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A straightforward technique for removal of the substernal bar after the Nuss operation
Journal of Pediatric Surgery (2007) 42, 1789–1791
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A straightforward technique for removal of the substernal bar after the Nuss operation Shawn D. St Peter, Ronald J. Sharp, Prashant Upadhyaya, KuoJen Tsao, Daniel J. Ostlie, George W. Holcomb ⁎ Children's Mercy Hospital, Katharine Berry Richardson Professor of Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
Index words: Pectus bar removal; Pectus excavatum; Minimally invasive technique
Abstract Pectus excavatum is the most common chest wall deformity seen in the pediatric population. There have been a number of reports describing the operative correction of pectus excavatum, but scant literature is available describing removal of the substernal bar. This report describes a straightforward technique for removal of the substernal bar after the Nuss operation. This technique has been used in more than 110 patients without complications. © 2007 Elsevier Inc. All rights reserved.
Pectus excavatum is the most common chest wall deformity seen in the pediatric population. Minimally invasive repair of pectus excavatum (the Nuss operation) has rapidly evolved to become the preferred technique in the last decade. Most surgeons remove the bar as an outpatient procedure 2 to 3 years after its placement. Very few published data are available detailing the technique of pectus bar removal. Therefore, we report our straightforward operative technique for bar removal after a Nuss procedure.
1. Technique Two operating tables are abutted perpendicular to each other forming a T (Fig. 1). The patient is induced and intubated with his or her head on the transverse table and his or her body on the vertically oriented table. After intubation, the patient's arms are extended 90° on the transverse table. The longitudinal table is then shifted caudally to create an ⁎ Corresponding author. Tel.: +1 816 234 3578; fax: +1 816 983 6885. E-mail address: [email protected] (G.W. Holcomb). 0022-3468/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2007.04.042
open space around the chest. The space extends from the base of the axilla to the lower ribcage. Thus, only the thoracic spine is unsupported. The chest is prepared circumferentially and wrapped with 2 half sheets (Fig. 2). The tables are situated at a height where the incisions are about the center of the surgeons' chest. The lateral chest incisions are incised simultaneously to remove the lateral stabilizers that are routinely used on each side. After removal of the stabilizers, the end of the bar is grasped on one side with vice grip pliers and removed with a single pull taking advantage of the open space to rotate the bar around the torso and under the patient's back (Fig. 3). The lateral incisions are then closed. After removal of the drapes, the vertical table is moved to abut the transverse table. To move the patient off the operating tables at the end of the procedure, the transverse table is shifted to one side to allow the transport bed to be positioned beside the operating table (Fig. 4).
2. Discussion Our surgical group has performed more than 240 Nuss operations to date [1] Several authors, including our group,
1790
Fig. 1 Photograph of the 2 tables demonstrating the circumferential space around the patient. The patient is induced with the tables adjacent to each other (A). The vertical table is then moved caudally, allowing a 360° preparation and drape (B).
Fig. 2 Two half sheets are wrapped around the patient after preparation.
S.D. St Peter et al.
Fig. 3 The bar is secured with sterile vice grips (A) and the bar (arrow) is then rotated around the patient's torso (B).
Fig. 4 The table that was positioned horizontally is moved to the right to allow the patient's recovery room bed to be positioned next to the patient.
Removal of the substernal bar after the Nuss operation
1791
have described minor modifications to the original Nuss procedure [1-5]. Currently, the bars are removed after a period of 2 to 3 years. Published data on the technique for pectus bar removal are scant. The procedure to remove the bar has been detailed to some extent in the review of 303 patients by Nuss and his colleagues [5]. Their described technique uses a bone hook to pull the end of the bar while the patient is rotated in the opposite direction. They also describe an alternative method in which a small bar bender is used to straighten the externalized portion of the bar as it is withdrawn, which obviates the need for the lateral decubitus position. Rotating a patient halfway during a surgery can be cumbersome and may result in a breach of the sterile barriers. To overcome this concern and to avoid patient rotation, the use of bar benders on both sides has been described [6]. With this technique, the bar is mobilized in the soft tissue, straightened and removed without altering the patient's position. Our technique avoids altering patient position, assures sterility, and avoids the need for any complex equipment or bar bending. This allows the bar to be removed smoothly following its resting arc, which avoids any torque on the bar and should minimize the risk of cardiac injury. Our technique uses 2 tables and can easily be used in all patients. The transverse table can have the table extensions removed leaving only the core of the table. This will result in the total space being equivalent to a patient with both arms left out on
arm boards with a single table. Thus, we have never found the 2-bed technique to be a compromise in space. We have used this technique in more than 110 patients and have not had any complications in removing the substernal bars in these patients. We use 2 stabilizers in every case of bar insertion. However, it is worth noting that surgeons using 1 stabilizer could easily perform this technique with a single incision on one side.
References [1] Miller KA, Woods RK, Sharp RJ, et al. Minimally invasive repair of pectus excavatum: a single institution's experience. Surgery 2001;130:652-7. [2] Fonkalsrud EW, Dunn JC, Atkinson JB. Repair of pectus excavatum deformities: 30 years of experience with 375 patients. Ann Surg 2000;231:443-8. [3] Hebra A, Swoveland B, Egbert M, et al. Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases. J Pediatr Surg 2000;35:252-7. [4] Osawa H, Mawatari T, Watanabe A, et al. New material for Nuss procedure. Ann Thorac Cardiovasc Surg 2004;10:301-3. [5] Croitoru DP, Kelly Jr RE, Goretsky MJ, et al. Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients. J Pediatr Surg 2002;37: 437-45. [6] Noguchi M, Fujita K. A new technique for removing the pectus bar used in the Nuss procedure. J Pediatr Surg 2005;40:674-7.
www.elsevier.com/locate/jpedsurg
A straightforward technique for removal of the substernal bar after the Nuss operation Shawn D. St Peter, Ronald J. Sharp, Prashant Upadhyaya, KuoJen Tsao, Daniel J. Ostlie, George W. Holcomb ⁎ Children's Mercy Hospital, Katharine Berry Richardson Professor of Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
Index words: Pectus bar removal; Pectus excavatum; Minimally invasive technique
Abstract Pectus excavatum is the most common chest wall deformity seen in the pediatric population. There have been a number of reports describing the operative correction of pectus excavatum, but scant literature is available describing removal of the substernal bar. This report describes a straightforward technique for removal of the substernal bar after the Nuss operation. This technique has been used in more than 110 patients without complications. © 2007 Elsevier Inc. All rights reserved.
