Nuss Procedure (Pectus Excavatum Surgery)

The Nuss procedure is a minimally invasive surgery to treat pectus excavatum, the most common chest wall deformity in children. Abnormal cartilage growth inside the chest pushes a child's sternum (breastbone) downward, causing a sunken or concave-looking chest.

The sternum may also press on your child's heart or lungs, causing exercise intolerance and other symptoms. In addition, many children deal with self-esteem or body image issues because of how their chest looks.

The goal of the Nuss procedure is to restore the sternum to its natural position.

Benefits include:

• Improving the chest's appearance.
• Relieving heart- and lung-related symptoms.

The Nuss procedure is the most common surgical procedure for pectus excavatum. It requires small incisions on the chest. Because it's minimally invasive, it has a low risk of complications and requires a shorter hospital stay. Using a technique called cryoablation to freeze the intercostal nerves around the sternum during the procedure can reduce post-op pain.

The Nuss procedure has largely replaced the Ravitch procedure, which uses a large incision across the chest and excises the cartilage on each side of the sternum. The Ravitch procedure now is only performed in rare circumstances, such as when pectus excavatum recurs after the Nuss procedure.

Before surgery takes place, you and your child will meet with a pediatric thoracic (chest) surgeon. They'll discuss the benefits and risks of the Nuss procedure with you to see if you wish to move forward. They'll also perform tests to see if your child qualifies for surgery.

These tests include:

• CT scan — Measures the depth of the impression in your child's chest.
• Echocardiogram — Determines whether the sternum is affecting how the heart functions.
• Pulmonary (lung) function test — Determine whether the sternum is affecting the lungs' ability to function.

Once your child is scheduled for surgery, their care team will provide instructions on how to prepare. They'll give you specific directions for eating and drinking before the surgery and let you know when to arrive.

On the day of the procedure, your child will be placed under general anesthesia. Afterward, they'll be moved to the operating room.

During the procedure, the surgeon will make small incisions on each side of the chest. They'll insert a tiny camera into the chest through another incision to see what they're doing during the procedure.

The surgeon will then place a curved metal bar into the chest. The bar is specifically modified and fitted for each child. Using the camera for guidance, they'll place the bar behind the sternum and flip it.

Depending on the age of the child and the severity of the defect, a second, or even third bar may be placed.

The bar will immediately push the sternum up into its rightful position.

After placing the bar, the surgeon will use side stabilizers and wires, sutures, or other fasteners to secure it inside the chest.

During the procedure, the surgeon may also perform cryoablation. This technique involves freezing the intercostal nerves in the area around the sternum. Cryoablation can help reduce your child's pain after the procedure.

After completing the procedure, the surgeon will close the small incisions in your child's chest.

The procedure typically lasts from 90 minutes to three hours. The bar will remain in place for three years before the surgeon removes it.

Like any surgery, the Nuss procedure carries risks of bleeding and infection. More specific risks of the Nuss procedure include damage to the heart and lungs while placing the bar. Using the camera to place the bar minimizes these risks.

You'll receive specific instructions from your child's care team about how to prepare your child for the Nuss procedure. Because this surgery includes general anesthesia, there will be specific eating and drinking instructions for your child before the procedure.

Eating and drinking instructions are based on a child's age. Below are the typical instructions for eating and drinking before the surgery. But no matter how old your child is, you should follow the specific instructions you receive from their care team.

For all children:

• After midnight on the night before the surgery, do not give your child any solid food or non-clear liquids. This includes milk, formula, juices with pulp, coffee, chewing gum, or candy.
• Up to two hours before the scheduled arrival time, give only clear liquids. Clear liquids include water, Pedialyte^®, Kool-Aid^®, and see-through juices like apple or white grape juice.
• Beginning two hours before you're scheduled to arrive at the hospital, give your child nothing to eat or drink.

If your child is taking any medications, ask their care team if they can continue to use them until the day of the procedure.

They can continue to stay active until the day of the procedure.

If you have any specific questions, including when to arrive, what to bring, what your child should wear, ask your child's care team.

While your child is under general anesthesia, their care team will continuously monitor their vital signs.

These include their:

• Blood pressure
• Heart rate
• Oxygen level
• Temperature

Your child will have a breathing tube placed during the surgery, which may cause a sore throat after the procedure.

To keep your child asleep during the procedure, they may receive anesthetic medicine through the breathing tube, IV tube, or both. These medications will stop after the procedure, and your child will start to wake up.

After the surgery, your child will be moved to the recovery room. You'll also be brought to the room so you can be there when they wake up.

