Ultrasound-Guided Extrapleural Nuss Procedure for Pectus Excavatum Repair Jinbo Zhao, MD, PhD,* Nan Ma, MD,* Lijun Yuan, MD, PhD, Xiaofei Li, MD, PhD, and Yong Han, MD, PhD Departments of Thoracic Surgery, Ophthalmology, and Diagnostic Ultrasound, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
The minimally invasive Nuss procedure has been widely utilized to treat pectus excavatum. In the present study, intraoperative ultrasonography to guide placement of a Nuss bar, instead of thoracoscopy, is described. This
technique may be a simple and safe method to avoid cardiac injury. (Ann Thorac Surg 2014;98:1863–4) Ó 2014 by The Society of Thoracic Surgeons
he Nuss procedure has been performed clinically for more than 2 decades to treat pectus excavatum, the most common chest wall malformation in humans [1]. Special techniques or modifications have been developed to reduce complications associated with the Nuss procedure [2, 3]. However, one of the most severe complications, heart injury, remains even with thoracoscopic visualization. We have developed a safe and feasible extrapleural Nuss procedure using intraoperative ultrasonography to safely guide placement of the Nuss bar.
Technique Our previous technique has been an extrapleural Nuss procedure [2]. Although this previous experience was successful, we have been concerned about the possibility of cardiac injury. This concern led us to explore ultrasonographic visualization as a means to avoid this complication. This report describes our new technique. A waterfilled balloon is placed in the sternal depression to facilitate ultrasound visualization (Fig 1). Ultrasonography can measure the distance between the inner table of the sternum and the pericardium, monitor creation of an extrapleural tunnel bilaterally, and guide the dissector tip, placed laterally to the sternum, during its passage between the sternum and pericardium to the opposite side, avoiding cardiac injury (Fig 2). From January 1, 2013, to December 1, 2013, 4 patients with pectus excavatum successfully received ultrasoundguided extrapleural Nuss Procedure at Tangdu Hospital, Xi’an, China. Compared with our previous technique [2], the current procedure is slightly longer. There has been no blood loss or pneumothorax. Accepted for publication April 4, 2014. *Drs Zhao and Ma contributed equally to this work. Address correspondence to Dr Han, Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi’an 710038, China; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. The scanning position for ultrasound-guided extrapleural Nuss procedure. A water-filled balloon (WB) is used to fill the gap between the ultrasonic probe (UP) and the chest wall. With the guidance of ultrasonography, the dissector can be safely inserted through the deepest depression of the sternum and inserted into the space between the sternum and the pericardium.
Comment The most dangerous maneuver during the Nuss procedure is placement of the dissector through the space between the sternum and the heart. Even with the help of thoracoscope, the risk of cardiac perforation still exists [3]. Several methods have been developed to avoid this life-threatening complication. For example, special instruments have been designed to elevate the chest wall and the sternum [4–6]. A modified bilateral thoracoscopic approach was recommended [3]. Despite these techniques, a portion of the retrosternal space may still not be visible. Additional incisions and technique may cause more pain. Here, we reported a new method of using intraoperative ultrasonography to guide the dissector and the Nuss bar insertion. This method has certain advantages. First, the whole surgical procedure can be directly monitored by ultrasonography, which may reduce the potential injury to the pericardium and to the heart. Second, our technique can be used in patients who have an obliterated pleural cavity, where thoracoscopy would be hazardous. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.04.065
FEATURE ARTICLES
T
1864
HOW TO DO IT ZHAO ET AL ULTRASOUND-GUIDED NUSS PROCEDURE
Ann Thorac Surg 2014;98:1863–4
Although our experience is small, we believe the described technique may make the Nuss procedure safer, by avoiding the most serious complication—cardiac perforation. The authors would like to thank Drs Yonggang Zhou and Hongkui Gao for performing the intraoperative ultrasonography guidance. We greatly appreciated Dr Mingyao Liu, Professor of Surgery, Faculty of Medicine, University of Toronto, for critically reading and revising this manuscript.
References
FEATURE ARTICLES
1. Kelly RE, Goretsky MJ, Obermeyer R, et al. Twenty-one years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients. Ann Surgery 2010;252:1072–81. 2. Han Y, Wang J, Li W, et al. Non-thoracoscopic extrapleural Nuss procedure for the correction of pectus excavatum in children. Eur J Cardiothorac Surg 2010;37:312–5. 3. Ohno K, Nakamura T, Azuma T, et al. Modification of the Nuss procedure for pectus excavatum to prevent cardiac perforation. J Pediatr Surg 2009;44:2426–30. 4. Johnson WR, Fedor D, Singhal S. A novel approach to eliminate cardiac perforation in the Nuss procedure. Ann Thorac Surg 2013;95:1109–11. 5. Takagi S, Oyama T, Tomokazu N, et al. A new sternum elevator reduces severe complications during minimally invasive repair of the pectus excavatum. Pediatr Surg Int 2012;28:623–6. 6. Tedde ML, de Campos JR, Wihlm JM, Jatene FB. The Nuss procedure made safer: an effective and simple sternal elevation manoeuvre. Eur J Cardiothorac Surg 2012;42:890–1.
Fig 2. (A) The tip of the dissector was guided by ultrasonography and safely inserted into the space between the sternum and the pericardium. Yellow dotted line indicates the outline of the echogenicity of the dissector. (B) The ultrasonic view after operation. Yellow dotted line indicates the outline of the echogenicity of the Nuss bar. Red dotted line indicates the edge of the echogenicity of the pericardial surface. (H ¼ heart; S ¼ sternum; WB ¼ water-filled balloon.)
