Nuss Procedure

Overview

The Nuss procedure is a minimally invasive surgical technique used to correct pectus excavatum, a condition where the chest appears sunken. It is preferred over open surgery with a larger incision for eligible candidates. During the procedure, titanium bars are inserted to push the sunken breastbone outward, and these bars typically remain in place for three years.

Typically performed during adolescence, children undergoing the Nuss procedure are usually aged 14 and older. There is no upper age limit, meaning adults can also undergo this procedure.

Reasons for undergoing the procedure

The Nuss procedure immediately improves the appearance of pectus excavatum, or sunken chest, by pushing the breastbone forward to flatten the chest. While the bar remains in place, it supports proper growth of the breastbone. This surgery can also enhance the function of the heart and lungs compared to their condition before the procedure.

The Nuss procedure can provide benefits for:

• Pain in the chest.
• Breathing difficulty.
• Palpitations of the heart.
• Being unable to engage in prolonged exercise.

After the Nuss procedure, your child will have a bar in their chest for three years. When it’s time for the bar to be removed, your child will undergo the procedure under general anesthesia, but typically won’t need to stay overnight in the hospital.

Pectus excavatum is a congenital condition where the chest bones do not develop properly, often present from birth. It affects approximately one in every 1,000 people.

In pectus excavatum, the breastbone (sternum) appears sunken or hollow, and the ribs may appear uneven.

Risks

Among the dangers of a Nuss procedure are:

• Pain.
• Bleeding.
• Infection.
• The bar(s) shifting position.

During the first four weeks, to help prevent the bar(s) from moving, have your child:

• Maintain a straight posture.
• Curl in at the hips.
• Avoid rolling onto their sides.

Before the procedure

In the days leading up to the surgery, your child will need several tests, including lung function exams, a chest CT scan or MRI to obtain measurements and images, and the entire Nuss operation typically takes about four hours.

During the procedure

Your child will receive general anesthesia to ensure they are asleep throughout the procedure. Here are the steps your pediatric surgeon will follow:

1. Make small incisions on both sides of your child’s chest.
2. Insert a tiny camera through one of the openings to visualize the area.
3. Use cryoablation, if necessary, to manage post-operative discomfort by freezing nerves in the chest.
4. Insert a customized curved metal bar through the incision to elevate your child’s breastbone.
5. If needed, insert additional bars to address the issue.
6. Remove the camera.
7. Close the incisions.

After the procedure

Your child will typically stay overnight at the hospital, possibly longer if necessary. The day after surgery, a doctor will encourage your child to sit up in bed and take deep breaths. They may also suggest using a walker to walk short distances down the corridor. These gentle exercises support healing and can be gradually increased each day.

To prevent constipation, the doctor will prescribe laxatives or stool softeners for your child.

Outcome

The Nuss operation typically takes about six months to fully heal, though many patients resume normal activities much sooner, except for heavy lifting and contact sports. Activities involving twisting or frequent arm movements may affect the positioning of the bar, so your child’s return to physical activities will need careful monitoring to ensure proper healing.

Your surgeon will discuss a gradual return to activities with you in detail. Most children can return to school approximately a month after Nuss surgery.