Nuss Procedure

The Nuss procedure is a minimally invasive procedure for surgical correction of pectus excavatum. Children’s Hospital surgeons have performed more than 500 Nuss procedures, and typically perform approximately 40 cases each year. The procedure is typically performed from age 10 up until the age of 19.

The Nuss procedure involves a concave stainless steel bar that is slipped under the sternum with the assistance of a scope (small camera) using two small incisions on each side of the chest. The bar is then flipped, and the sternum moves to the proper position.

To support the bar and keep it in place, a metal plate called a stabilizer is inserted on both sides of the chest. The stabilizer fits around the bar and into the ribcage where it is secured in place.

The stainless steel bar does have tiny nickel and chromium components; therefore, if your child has a nickel or chromium allergy, a titanium bar will be used. Take note of your child’s reaction to wearing earrings or belts. Getting a rash from a belt buckle or swollen ears from stainless steel earrings can be indicative of a nickel allergy. Let your surgeon know if you have observed the signs of a nickel allergy. Before surgery, all patients will have patch testing (special allergy testing) to determine whether or not they have a true nickel allergy and require a titanium bar.

The bar and stabilizers are typically kept in place for 3 years. The bar removal procedure is done as a same day surgery; your child will go home after the procedure. The incisions on the side of the chest will be re-opened and the bar will be removed. The surgeon will use dissolvable sutures to close the incisions.

One week before surgery, your child will begin taking a stool softener. This helps to decrease difficulties with constipation following the surgery. Your medical team will provide specific instructions.

The night before the procedure your child will be asked to use special cleansing cloths containing 2 percent chlorhexadine gluconate (CHG) to help prevent a surgical site infection. You will be given the cloths and instructions on how to use them at your pre-operative evaluation. These videos show step by step instructions on how to perform a CHG treatment:

• For a child under 22 pounds
• For a child 22 - 66 pounds
• For a child over 66 pounds

Please let someone from our team know if your child has an allergy/sensitivity to CHG so that an alternative cleanser can be used. You will also be provided with pre-operative fasting instructions at your pre-operative evaluation. 

Following the Nuss procedure, your child will remain hospitalized for 3-4 days. In order to be discharged from the hospital, your child must meet the following criteria:

1. Adequate pain control on oral medications only. Your child will be discharged with a combination of medications for pain that may be used up to a month after surgery. These medications may include over-the-counter medications (such as ibuprofen), narcotics, and muscle relaxants. Your child may return to school when the narcotics have been weaned.
2. Walking with minimal assistance.
3. Tolerating adequate amounts of food and fluids by mouth.
4. No fever.
5. Established bowel regimen. Your child may continue to use the stool softeners and laxatives started in the hospital to ensure regular bowel function while on narcotics.

After being discharged from the hospital, your child will follow-up in the general surgery clinic in 2-4 weeks.

Pain management

The length of hospitalization is mainly determined by pain management. At CHOP, our pediatric surgeons work closely with our dedicated Pain Management Program team to manage your child’s pain.

For many patients who undergo the Nuss procedure, we have found that we can effectively manage post-operative pain with a combination of medications. This approach to managing pain after surgery has decreased the length of hospital stay by 1-3 days for many patients. (Read an article on this topic by members of our team.)

We start with a dose of oral medication called Gabapentin that is given at home the morning of the surgery. A variety of additional medications are used during your child’s post-operative recovery in the hospital, including pain patches that are applied to the skin, and IV pain medications such as Tylenol and Motrin.

When your child begins to eat, a combination of oral pain medications (which may include narcotics or over-the-counter medications) and muscle relaxants will be used. Your child may also be prescribed stool softeners and/or laxatives because narcotic medications can cause severe constipation.

We emphasize the safe and controlled use of all pain medications. We will provide guidance and a schedule for weaning off of these medications at home.

Activity

The first night after the operation your child will be on bed rest. They will be given an incentive spirometer, which encourages deep breaths, to use every hour while awake.

An important part of the recovery process is getting up and moving around. The day after surgery, your child will begin to get out of bed to a chair with assistance from the healthcare team. Once they are able to move to the chair, they’ll work with a physical therapist to help regain strength. They’ll practice things like walking around the hospital room and in the hallways, and safely demonstrate walking up and down stairs.

It is very important that your child get out of bed early in the recovery period. Physical therapy activities promote movement, rebuild strength, expand the lungs, promote bowel function, and prevent possible complications.

A chest X-ray will be performed prior to your child being discharged from the hospital. In the hospital, your child will have activity restrictions that will continue after discharge. The restrictions are in place to protect the bar placement. Your child’s surgeon or nurse practitioner will discuss these restrictions with you.

The following restrictions are in place for the first 4 weeks after surgery:

1. No log-rolling
2. No side-lying or laying on one’s stomach
3. No bending/twisting/straining/heavy lifting or reaching high over head
4. No contact sports or physical education
5. No carrying a backpack at school

There may be ongoing activity restrictions such as avoidance of football, wrestling and pole vaulting during the entire time the bar is in place.

While it is not mandatory to wear a Medical Alert bracelet after the Nuss procedure, it is strongly recommended. Information can be provided to you at a post-operative visit on obtaining a Medical Alert bracelet. The inscription on the bracelet should read “steel bar in chest, CPR more force, cardioversion ant/post placement.”

Having a steel bar in the chest raises several common questions about daily activities. Here are a few things you should know:

• The bar should not set off metal detectors in the airport, but depending on the type of material, it may in some cases (titanium bar is more likely to set off detectors, while stainless steel will not). We can provide documentation of the bar if necessary.
• Antibiotics are not required prior to dental procedures while the bar is in place.
• If needed, your child can still receive CPR while the bar is in place. Chest compressions should be done with more force due to the bar placement. An AED can also be used with the bar in place; however, the paddle placement will be different. One paddle should be placed on the front of the chest and the other should be on the back.

Please call the Division of Pediatric General, Thoracic and Fetal Surgery at 215-590-2730 if your child has any of the following symptoms after the Nuss procedure:

• Fever greater than 101.5 F
• Increased redness or swelling at the incisions
• Any drainage from the incisions
• Difficulty breathing
• Change in the appearance of the chest
• New chest pain or increase in pain
• Injury to the chest