Your child's surgeon will discuss the procedure with you. You can ask questions about the surgery, their recovery, and instructions for pain medications, diet, and activity.

Your child will stay in the recovery room until they're alert and their vital signs are stable. The amount of time spent in recovery varies, as some children take longer to wake up from anesthesia.

Children coming out of anesthesia react in different ways. These normal reactions will go away as the anesthesia wears off.

Your child will spend the night after the procedure in the intensive care unit (ICU) before moving to the postoperative inpatient unit.

The most important role of a parent or guardian is to help your child stay calm and relaxed before the surgery. The best way to help your child stay calm is for you to stay calm.

During the surgery, at least one parent or guardian should remain in the surgical family waiting area at all times in case the family needs to be reached.

Recovery from the Nuss procedure will take place over several months.

How long will my child be in the hospital?

The typical hospital stay after the Nuss procedure is three to seven days.

What's the general recovery process before discharge?

Beginning the day after surgery, your child's care team will get them out of bed and moving around. They'll check your child's pain tolerance and determine whether they can perform routine daily activities.

How much pain will my child be in?

Your child's pain level after the Nuss procedure may depend on whether the surgeon used cryoablation and whether it was successful.

If cryoablation was successful, your child will likely feel less pain. This can typically be managed with over-the-counter (OTC) pain medications, such as acetaminophen (Tylenol®) or ibuprofen (Motrin®).

If cryoablation wasn't used or wasn't successful, your child's doctor may prescribe stronger medications for their pain.

What will you send home with my child?

When your child is discharged, you'll receive specific instructions on how to care for them. This includes instructions on caring for their incisions, what activities they can and can't do, and which medications to use.

What should I use to manage my child's pain?

For most children, over-the-counter (OTC) medications like acetaminophen or ibuprofen will be able to manage their pain — especially if cryoablation was used during the procedure.

If your child is in severe pain after the procedure, their doctor may write a prescription for a stronger pain medication.

If your child is in a lot of pain in the days and weeks after their surgery, contact their doctor and ask about a stronger medication.

When can my child return to activity?

The return to activity after the Nuss procedure occurs over the course of about six months:

• In the first two weeks after the operation, activity should be strictly limited. Your child should limit movement of the arms and upper body as much as possible. They may need to stay home from school and refrain from other activities.
• From two to six weeks after the operation, your child can start regaining their arm mobility and begin moving around more.
• From six weeks to three months after the procedure, your child can regain normal activity — except for sports and exercise.
• At three months post-procedure, your child should be cleared for noncontact sports.
• At six months post-procedure, your child should be cleared for contact sports.

It's important to follow this schedule to avoid complications, such as the bar flipping inside the chest.

How often will my child need to come back for follow-ups?

After the procedure, your child will have follow-up visits at:

• Two weeks post-op.
• Six weeks post-op.
• Three months post-op.
• Six months post-op.
• One-year post-op.
• Then every six months post-op until the bar is removed at three years.

Their doctor will check their recovery status and make recommendations about how much activity they can do.

Beginning one year after the surgery, your child will visit the surgeon every six months until the bar is removed.

When is the bar removed after the Nuss procedure?

The bar is typically removed three years after the Nuss procedure in an outpatient procedure.

What is my child's outlook after the Nuss procedure?

After the Nuss procedure, most children can resume normal, healthy lives moving forward. If they had heart or lung symptoms because of their pectus excavatum, the Nuss procedure can resolve those.

The Nuss procedure also restores the look of the chest. If your child experienced body image or self-esteem issues because of their chest's appearance, the Nuss procedure may help resolve those.

Complications of the procedure are very rare.

They may include:

• Bar displacement.
• Bleeding.
• Heart or lung damage.
• Hemothorax (a collection of blood in the area between the lungs and chest wall).
• Infection.
• Pleural effusion (a buildup of fluid between the lungs and chest wall).
• Pneumothorax (collapsed lung).
• Recurring pectus excavatum.

Call your child's surgeon if your child:

• Feels like the bar has moved or flipped.
• Has an unexplained fever.
• Has increased bleeding, drainage, bulging, or swelling at the site of their incisions.
• Has lingering or increased pain.
• Notices that their pectus excavatum is returning.
• Suffers a blow to the chest.

If you have any specific questions about your child’s surgery, you should discuss them with the surgeon before surgery. You can also speak with them during the presurgical exam on the day of surgery.

If your child has any special needs or health issues the doctor needs to know about, please contact the surgeon before their surgery. It's important to notify us in advance about any special needs your child might have.