What is the Nuss procedure?
The Nuss procedure is used to correct a condition called pectus excavatum (funnel chest).
This is a minimally invasive (keyhole) type of operation that is used to correct pectus excavatum. Pectus excavatum (also known as funnel chest) is a condition in which, instead of being level with the ribs, the breastbone (sternum) is ‘sunken’ so that the middle of the chest looks ‘caved in’. There may be a genetic link to ribcage problems, as it seems to run in families.
Pectus excavatum affects about 1 in 1000 children and is four times as common in boys than in girls.
The Nuss procedure was developed by a surgeon in the United States called Dr Donald Nuss and is named after him. This surgery is usually suggested when a child’s ribcage problem is affecting his or her breathing or lung function. It may also be suggested if it is causing severe psychological problems.
What happens before the operation?
A variety of tests are used to diagnose pectus excavatum and these will also be used to plan the operation. They will include breathing tests to show the effect of the ribcage problem on your child’s breathing and scans to give detailed measurements of his or her ribcage.
Your child will need to come to the hospital two to three weeks before the operation for a pre-admission check. The doctors will explain the operation again, discuss any worries you may have and ask you to give your permission for the operation by signing a consent form. Another doctor will visit you on the ward to explain about the anaesthetic.
The doctors may ask for some blood samples to check that your child is well before the operation. If your child has any medical problems, like allergies, please tell the doctor about these.
After the pre-admission check, you will be able to go home. Before you leave, the nurses will explain about fasting times for the operation. It is important that your child does not eat or drink anything for several hours before the anaesthetic. This reduces the risk of vomiting during and after the operation. After this time, your child should have nothing at all to eat or drink. You should follow these instructions exactly. Otherwise, his or her operation will be delayed or even cancelled.
What does the operation involve?
The Nuss procedure is carried out by a thoracic surgeon (doctor specialising in operations on the chest) while your child is under a general anaesthetic. The operation usually lasts between one and two hours.
When your child has been anaesthetised, the surgeon will make two small incisions (cuts) about three centimetres long on either side of your child’s ribcage. He or she will also make a smaller cut in the centre of your child’s chest. The surgeon will insert an endoscope (thin tube containing a light and a camera) into the chest cavity so that he or she can see inside during the operation.
When the endoscope is showing a clear picture, the surgeon will insert the steel bar that will push your child’s chest into shape. It is inserted with the curve away from the front of your child’s chest through the incision on one side until it reaches the other.
Once the bar is in place, the surgeon will check its position using the endoscope and then carefully turn it so that the curved section is pressing against your child’s sternum (breastbone).
Once the surgeon is happy that the bar is in the right place, it will be secured with stabilisers and wires and the incisions will be closed. The bar, stabilisers and wires will not be visible as they are contained by the ribcage. The endoscope will be taken out of the chest cavity and this smaller incision closed too. Your child will be taken to the recovery room to wake up gradually from the anaesthetic. While in the recovery room, your child will be given pain relief and will then be transferred back to the ward. Your child may seem to spend a long time in the recovery room, but this is essential to make sure that he or she is receiving enough pain relief.
Are there any risks with the operation?
Every anaesthetic carries a risk, but this is very small. Your child’s anaesthetist is an experienced doctor who is trained to deal with any complications. The surgeon and anaesthetist will discuss potential risks with you before the operation. Your child may have a headache, sore throat or feel dizzy or sick after an anaesthetic. These side effects are usually short-lived and not severe.
Infection is a risk with any operation so your child will have a two-day course of antibiotics given into a vein (intravenously) to reduce the chance of this happening. The risk of infection is much smaller with the Nuss procedure than with the open chest surgery previously used as the incisions are much smaller.
Any operation on the chest can cause air or blood to collect in the space around the lungs. The lungs and inside of the chest cavity have a smooth covering called the pleura that lets the lungs expand without rubbing on the inside of the chest. The two layers of pleura are usually in close contact with only a small space in between (the pleural space). The pleural space can fill up with air (pneumothorax) during the operation. Usually this is not severe and can be cleared by deep breathing exercises but occasionally a chest drain may be needed.
