Nuss procedure

Overview

The Nuss procedure is a surgery to correct pectus excavatum. The Nuss procedure also is called minimally invasive repair of pectus excavatum (MIRPE).

Pectus excavatum is a condition in which the breastbone and rib cartilage sink inward. Pectus excavatum can affect more than how your chest looks. More-severe forms can cause symptoms such as shortness of breath, chest pain or a fast heartbeat that can feel like pounding or fluttering.

The goal of the Nuss procedure is to reposition the sunken chest wall without removing cartilage. For some people, surgery can improve symptoms such as pain or breathing issues. Most mild forms of pectus excavatum do not need surgery.

The Nuss procedure is different from the Ravitch procedure, which is another operation surgeons use to treat pectus excavatum. The Nuss procedure is minimally invasive. A surgeon makes small cuts on the sides of the chest and places a curved metal bar behind the sunken breastbone to lift it forward.

The Ravitch procedure is an open surgery. A surgeon makes a larger cut in the chest to remove rib cartilage and reshape the breastbone.

The Nuss procedure is commonly done to correct pectus excavatum in children and teenagers. The Nuss procedure also can be performed in adults. Because the chest wall becomes less flexible with age, surgery may be more complex in older teens and adults. Adults also may have more pain and bleeding after surgery than younger people.

Why it's done

Your healthcare team may consider the Nuss procedure if your sunken breastbone is causing:

• Chest pain.
• Breathing issues.
• Fatigue.
• Decreased exercise tolerance.

The Nuss procedure also may be considered for people who feel concerned about their appearance or people who had previous surgery that did not correct the pectus excavatum.

The Nuss procedure is not used to treat a condition called pectus carinatum. With pectus carinatum, the chest wall is not sunken. It projects outward.

Risks

The Nuss procedure can cause pain, nausea and vomiting after surgery.

Surgical complications may include:

• Infection. The tissue around the implanted bar can become infected.
• Fluid, air or blood around the lungs. Fluid can collect around the lungs. This is called a pleural effusion. Blood also can collect around the lungs. This is called a hemothorax. Air can partially collapse a lung. This is called a pneumothorax.
• Fluid or inflammation around the heart. Fluid that collects around the heart is called a pericardial effusion. Inflammation around the heart is called pericarditis.
• Bar movement. Sometimes the implanted bar can move or shift after surgery.
• Chest injury. Rarely, the bar can injure the lungs, heart or blood vessels during placement.
• Allergic reaction to the metal in the bar. Some people can have an allergic reaction to the metal in the bar.

What you can expect

Even though the surgeon uses small cuts during the Nuss procedure, the surgery can still cause pain. Your healthcare team can help you manage nausea and pain before, during and after surgery.

During the procedure, the surgeon places one or more curved metal bars behind your breastbone to lift your sunken chest. The bar remains inside your chest for several years while your chest wall adapts to its new shape. The bar will be removed during a future operation.

Before the procedure

Before a Nuss procedure, your healthcare team may:

• Review your medical history, symptoms and results from any previous imaging.
• Do a physical exam.
• Order chest X-rays, magnetic resonance imaging (MRI) scan, computerized tomography (CT scan) to see if the pectus excavatum is affecting your heart or lungs. Imaging also may be used to help calculate the Haller index. This index measures how much your chest is sinking.

Your healthcare team also may order the following tests:

• Electrocardiogram (ECG or EKG). An EKG shows how the heart is beating.
• Echocardiogram. An echocardiogram uses sound waves to take pictures of the heart.
• Cardiopulmonary exercise tests (CPET). A CPET measures how the heart and lungs work during exercise.

Tell your healthcare team if you have a heart condition or if you have any known allergies to metals.

During the procedure

During a Nuss procedure, you are given general anesthesia. This puts you in a sleeplike state during the operation.

You lie on your back for the procedure. The surgeon makes small cuts on each side of your chest and places a small camera, called a thoracoscope, inside the chest. The thoracoscope helps the surgeon see your heart, lungs and other structures. The thoracoscope also helps guide the surgeon to the area behind your breastbone. Once there, the surgeon inserts one or more curved metal bars that push the breastbone forward. The bar is then secured to your ribs and chest wall with stitches and small metal pieces called stabilizers.

Your healthcare team may manage your pain using one or more of the following methods:

• Intravenous (IV) medicines. During and after a Nuss procedure, pain medicines are given directly into a vein through a small, flexible tube called an intravenous (IV) line.
• Intercostal nerve cryoablation. During the Nuss procedure, the surgeon places a freezing probe against the intercostal nerves. The intercostal nerves are located between the ribs. The cold temporarily stops the nerve from carrying pain signals.

After the procedure

After a Nuss procedure, you go to a recovery area to rest while your anesthesia wears off. Your healthcare team monitors you to make sure you are comfortable, with your pain controlled and breathing as usual.

Your healthcare team continues to manage your pain and nausea with a variety of medicines. People usually have chest X-rays taken to check on the bar's position and to see if there is any fluid or air around your lungs.

Adults usually have more pain and may have more complications after surgery compared with children and teens.

Recovery time is different for everyone. You typically can go home once you are able to breathe well, walk safely, and control your pain with pills or liquid medicines. Your healthcare team lets you know when to schedule a follow-up appointment. Follow-up appointments are to monitor your chest and make sure the bar stays in place. Your care team will tell you how long the bar needs to stay in place. The bar will be removed in a later operation.

Results

Success can mean different things to different people. For some people, success means the chest is less sunken and they are happier with how they look. For others, success may mean fewer symptoms or being able to exercise more easily.

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