K, Rouse T, Scherer LR, Grosfeld J. Is the grass Greener? Early results of the Nuss procedure. J Pediatr Surg 2000;35:246-51.
A man went to see his doctor because he was suffering from a miserable cold. His doctor prescribed some pills, but they didn’t help. On his next visit the doctor gave him a shot, but that didn’t do any good. On his third visit the doctor told the man, “Go home and take a hot bath. As soon as you finish bathing throw open all the windows and stand in the draft.” “But doc,” protested the patient, “if I do that, I’ll get pneumonia.” “I know,” said the doctor, “I can cure pneumonia.”
MJAFI, Vol. 59, No. 4, 2003
+
VSM
, Lt Col MM Harjai#
Abstract The technique of minimally invasive repair of pectus excavatum is a new operation that allows for repair of this deformity without any cartilage resection or sternal osteotomy. The procedure has revolutionized the management of pectus excavatum. Six cases of pectus excavatum were referred to our centre for surgical correction. However, based on Haller’s CT index 2 merited surgery. Our results suggest that the minimally invasive repair of pectus excavatum is an exciting operation with minimal morbidity and excellent results. The innovative incorporation of thoracoscopic techniques and small but important modifications to the techniques will make this operation very effective and safe. MJAFI 2003; 59 : 316-319 Key Words : Minimally invasive surgery; Pectus excavatum
Introduction he repair of Pectus Excavatum (PE) defect in childhood has over the years gained wide acceptance. The development of restrictive lung disease after repair of PE by the somewhat extensive Ravitch procedure [1] is unusual, but may result in pulmonary symptoms that may vary from mild to severe. Poor growth of the bony thorax after pectus repair combined with increasing rigidity of the chest wall can severely limit vital capacity and air flow characteristics. This iatrogenically acquired morbidity stimulated the search for lesser surgical procedures with similar or better postoperative cosmetic results. It was in this backdrop then, the minimally invasive technique for PE correction was described by Donald Nuss in 1998 [2], which has rapidly achieved wide acceptance. This report presents our early experience of the minimally invasive technique utilized over a period of two years.
T
Material and Methods Six children with PE defects were seen in the Paediatric Surgery OPD of our hospital from May 1998 to date. There were 4 boys and 2 girls. All patients presented with a significant cosmetic defect and all of them were subjected to an initial exercise and posture programme in an attempt to halt / improve their deformity. Patients underwent history evaluation, physical examination, chest X-ray, CBC, PT, PTT, CT Chest (Fig 1 & 2), echocardiography and a cardiology and pulmonary consultation. All children were evaluated to assess nutritional or syndromic causes of this defect. There was this one child with florid Rickets with asymmetrical defect, who is on medical treatment and follow up. Of the 6 patients, only 2 were judged to warrant reconstructive surgery based on the severity of *
the defect. Haller’s CT index was 7.3 and 8 respectively in the operated patients and Pulmonary Function Tests (PFT) were severely affected in one of the operated patients. Surgical Technique The patient’s chest was measured before surgery and the correct length steel bar selected and bent using anvil bar benders. The operation was performed under general anaesthesia with muscle relaxation. The patient was positioned with both arms abducted at the shoulder to allow access to the lateral chest wall. After draping the patient, the selected steel bar was placed on the patient’s chest and bent into its final convex shape to conform to the desired anterior chest wall curvature. The stainless steel bar was given a slightly exaggerated convex curvature to allow for anterior chest wall pressure. A transverse incision 2.5 cm long was made in each lateral chest wall between the anterior and posterior axillary line. A skin tunnel was negotiated anteriorly and the previously selected intercostal space was entered with a Roberts clamp (Fig 3). The clamp was slowly advanced across the mediastinum immediately under the sternum, until it emerged on the opposite side. Two strands of No 1 silk were pulled through the tract, by a small incision over the contralateral corresponding intercostal space. Another Roberts clamp was negotiated through a skin tunnel entered from the opposite mid-axillary line to the midline and the silk suture were thus pulled across. After adequate widening of the tract, the previously prepared 1.5 cm wide and 2 mm thick surgical stainless steel bar was pulled beneath the sternum using the silk suture for traction. The bar was initially passed under the sternum with the convexity facing posteriorly. When the bar was in position, it was turned over so that the convexity of the bar now faced anteriorly, thereby raising the sternum to the desired position. The bar was secured with No 1 prolene sutures to the lateral chest wall muscles and
Classified Specialist (Surgery & Paediatric Surgery), Command Hospital (Southern Command), Pune - 411 040, +Commandant, Military Hospital, Namkum, #Classified Specialist (Surgery and Paediatric Surgery), 166 Military Hospital, C/o 56 APO.