There is a very small chance that the bar could knock the internal organs in the chest as it is being turned to the right position but the surgeon will be able to see inside the chest cavity with the endoscope and so minimise the chance of this happening.
Very rarely the bar becomes loose or slips out of position, so it needs to be put back in place in a second operation. It is secured strongly to the ribs so this is unlikely to happen.
What happens afterwards?
Your child will come back to the ward to recover from the operation. He or she will have had some pain relief during the operation but this will be topped up through an epidural to keep your child comfortable. In addition, pain relief will be given intravenously (through a drip) on a patient controlled analgesia (PCA) pump, so that your child can push the button to give pain relief when needed.
When your child has started eating and drinking again, the epidural and drip will be removed and he or she will have medicine or tablet pain relief. Your child will have a bladder catheter for the first few days while he or she has the epidural. Chest x-rays will also be taken after the operation to confirm that the bar is in the right place. Coughing and breathing deeply will help so your child will be encouraged to do this, often with the help of a physiotherapist for the first few days.
The day after the operation, your child will be encouraged to get out of bed and start to move around, with the help of the physiotherapist. Your child will find this uncomfortable to begin with, so we start to raise the head of the bed gradually in the morning, so that by lunchtime, he or she is sitting upright in bed.
The chest drain (if needed) will be removed when he or she no longer needs it, usually one to two days after the operation. The chest incisions will be checked regularly and redressed if needed. Your child will be able to go home around five days after the operation when the surgeon is happy that everything is healing well.
Going home
Following completion of the assessments, a report will be written and copies sent to you, to the person referring your child and to any relevant professionals such as your family doctor (GP). This will include the scores your child achieved. It will also indicate any recommendations that are appropriate for your child. This report will take some time to prepare but we aim to send it out as soon as possible.
The surgeon will see your child in an outpatient appointment a few weeks after the operation, to check that he or she is recovering well and that the operation site is healing properly. We will send you the date of the appointment in the post.
You should call the hospital if:
In the first few days back at home:
- your child’s pain is getting worse and pain relief does not seem to help
- your child shows any signs of infection – the incisions are red, sore, oozing or raised
- your child has a high temperature and paracetamol does not bring it down
- your child is not eating or drinking
After this, if your child has:
- a persistent cough
- breathing difficulties
- chest pain
- has a chest injury, such as a severe knock to the ribcage
Getting back to normal
There are some simple precautions your child will need to take to make sure that he or she heals well and life gets back to normal as quickly and safely as possible.
- Your child should not overdo things for the first four to six weeks.
- He or she should be able to go back to school when he or she feels able. Most children stay off school for a few weeks after the operation.
- Contact sports are not allowed for the first three months, due to the risk of damage to the chest.
- Your child should avoid lifting anything heavy, including school bags or rucksacks for three months.
- He or she will be able to go swimming three months after the operation.
- Certain tests and scans may be more problematic in the future, due to the metal bar. Your child should wear a Medicalert® bracelet or equivalent to alert doctors and paramedics.
Removal of the bar
This usually takes place a year or two after the operation to insert it. By this time, the ribs and sternum are fixed in the correct position so the bar is no longer needed. The bar is removed in another operation under general anaesthetic, through the same incisions used to insert it. This operation is usually done as a day case, that is, your child comes into hospital in the morning and is able to go home the same evening.
What is the outcome for children having the Nuss procedure?
Pectus excavatum is usually cured by the Nuss procedure, but occasionally it can develop again years later when the bar is removed. If this happens, the bar may need to be inserted. This only happens rarely.
The development of the Nuss procedure means that patients have a shorter stay in hospital and less noticeable scarring compared with the previously used open chest operation. At GOSH, we have carried out more than 100 Nuss procedures to date with excellent results.
Sources of support and further information
Members of the cardiothoracic team are able to put you in touch with other children who have previously had a Nuss procedure at GOSH. In addition, the following websites contain further information about the procedure.
- UK Pectus Excavatum and Pectus Carinatum Information Site – www.pectus.org
- National Institute for Health and Clinical Excellence (NICE) guidelines on the Nuss procedure - guidance.nice.org.uk/IPG310 [note: no www]
Please note: Inclusion of any organisation, product or service in this list does not constitute endorsement by GOSH.