Pectus excavatum is the most common chest wall deformity seen in the pediatric population. Minimally invasive repair of pectus excavatum (the Nuss operation) has rapidly evolved to become the preferred technique in the last decade. Most surgeons remove the bar as an outpatient procedure 2 to 3 years after its placement. Very few published data are available detailing the technique of pectus bar removal. Therefore, we report our straightforward operative technique for bar removal after a Nuss procedure.
1. Technique Two operating tables are abutted perpendicular to each other forming a T (Fig. 1). The patient is induced and intubated with his or her head on the transverse table and his or her body on the vertically oriented table. After intubation, the patient's arms are extended 90° on the transverse table. The longitudinal table is then shifted caudally to create an ⁎ Corresponding author. Tel.: +1 816 234 3578; fax: +1 816 983 6885. E-mail address: [email protected] (G.W. Holcomb). 0022-3468/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2007.04.042
open space around the chest. The space extends from the base of the axilla to the lower ribcage. Thus, only the thoracic spine is unsupported. The chest is prepared circumferentially and wrapped with 2 half sheets (Fig. 2). The tables are situated at a height where the incisions are about the center of the surgeons' chest. The lateral chest incisions are incised simultaneously to remove the lateral stabilizers that are routinely used on each side. After removal of the stabilizers, the end of the bar is grasped on one side with vice grip pliers and removed with a single pull taking advantage of the open space to rotate the bar around the torso and under the patient's back (Fig. 3). The lateral incisions are then closed. After removal of the drapes, the vertical table is moved to abut the transverse table. To move the patient off the operating tables at the end of the procedure, the transverse table is shifted to one side to allow the transport bed to be positioned beside the operating table (Fig. 4).
2. Discussion Our surgical group has performed more than 240 Nuss operations to date [1] Several authors, including our group,
1790
Fig. 1 Photograph of the 2 tables demonstrating the circumferential space around the patient. The patient is induced with the tables adjacent to each other (A). The vertical table is then moved caudally, allowing a 360° preparation and drape (B).
Fig. 2 Two half sheets are wrapped around the patient after preparation.
S.D. St Peter et al.
Fig. 3 The bar is secured with sterile vice grips (A) and the bar (arrow) is then rotated around the patient's torso (B).
Fig. 4 The table that was positioned horizontally is moved to the right to allow the patient's recovery room bed to be positioned next to the patient.
Removal of the substernal bar after the Nuss operation
1791
have described minor modifications to the original Nuss procedure [1-5]. Currently, the bars are removed after a period of 2 to 3 years. Published data on the technique for pectus bar removal are scant. The procedure to remove the bar has been detailed to some extent in the review of 303 patients by Nuss and his colleagues [5]. Their described technique uses a bone hook to pull the end of the bar while the patient is rotated in the opposite direction. They also describe an alternative method in which a small bar bender is used to straighten the externalized portion of the bar as it is withdrawn, which obviates the need for the lateral decubitus position. Rotating a patient halfway during a surgery can be cumbersome and may result in a breach of the sterile barriers. To overcome this concern and to avoid patient rotation, the use of bar benders on both sides has been described [6]. With this technique, the bar is mobilized in the soft tissue, straightened and removed without altering the patient's position. Our technique avoids altering patient position, assures sterility, and avoids the need for any complex equipment or bar bending. This allows the bar to be removed smoothly following its resting arc, which avoids any torque on the bar and should minimize the risk of cardiac injury. Our technique uses 2 tables and can easily be used in all patients. The transverse table can have the table extensions removed leaving only the core of the table. This will result in the total space being equivalent to a patient with both arms left out on
arm boards with a single table. Thus, we have never found the 2-bed technique to be a compromise in space. We have used this technique in more than 110 patients and have not had any complications in removing the substernal bars in these patients. We use 2 stabilizers in every case of bar insertion. However, it is worth noting that surgeons using 1 stabilizer could easily perform this technique with a single incision on one side.
References [1] Miller KA, Woods RK, Sharp RJ, et al. Minimally invasive repair of pectus excavatum: a single institution's experience. Surgery 2001;130:652-7. [2] Fonkalsrud EW, Dunn JC, Atkinson JB. Repair of pectus excavatum deformities: 30 years of experience with 375 patients. Ann Surg 2000;231:443-8. [3] Hebra A, Swoveland B, Egbert M, et al. Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases. J Pediatr Surg 2000;35:252-7. [4] Osawa H, Mawatari T, Watanabe A, et al. New material for Nuss procedure. Ann Thorac Cardiovasc Surg 2004;10:301-3. [5] Croitoru DP, Kelly Jr RE, Goretsky MJ, et al. Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients. J Pediatr Surg 2002;37: 437-45. [6] Noguchi M, Fujita K. A new technique for removing the pectus bar used in the Nuss procedure. J Pediatr Surg 2005;40:674-7.