Nuss Procedure
Fig. 1 : Pre-operative and post-operative CT scan of case No. 1
Fig. 2 : Pre-operative and post-operative CT scan of case No. 2
317
secured to another vertically disposed lateral stabilizing stainless steel bar. Before closing the incisions,positive end expiratory pressure of 4 to 5 cm of water was added to prevent pleural air trapping. A chest radiograph was obtained in operation theatre to check for pneumothorax (Fig 4). Liberal use of post-operative analgesia was instituted in the initial 3 to 5 days after surgery. The patients were discharged from hospital on the 10th and 12th postoperative days. Regular activity was permitted by the 30th day post operatively. Results Of the 2 patients selected for surgery, the first had been operated by the Ravitch procedure prior to this presentation and presented with a recurrent severe defect. The operation time was 95 and 75 minutes respectively. Blood loss in both our minimally invasive procedures ranged between 10 to 25 ml and length of hospitalization varied between 10 to 12 days. We had no complications in both the operated cases except for prolonged postoperative pain, which was adequately treated with opiates and NSAIDs. Postoperative cosmetic result was excellent and both the children continue to be on 3 monthly regular follow-up and await removal of their bars 2 years after the procedure.
Fig. 3 : Operative photograph showing technique
Fig. 4 : Post-operative X-ray showing SS bar in situ MJAFI, Vol. 59, No. 4, 2003
Discussion The technique for minimally invasive repair of PE was introduced to the American Paediatric Surgery Association in 1997, and the first report describing the experience and results with 42 patients was reported by Donald Nuss in 1998 [2]. The acceptance and popularity of this technique developed quickly among patients and surgeons mainly because of its less radical approach and excellent results. The principal advantage of the minimally invasive repair for pectus excavatum (MIRPE) technique was based on the fact that there was no need for an anterior chest wall incision, pectoralis muscle flap resection of rib cartilage or to perform sternal osteotomy. This resulted in a shorter operating time, minimal blood
318
Puri, Kaul and Harjai
Fig. 7 : Case No. 2 preoperatively
Fig. 5 : Case No. 1 preoperatively
Fig. 6 : Case No. 1 postoperatively
Fig. 8 : Case No. 2 postoperatively MJAFI, Vol. 59, No. 4, 2003
Nuss Procedure
loss and early return to full activity. The long term cosmetic result was considered excellent with normal long term chest expansion, flexibility and elasticity. The apparent simplicity of the technique combined with the good results reported, probably led to early enthusiasm and widespread use of this operation among Paediatric surgeons. The common complications observed in literature include displacement of the stainless steel bar, postoperative pneumothorax and postoperative infection [3]. Other less common complications included thoracic outlet syndrome, cardiac injury and anterior thoracic artery pseudoaneurysm. Though our follow-up is small (14 and 12 months) respectively, we have had no complications till now. Most surgeons performing MIRPE consider their results and patient satisfaction excellent or good. The overall incidence of complications and problems with this new technique is reportedly high (21%). It is believed that this may be related to the learning curve associated with a new operation. To improve results, strict
319
adherence to technique, careful patient selection, use of lateral stabilizing bars, and use of thoracoscopy are all considered essential. The minimally invasive repair for PE is soon emerging as a suitable alternative to the hitherto standard Ravitch procedure. Ours is a small study with a limited follow up. We feel that results of MIRPE would be suboptimal in asymmetrical defects due to difficulty in contouring of the stainless steel bar to the sternal curvature. Notwithstanding the above, this minimally invasive technique for correction of PE has produced encouraging results. References 1. Ravitch MM. The operative treatment of pectus excavatum. Ann Surg 1949;129:429-44. 2. Nuss D, Kelly RE Jr, Croitoru DP, Katz ME. A 10 year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545-52. 3. Engum S, Rescorla F, West K, Rouse T, Scherer LR, Grosfeld J. Is the grass Greener? Early results of the Nuss procedure. J Pediatr Surg 2000;35:246-51.
A man went to see his doctor because he was suffering from a miserable cold. His doctor prescribed some pills, but they didn’t help. On his next visit the doctor gave him a shot, but that didn’t do any good. On his third visit the doctor told the man, “Go home and take a hot bath. As soon as you finish bathing throw open all the windows and stand in the draft.” “But doc,” protested the patient, “if I do that, I’ll get pneumonia.” “I know,” said the doctor, “I can cure pneumonia.”
MJAFI, Vol. 59, No. 4, 2003
