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Efficacy of left thoracoscopy and blunt mediastinal dissection during the Nuss procedure for pectus excavatum
Journal of Pediatric Surgery (2005) 40, 1312 – 1314
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Efficacy of left thoracoscopy and blunt mediastinal dissection during the Nuss procedure for pectus excavatum Richard J. Hendricksona,*, Denis D. Bensarda, Joseph S. Janikb, David A. Partricka a
Division of Pediatric Surgery, The Children’s Hospital/The University of Colorado Health Science Center, Denver, CO 80218, USA b Banner Children’s Hospital, Arizona Children’s Surgery, Mesa, AZ, USA Index words: Nuss procedure; Pectus excavatum; Thoracoscopy; Mediastinal dissection; Endo-kittner
Abstract Background/Purpose: The minimally invasive Nuss procedure is emerging as the preferred technique for repair of pectus excavatum. Original methods of pectus bar placement have been modified to improve safety and efficacy and avoid cardiothoracic complications. The currently reported modifications to facilitate retrosternal pectus bar placement include routine use of right thoracoscopy or a subxiphoid incision. The purpose of this article is to describe additional modifications of the Nuss procedure to improve safety and efficacy. Methods: A retrospective analysis was performed on 51 patients who have had a thoracoscopic-assisted Nuss procedure at The Children’s Hospital, Denver, Colo, between 1999 and 2002. Technical modifications included patient positioning, routine use of left thoracoscopy, and an Endo-kittner. Results: Fifty-one patients have successfully undergone the Nuss procedure using the new modifications. Surgical time ranged from 45 to 120 minutes. There have been no intraoperative or postoperative bleeding complications. There have been 2 large pneumothoraces requiring needle thoracenteses in the operating room before extubation. No chest tubes were required postoperatively. Subjectively, all patients have been satisfied with their surgical correction. Average length of hospital stay was 4 to 6 days. Conclusions: By using left chest thoracoscopy and Endo-kittner dissectors, the risk of cardiothoracic injury can be eliminated. Moreover, other methods to ensure safe substernal dissection are unnecessary. D 2005 Elsevier Inc. All rights reserved.
In 1997, Nuss et al [1] reported a 10-year review of a minimally invasive technique for the correction of pectus excavatum. In 2002, they reported an updated experience Presented at the Annual Meeting—Pacific Association of Pediatric Surgeons, Sydney, Australia, May 12, 2003. T Corresponding author. Tel.: +1 303 861 6530; fax: +1 303 764 8077. E-mail address: [email protected] (R.J. Hendrickson). 0022-3468/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2005.05.017
and modification of the Nuss technique [2]. They reported using routine thoracoscopy via the right chest to improve safety during the mediastinal dissection. Another method of mediastinal dissection includes making an additional subxiphoid incision for mediastinal dissection [3,4]. The purpose of this study was to describe further modifications of the Nuss procedure that improve safety and efficacy.
Efficacy of left thoracoscopy for Nuss procedure
1313
1. Materials and methods A retrospective analysis was performed on 51 children and adolescents who underwent a thoracoscopic-assisted Nuss procedure at The Children’s Hospital, Denver, Colo, between 1999 and 2002. All patients had a thoracic epidural for intraoperative and postoperative pain control. Technical modifications included placing the patient on the left edge of the table with the left arm padded over the forehead (Fig. 1). A right arm board was routinely used. Bilateral vertical skin incisions were made in the midaxillary line. Left chest thoracoscopy with a 308 scope and pressure of 4 mm Hg was performed via a 5-mm Step Access Device (United States Surgical, Tyco Healthcare LTD, Norwalk, Conn) (Fig. 2). An Endo-Peanut (Auto-Suture, US Surgical Corp, Norwalk, CT) through a second 5-mm port was used for blunt dissection across the mediastinum under direct thoracoscopic vision (Fig. 3). These 5-mm ports are placed within the left vertical chest incision. The Nuss bar introducer was inserted through either the right or the left chest and passed across the mediastinum, again under direct thoracoscopic visualization. A tracheostomy tape was then grasped and pulled across the mediastinum. The pectus bar was tied to one end of the tracheostomy tape and the bar advanced across the mediastinum under direct thoracoscopic visualization. After the pectus bar was rotated and anchored into position with bilateral stabilizers, a final inspection of the mediastinum and left chest was performed. The lateral stabilizers are secured with either nonabsorbable suture or wire depending upon attending preference. A postprocedure chest radiograph was obtained before extubation.
Fig. 1 Patient positioned at left edge of operating table with left arm padded over their forehead. Ink line marks vertical incision.
Fig. 2 Two 5-mm ports inserted within the vertical incision. The thoracoscope is inserted through the superior port and the Endokittner is inserted through the inferior port.