The minimally invasive Nuss procedure has been widely utilized to treat pectus excavatum. In the present study, intraoperative ultrasonography to guide placement of a Nuss bar, instead of thoracoscopy, is described. This
technique may be a simple and safe method to avoid cardiac injury. (Ann Thorac Surg 2014;98:1863–4) Ó 2014 by The Society of Thoracic Surgeons
he Nuss procedure has been performed clinically for more than 2 decades to treat pectus excavatum, the most common chest wall malformation in humans [1]. Special techniques or modifications have been developed to reduce complications associated with the Nuss procedure [2, 3]. However, one of the most severe complications, heart injury, remains even with thoracoscopic visualization. We have developed a safe and feasible extrapleural Nuss procedure using intraoperative ultrasonography to safely guide placement of the Nuss bar.
Technique Our previous technique has been an extrapleural Nuss procedure [2]. Although this previous experience was successful, we have been concerned about the possibility of cardiac injury. This concern led us to explore ultrasonographic visualization as a means to avoid this complication. This report describes our new technique. A waterfilled balloon is placed in the sternal depression to facilitate ultrasound visualization (Fig 1). Ultrasonography can measure the distance between the inner table of the sternum and the pericardium, monitor creation of an extrapleural tunnel bilaterally, and guide the dissector tip, placed laterally to the sternum, during its passage between the sternum and pericardium to the opposite side, avoiding cardiac injury (Fig 2). From January 1, 2013, to December 1, 2013, 4 patients with pectus excavatum successfully received ultrasoundguided extrapleural Nuss Procedure at Tangdu Hospital, Xi’an, China. Compared with our previous technique [2], the current procedure is slightly longer. There has been no blood loss or pneumothorax. Accepted for publication April 4, 2014. *Drs Zhao and Ma contributed equally to this work. Address correspondence to Dr Han, Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi’an 710038, China; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. The scanning position for ultrasound-guided extrapleural Nuss procedure. A water-filled balloon (WB) is used to fill the gap between the ultrasonic probe (UP) and the chest wall. With the guidance of ultrasonography, the dissector can be safely inserted through the deepest depression of the sternum and inserted into the space between the sternum and the pericardium.
Comment The most dangerous maneuver during the Nuss procedure is placement of the dissector through the space between the sternum and the heart. Even with the help of thoracoscope, the risk of cardiac perforation still exists [3]. Several methods have been developed to avoid this life-threatening complication. For example, special instruments have been designed to elevate the chest wall and the sternum [4–6]. A modified bilateral thoracoscopic approach was recommended [3]. Despite these techniques, a portion of the retrosternal space may still not be visible. Additional incisions and technique may cause more pain. Here, we reported a new method of using intraoperative ultrasonography to guide the dissector and the Nuss bar insertion. This method has certain advantages. First, the whole surgical procedure can be directly monitored by ultrasonography, which may reduce the potential injury to the pericardium and to the heart. Second, our technique can be used in patients who have an obliterated pleural cavity, where thoracoscopy would be hazardous. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.04.065
FEATURE ARTICLES
T
1864
HOW TO DO IT ZHAO ET AL ULTRASOUND-GUIDED NUSS PROCEDURE
Ann Thorac Surg 2014;98:1863–4
Although our experience is small, we believe the described technique may make the Nuss procedure safer, by avoiding the most serious complication—cardiac perforation. The authors would like to thank Drs Yonggang Zhou and Hongkui Gao for performing the intraoperative ultrasonography guidance. We greatly appreciated Dr Mingyao Liu, Professor of Surgery, Faculty of Medicine, University of Toronto, for critically reading and revising this manuscript.
References
FEATURE ARTICLES
1. Kelly RE, Goretsky MJ, Obermeyer R, et al. Twenty-one years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients. Ann Surgery 2010;252:1072–81. 2. Han Y, Wang J, Li W, et al. Non-thoracoscopic extrapleural Nuss procedure for the correction of pectus excavatum in children. Eur J Cardiothorac Surg 2010;37:312–5. 3. Ohno K, Nakamura T, Azuma T, et al. Modification of the Nuss procedure for pectus excavatum to prevent cardiac perforation. J Pediatr Surg 2009;44:2426–30. 4. Johnson WR, Fedor D, Singhal S. A novel approach to eliminate cardiac perforation in the Nuss procedure. Ann Thorac Surg 2013;95:1109–11. 5. Takagi S, Oyama T, Tomokazu N, et al. A new sternum elevator reduces severe complications during minimally invasive repair of the pectus excavatum. Pediatr Surg Int 2012;28:623–6. 6. Tedde ML, de Campos JR, Wihlm JM, Jatene FB. The Nuss procedure made safer: an effective and simple sternal elevation manoeuvre. Eur J Cardiothorac Surg 2012;42:890–1.
Fig 2. (A) The tip of the dissector was guided by ultrasonography and safely inserted into the space between the sternum and the pericardium. Yellow dotted line indicates the outline of the echogenicity of the dissector. (B) The ultrasonic view after operation. Yellow dotted line indicates the outline of the echogenicity of the Nuss bar. Red dotted line indicates the edge of the echogenicity of the pericardial surface. (H ¼ heart; S ¼ sternum; WB ¼ water-filled balloon.)
