Nuss procedure

Nuss procedure is a surgical technique that aims to rectify a condition called pectus excavatum. It is also known as minimally invasive repair of pectus excavatum or MIRPE because only three to five small cuts are required for the procedure. 

Pectus excavatum is a condition wherein the breastbone (the bone in the centre of the chest) sinks into the chest cavity, giving a caved-in appearance to the middle region of the chest. The actual cause of the condition is unknown; however, as it seems to run in families, a genetic link is suggested. This condition is prevalent in about 1 of every 1,000 children and is more predominant in boys than in girls. Pectus excavatum is visible soon after birth, but it does not affect the internal organs, such as the heart and lungs, of a developing child. The complications of the condition are usually observed in the later stages of the child’s life. These complications can be breathing issues and decreased stamina.

In the Nuss procedure, the surgeon inserts curved steel bars under the breastbone, which gradually move the breastbone towards the front. The steel bars are removed once the chest attains a natural or suitable shape. The procedure can be performed in children, adolescents and adults. In children and adolescents, the steel bars are removed after about 10 years, whereas in adults, the bars are removed three to five years after surgery.

The sole indication for the Nuss procedure is pectus excavatum. The commonly occurring symptoms of pectus excavatum are:

• A sunken chest
• Pain in the chest 
• Fatigue
• Difficulty in performing certain physical activities and exercises due to the inability to breathe properly
• Coughing
• Wheezing
• Recurrent respiratory infections
• Irregular heartbeats

The surgeon may not perform this surgery if you have any of the following conditions:

• Heart diseases (unrelated to pectus excavatum)
• Neurological or mental conditions
• Congenital abnormalities (conditions present from birth)
• History of chest surgery

The following preparation is needed before the surgery:

• You will be asked to get a series of tests done during the pre-operative assessment. Some of these tests are as follows:
  • Blood tests
  • Electrocardiogram (to measure and examine the electrical activity of your heart)
  • Chest x-ray (to learn about the internal organs)
  • Computed tomography scan (to get a detailed view of internal organs and plan surgery)
• You must stop smoking as it increases the risk of a lung infection after surgery.
• Do not wear any jewellery, valuables, nail polish, contact lens, make-up and dentures to the hospital on the day of the surgery.
• In addition, the surgeon will provide you with specific instructions on when to begin fasting before the surgery. You may be asked to start fasting six hours prior to the scheduled time of the surgery. However, you will be allowed to drink water and other clear liquids up to two hours prior to the procedure.
• You should ask a friend, family member or a responsible adult to drive you home after the surgery.

At the hospital, the following steps will be followed before the surgery:

• The hospital staff may ask you to bathe with an antiseptic/antibacterial solution and change into a hospital gown.
• They will also provide you with a pair of anti-thrombus stockings, which will help prevent the formation of blood clots in your legs.
• You will be given a medicine to take before the surgery that will make you feel drowsy or light-headed; hence, it is advised that you should stay in your bed after taking it.
• You will then be taken to the operation theatre.

You can expect the following procedures in the operation theatre:

• The surgical team will connect you to a heart and pulse monitor.
• They will insert a small plastic tube in a vein in your arm to give you medicines.
• An anesthesiologist will then inject you with anaesthesia to put you to sleep for the duration of the surgery.
• A breathing tube will be inserted into your throat to help you breathe.
• The surgeon will then make tiny incisions in the side of your chest.
• With the assistance of a tiny camera, he/she will insert one or more curved steel bars through the incisions behind your breastbone and adjust the bars at the appropriate position. 
• Thereafter, the surgeon will turn the steel bars outwards. This will help move the breastbone towards the front.
• The surgeon will fix the ends of the steel bars to the outer edges of your ribs by using a metal plate, stitches or wires.
• Finally, he/she will close the incisions with sutures.

The hospital staff will move you to the recovery ward after the surgery. You may need to stay at the hospital for about five to seven days. During your hospitalisation period, you can expect the following:

• You may have a small tube (catheter) inserted in your bladder to drain out urine.
• Additionally, you may also have drainage tubes inserted in your chest to remove the excess body fluid that may get collected in the surgical area.
• Medications and fluids will also be administered by an intravenous drip inserted in your arm.
• The medical team at the hospital will strictly monitor your vital signs.
• You will feel drowsy for a while after regaining consciousness post-surgery.
• The hospital staff will remove the catheter, intravenous lines and the heart monitor once you wake up after the surgery.
• You may have some post-surgical pain. The surgeon will control your pain by giving you medication either through epidural injection (medication provided through a tube inserted in your back), intravenous lines or oral routes.
• If the surgeon feels that you can get out of the bed, then the hospital staff will motivate you to stand up or sit in a chair. 
• An x-ray will be performed to ensure that there is no accumulation of fluid inside your chest cavity. Thereafter, the chest drain will be removed.
• The physiotherapists at the hospital will help you in the recovery process. They will suggest you to walk regularly for an hour and to climb stairs at a slow pace.
• Because you should not bend or twist your spine after the surgery, the physiotherapist will teach you how to sit and stand by bending your knees, instead of bending the spine.
• They will also teach you a few essential breathing exercises and shoulder exercises before you are discharged from the hospital. These exercises will help prevent infection and assist in a faster recovery.

The surgeon and physiotherapist may provide you with the following instructions to take care of yourself after the surgery:

• Continue practising all the exercises advised by the physiotherapists.
• Avoid the following activities during the first-month post-surgery:
  • Bending your spine
  • Twisting your trunk
  • Lying on the side
  • Sitting in a slumped position
• Avoid lifting heavy objects for the initial two months post-surgery.
• Do not indulge in sports or activities that would put your body under stress, such as weight-lifting, golf and so on.
• Do not drive for the initial three months after surgery and minimise travelling in a car. Discuss with your surgeon before resuming these activities.
• If your child underwent this procedure, then he/she should stay away from school for at least three months. The child may require up to six months to resume normal activities.

When to see the doctor?

Contact the surgeon as soon as you experience any of the following signs:

• Redness at the surgical site
• Fluids leaking from the surgical area
• Body temperature ≥ 101^°F
• Increasing pain

Although the Nuss procedure is known for its safety, some risks or complications can still occur. These complications are as follows:

• Infection at the surgical site
• Uncontrolled loss of blood
• Damage to the heart
• Development of red and itchy scars
• Collection of fluid in one or both the lungs
• Leakage of air from either of the lungs
• Discomfort because of the presence of steel bars in the chest
• An extended stay at the hospital

You will need to visit the hospital for a follow-up two to four weeks after getting discharged from the hospital. If this procedure is performed on your child, then you may need to take the child to a paediatrician one to two weeks after discharge from the hospital. You will also need to visit the surgeon a few years after surgery to get the steel bars removed from your chest.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.