This study was reviewed and approved by the Colorado Multiple Institution Review Board (02-618).
2. Results Fifty-one patients have successfully undergone the Nuss procedure using the above-mentioned modifications. Age range was 6 to 18 years. The Nuss bar introducer was inserted via the right chest in 28 patients and via the left chest in 23 patients, both under direct thoracoscopic visualization. Forty-nine patients had a single pectus bar and 2 patients had 2 pectus bars placed. Surgical time ranged from 45 to 120 minutes and does not include anesthesia time. There have been no intraoperative or postoperative bleeding complications. Blood loss was less than 5 mL in all cases. On routine chest radiography performed at the end of the surgical procedure, 2 (4%) large pneumothoraces greater than 20% in size were identified requiring needle thoracentesis in the operating room before extubation. Pneumothoraces less than 20% were observed clinically and no chest tubes were required. Postoperatively, patients were allowed ad lib activity and diet was advanced as tolerated. Average length of epidural
Fig. 3 Intraoperative photo illustrating the sternum, mediastinum, heart, and Endo-kittner.
1314 use was 3 days. Length of hospital stay ranged from 4 to 6 days. Subjectively, all patients have been satisfied with their surgical correction. There have been 5 (10%) bar dislodgements, all requiring surgical revision. Each of these dislodgements was associated with a traumatic event: car accident (1), skiing accident (2), and jungle gym accidents (2). Nine (17.6%) pectus bars have been removed between 2 and 3 years postoperatively as an outpatient procedure. These patients have all maintained initial correction without evidence of recurrent pectus excavatum or development of pectus carinatum.
3. Discussion Traditionally, repair of pectus excavatum was performed using an open technique as described by Ravitch [5]. In 1997, Nuss et al [1] reported their 10-year experience using a minimally invasive approach with pectus bar placement for the correction of pectus excavatum. A follow-up report last year described their experience and modifications of the Nuss procedure [2]. Modifications to the Nuss procedure included a new introducer, bar rotational device, and stabilizer, as well as routine use of thoracoscopy via the right lateral chest. We describe our modification to the Nuss procedure using the left hemithorax for thoracoscopy rather than the right. Although the chest wall deformity shifts the heart toward the left, careful insertion of a 5-mm, 308 scope is safe. To help facilitate left thoracoscopy, patient position is crucial. Having the left arm away from the lateral chest wall permits an adequate area for camera movement. To improve cosmesis, a vertical rather than a horizontal skin incision is made in the midaxillary line on each side. A 5-mm port is carefully inserted via the superior aspect of the incision in the left hemithorax using a Veress needle. A 5-mm, 308 scope is introduced after pneumothorax is achieved. The heart is usually the first structure identified and can be kept in the operative field at all times. This is crucial because a cardiac injury is the most feared complication [6]. A second 5-mm port is placed in the inferior aspect of the vertical incision to accommodate an
R.J. Hendrickson et al. Endo-kittner, which allows accurate and detailed dissection of the retrosternal area. Once the mediastinal dissection is complete, the Nuss bar introducer is inserted and advanced across the mediastinum under direct visualization. Next, the pectus bar is inserted with the tracheostomy tape and advanced across the mediastinum under direct visualization. Once the bar has been rotated, thoracoscopic evaluation of the hemithorax and mediastinum assures adequate positioning of the bar and confirms no injury to vital structures. The minimally invasive Nuss procedure is an effective method for pectus excavatum repair. This report illustrates additional modifications that we have instituted to ensure safety. Left thoracoscopy ensures that the heart is under direct visualization during the entire procedure, and the use of the Endo-kittner dissector permits accurate and detailed mediastinal dissection. Although right thoracoscopy is an option already described, we submit that left thoracoscopy is superior because of the ability to see the heart during mediastinal dissection and pectus bar placement. These modifications help eliminate the risk of cardiothoracic and vascular injury [6]. Moreover, other methods to ensure safe substernal dissection such as using a subxiphoid incision are unnecessary [3,4].
References [1] Nuss D, Kelly RE, Croitoru DP, et al. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545 - 52. [2] 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(3): 437 - 45. [3] Miller KA, Woods RK, Sharp RJ, et al. Minimally invasive repair of pectus excavatum: a single institution’s experience. Surgery 2001; 130(4):657 - 9. [4] Haecker FM, Bielek J, vonSchweintz D. Minimally invasive repair of pectus excavatum (MIRPE) — the Basel experience. Swiss Surg 2003; 9(6):289 - 95. [5] Ravitch MM. The operative treatment of pectus excavatum. Ann Surg 1949;129:429 - 44. [6] Moss RL, Albanese CT, Reynolds M. Major complications after minimally invasive repair of pectus excavatum: case reports. J Pediatr Surg 2001;36(1):155 - 8.
