The Nuss Procedure for Pectus Excavatum

Important information:

Pectus excavatum is a congenital chest wall deformity caused by growth abnormality of the cartilage that connects the ribs to the breastbone (sternum). This causes a depression of the sternum, and the chest has a “sunken in” or “funnel chest” appearance. The condition affects more boys than girls. Severe cases can cause shortness of breath, difficulty exercising and/or chest pain. Children with severe pectus excavatum may need surgery to repair the defect. The Nuss procedure is a minimally invasive procedure for surgical correction of pectus excavatum. 

Before surgery

You will meet with your surgeon, and they will ask about your child’s medical history and do a physical exam. Your child will need a CT scan of their chest. The pictures from the CT scan tell us how severe the defect is. Sometimes we order tests that check your child’s heart and lung function. All this information helps us decide if the Nuss procedure is right for your child.

Prior to the Nuss procedure, your child will need to do allergy patch testing. The purpose of patch testing is to determine if they have an allergy to nickel or chromium, which are used in stainless steel bars. If your child is found to have an allergy or sensitivity to either of these metals, a titanium bar will be required.

Testing is a weeklong procedure. Your child will be scheduled for a separate office visit on Monday, Wednesday, and Friday of the week of testing. Testing should be arranged well before the operation date. In the event a titanium bar is required, it will need to be ordered directly from the manufacturer.

• Monday: We will evaluate your child and test patches will be placed on either the back or the upper arm.

• Wednesday: The patches are removed, and the initial (48 hour) interpretation will be recorded. Reactions can be seen or felt so in person visits are important.

• Friday: We will interpret the final results and discuss them with you at the visit. If tests are negative; we can proceed with scheduling the surgery. If there is a reaction; we will need to order a titanium bar.

Preparing for surgery

• Your child will be instructed to begin taking 1 capful of Miralax once per day starting 7 days before the surgery. This will help to ensure your child is not going into the operation constipated. 

• Your child will bathe with a special cleansing foam or wipes that your child will use the night before the surgery. This helps to decrease the bacteria on the skin which will help prevent a surgical infection. 

• A prescription will be sent to your pharmacy for a one-time dose of gabapentin (Neurontin®) which is a medicine that has been shown to help turn down the pain signal so that the pain perceived by the brain is less intense. This is given while still at home the morning of the surgery with a few sips of water. 

The Nuss procedure

The surgery to correct the chest wall defect will be done in the operating room. We will give your child general anesthesia so they will sleep through the surgery and will not remember anything. The surgeon will make two incisions in your child’s chest, one under each arm. They will then pass a long-curved clamp from one incision, under the sternum until it reaches the other side. Another small incision is made under your child’s arm. This will be for a tiny camera to watch the clamp as it is passed safely across the chest. The surgeon will then place a custom-made steel bar under the sternum between the two incisions. The bar is turned upward and flipped. This lifts the sternum and re-shapes the chest immediately. The main bar is held in place by two small side bars. 

The surgeon will then stitch the incision closed. Thin pieces of tape called Steri-Strips™ or surgical glue will be placed over the incisions and then covered with a bandage. Your child may have a catheter in their bladder so that we can measure urine output, this will be placed in the operating room while your child is asleep. The catheter will stay in until the following morning.

An X-ray is taken in the operating room to check placement of the bar and make sure the lungs are fully expanded.

After surgery

When the surgery is over, your child will go to the peri-anesthesia area (PACU) until they are awake, comfortable, and doing well waking from anesthesia. Then your child will transfer to their hospital room. Your child’s vital signs are checked frequently. They may be sleepy for the remainder of the day. Your child will remain on bedrest with the head of the bed raised slightly (30 degrees) until the following morning. 

A chest X-ray is taken two to three days following the surgery in the radiology department. It will include front and side views. This baseline X-ray gives your team something to compare to in the future.

Pain after surgery

Your child will be asleep under general anesthesia. Sometimes, cryotherapy is used during surgery for further pain control. Cryo nerve therapy involves freezing the nerves located in the chest underneath each rib. These nerves are one of the sources of pain after chest surgery, and cryo nerve therapy helps by temporarily shutting them off. With cryo nerve therapy, you’ll have a sensation of numbness after surgery, which can mean better pain control, possibly less narcotic medication needed, and potentially shorter length of stay in the hospital. Over several months, the nerve gradually regrows. The numbness will slowly go away as normal feeling resumes starting from the side and going towards the sternum. If your surgeon does cryotherapy, this is optional and would be part of the surgical consent. 

All patients will have a PCA (patient-controlled analgesia) pump. Once awake, patients with a PCA pump can also press a button to control their own pain medicine. As your child begins to eat more, they will transition from intravenous (IV) pain medicine to oral pain medicine.

Recovery

Your child will be ready to go home when they are eating and drinking enough, need only oral pain medicine and not IV pain medicine, and can get out of bed and walk safely. Most children stay in the hospital for 3 to 5 days. Your surgeon may want your child to have a bowel movement before they are discharged. Recovery at home takes about 2 to 4 weeks. We will provide you with a recommended medication schedule for home and how to decrease the medications as the days go on.

Activity 

• The day after surgery, we will help your child to get out of bed and walk. There will be activity restrictions after the surgery. We don’t want the bar in the chest to move and to have time to heal. Therefore, your child may not bend, twist, reach arms overhead, lie on their side or roll from side to side, lay on their abdomen for 4 weeks. To help assist in the recovery and provide instructions on how to get out of the bed safely and without rolling, physical therapy will be consulted and see your child. They will also have them walk in the hallways and in the stairwell to ensure they are safe at home using the steps. 

• The occupational therapy team will help your child with activities of daily living such as putting a shirt on, brushing their hair and teeth. Most children can shower 2-3 days after surgery, but will not be allowed to take tub baths or swim for at least 2 weeks. 

• No exercise, lifting heavy objects, gym, or sports, until thesurgeon gives permission (usually around 4 weeks). Contact sports such as wrestling, football, pole vaulting will not be permitted for the three years the bar is in your child’s chest. 

Follow-up appointments

The surgeon will see your child in clinic 3-4 weeks after the operation and then several times over the next 2 years while the bar is in place. The bar will remain in place for 3 years. When it is time to remove the bar, your child will need another operation. The incisions on each side of your child’s chest will be re-opened and the bar will be removed. The surgeon will close the incision with stitches under the skin. These stitches dissolve on their own. Your child will go home the same day as the surgery. 

Safety

Medical alert bracelet

It is recommended that your child wear a MedicAlert bracelet. We can provide you with an order form. The phone number for MedicAlert is 1-888-633-4298. The website is: www.medicalert.org. 

The bracelet needs to say:

• Metal bar in chest, CPR more force, cardioversion ant/post placement

• Medical info: Pectus Excavatum

CPR

Some families ask about CPR. If your child needed CPR, the compressions need to be more forceful since the steel bar is under the sternum. If an AED is needed in the resuscitation, the best placement for the paddles would be the front and the back of the chest instead of both paddles on the front. 

Metal detectors

Your child’s bar should not set off alarms in metal detectors unless they are high level detectors such as those in Washington DC airports.

Call your CHOP surgical team with questions concerns or if your child has:

• Temperature over 101.5° F(38.6° C)

• Bleeding

• Nausea or vomiting

• Severe chest pain

• Pain that is not relieved with prescribed medications

• Shortness of breath

• Redness or swelling around area of incisions

• Change in the appearance of the chest since surgery

Division of Pediatric General, Thoracic and Fetal Surgery

215-590-2730, 24 hours a day, every day of the week. 

Reviewed February 2024 by Gina Kroeplin, CRNP