www.elsevier.com/locate/jpedsurg
Efficacy of left thoracoscopy and blunt mediastinal dissection during the Nuss procedure for pectus excavatum Richard J. Hendricksona,*, Denis D. Bensarda, Joseph S. Janikb, David A. Partricka a
Division of Pediatric Surgery, The Children’s Hospital/The University of Colorado Health Science Center, Denver, CO 80218, USA b Banner Children’s Hospital, Arizona Children’s Surgery, Mesa, AZ, USA Index words: Nuss procedure; Pectus excavatum; Thoracoscopy; Mediastinal dissection; Endo-kittner
Abstract Background/Purpose: The minimally invasive Nuss procedure is emerging as the preferred technique for repair of pectus excavatum. Original methods of pectus bar placement have been modified to improve safety and efficacy and avoid cardiothoracic complications. The currently reported modifications to facilitate retrosternal pectus bar placement include routine use of right thoracoscopy or a subxiphoid incision. The purpose of this article is to describe additional modifications of the Nuss procedure to improve safety and efficacy. Methods: A retrospective analysis was performed on 51 patients who have had a thoracoscopic-assisted Nuss procedure at The Children’s Hospital, Denver, Colo, between 1999 and 2002. Technical modifications included patient positioning, routine use of left thoracoscopy, and an Endo-kittner. Results: Fifty-one patients have successfully undergone the Nuss procedure using the new modifications. Surgical time ranged from 45 to 120 minutes. There have been no intraoperative or postoperative bleeding complications. There have been 2 large pneumothoraces requiring needle thoracenteses in the operating room before extubation. No chest tubes were required postoperatively. Subjectively, all patients have been satisfied with their surgical correction. Average length of hospital stay was 4 to 6 days. Conclusions: By using left chest thoracoscopy and Endo-kittner dissectors, the risk of cardiothoracic injury can be eliminated. Moreover, other methods to ensure safe substernal dissection are unnecessary. D 2005 Elsevier Inc. All rights reserved.
In 1997, Nuss et al [1] reported a 10-year review of a minimally invasive technique for the correction of pectus excavatum. In 2002, they reported an updated experience Presented at the Annual Meeting—Pacific Association of Pediatric Surgeons, Sydney, Australia, May 12, 2003. T Corresponding author. Tel.: +1 303 861 6530; fax: +1 303 764 8077. E-mail address: [email protected] (R.J. Hendrickson). 0022-3468/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2005.05.017
and modification of the Nuss technique [2]. They reported using routine thoracoscopy via the right chest to improve safety during the mediastinal dissection. Another method of mediastinal dissection includes making an additional subxiphoid incision for mediastinal dissection [3,4]. The purpose of this study was to describe further modifications of the Nuss procedure that improve safety and efficacy.
Efficacy of left thoracoscopy for Nuss procedure
1313
1. Materials and methods A retrospective analysis was performed on 51 children and adolescents who underwent a thoracoscopic-assisted Nuss procedure at The Children’s Hospital, Denver, Colo, between 1999 and 2002. All patients had a thoracic epidural for intraoperative and postoperative pain control. Technical modifications included placing the patient on the left edge of the table with the left arm padded over the forehead (Fig. 1). A right arm board was routinely used. Bilateral vertical skin incisions were made in the midaxillary line. Left chest thoracoscopy with a 308 scope and pressure of 4 mm Hg was performed via a 5-mm Step Access Device (United States Surgical, Tyco Healthcare LTD, Norwalk, Conn) (Fig. 2). An Endo-Peanut (Auto-Suture, US Surgical Corp, Norwalk, CT) through a second 5-mm port was used for blunt dissection across the mediastinum under direct thoracoscopic vision (Fig. 3). These 5-mm ports are placed within the left vertical chest incision. The Nuss bar introducer was inserted through either the right or the left chest and passed across the mediastinum, again under direct thoracoscopic visualization. A tracheostomy tape was then grasped and pulled across the mediastinum. The pectus bar was tied to one end of the tracheostomy tape and the bar advanced across the mediastinum under direct thoracoscopic visualization. After the pectus bar was rotated and anchored into position with bilateral stabilizers, a final inspection of the mediastinum and left chest was performed. The lateral stabilizers are secured with either nonabsorbable suture or wire depending upon attending preference. A postprocedure chest radiograph was obtained before extubation.
Fig. 1 Patient positioned at left edge of operating table with left arm padded over their forehead. Ink line marks vertical incision.
Fig. 2 Two 5-mm ports inserted within the vertical incision. The thoracoscope is inserted through the superior port and the Endokittner is inserted through the inferior port.
This study was reviewed and approved by the Colorado Multiple Institution Review Board (02-618).
2. Results Fifty-one patients have successfully undergone the Nuss procedure using the above-mentioned modifications. Age range was 6 to 18 years. The Nuss bar introducer was inserted via the right chest in 28 patients and via the left chest in 23 patients, both under direct thoracoscopic visualization. Forty-nine patients had a single pectus bar and 2 patients had 2 pectus bars placed. Surgical time ranged from 45 to 120 minutes and does not include anesthesia time. There have been no intraoperative or postoperative bleeding complications. Blood loss was less than 5 mL in all cases. On routine chest radiography performed at the end of the surgical procedure, 2 (4%) large pneumothoraces greater than 20% in size were identified requiring needle thoracentesis in the operating room before extubation. Pneumothoraces less than 20% were observed clinically and no chest tubes were required. Postoperatively, patients were allowed ad lib activity and diet was advanced as tolerated. Average length of epidural
Fig. 3 Intraoperative photo illustrating the sternum, mediastinum, heart, and Endo-kittner.
1314 use was 3 days. Length of hospital stay ranged from 4 to 6 days. Subjectively, all patients have been satisfied with their surgical correction. There have been 5 (10%) bar dislodgements, all requiring surgical revision. Each of these dislodgements was associated with a traumatic event: car accident (1), skiing accident (2), and jungle gym accidents (2). Nine (17.6%) pectus bars have been removed between 2 and 3 years postoperatively as an outpatient procedure. These patients have all maintained initial correction without evidence of recurrent pectus excavatum or development of pectus carinatum.
3. Discussion Traditionally, repair of pectus excavatum was performed using an open technique as described by Ravitch [5]. In 1997, Nuss et al [1] reported their 10-year experience using a minimally invasive approach with pectus bar placement for the correction of pectus excavatum. A follow-up report last year described their experience and modifications of the Nuss procedure [2]. Modifications to the Nuss procedure included a new introducer, bar rotational device, and stabilizer, as well as routine use of thoracoscopy via the right lateral chest. We describe our modification to the Nuss procedure using the left hemithorax for thoracoscopy rather than the right. Although the chest wall deformity shifts the heart toward the left, careful insertion of a 5-mm, 308 scope is safe. To help facilitate left thoracoscopy, patient position is crucial. Having the left arm away from the lateral chest wall permits an adequate area for camera movement. To improve cosmesis, a vertical rather than a horizontal skin incision is made in the midaxillary line on each side. A 5-mm port is carefully inserted via the superior aspect of the incision in the left hemithorax using a Veress needle. A 5-mm, 308 scope is introduced after pneumothorax is achieved. The heart is usually the first structure identified and can be kept in the operative field at all times. This is crucial because a cardiac injury is the most feared complication [6]. A second 5-mm port is placed in the inferior aspect of the vertical incision to accommodate an
R.J. Hendrickson et al. Endo-kittner, which allows accurate and detailed dissection of the retrosternal area. Once the mediastinal dissection is complete, the Nuss bar introducer is inserted and advanced across the mediastinum under direct visualization. Next, the pectus bar is inserted with the tracheostomy tape and advanced across the mediastinum under direct visualization. Once the bar has been rotated, thoracoscopic evaluation of the hemithorax and mediastinum assures adequate positioning of the bar and confirms no injury to vital structures. The minimally invasive Nuss procedure is an effective method for pectus excavatum repair. This report illustrates additional modifications that we have instituted to ensure safety. Left thoracoscopy ensures that the heart is under direct visualization during the entire procedure, and the use of the Endo-kittner dissector permits accurate and detailed mediastinal dissection. Although right thoracoscopy is an option already described, we submit that left thoracoscopy is superior because of the ability to see the heart during mediastinal dissection and pectus bar placement. These modifications help eliminate the risk of cardiothoracic and vascular injury [6]. Moreover, other methods to ensure safe substernal dissection such as using a subxiphoid incision are unnecessary [3,4].
References [1] Nuss D, Kelly RE, Croitoru DP, et al. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545 - 52. [2] 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(3): 437 - 45. [3] Miller KA, Woods RK, Sharp RJ, et al. Minimally invasive repair of pectus excavatum: a single institution’s experience. Surgery 2001; 130(4):657 - 9. [4] Haecker FM, Bielek J, vonSchweintz D. Minimally invasive repair of pectus excavatum (MIRPE) — the Basel experience. Swiss Surg 2003; 9(6):289 - 95. [5] Ravitch MM. The operative treatment of pectus excavatum. Ann Surg 1949;129:429 - 44. [6] Moss RL, Albanese CT, Reynolds M. Major complications after minimally invasive repair of pectus excavatum: case reports. J Pediatr Surg 2001;36(1):155 - 8.