Nuss Procedure

Overview

What is a Nuss procedure?

A Nuss procedure is a minimally invasive surgical repair to fix pectus excavatum. People who have this sunken chest issue are candidates for the Nuss procedure instead of an open repair with a larger incision. The procedure uses a titanium bar or bars to push a child’s sunken breastbone out. Bars stay in your chest for three years.

What is the best age for a Nuss procedure?

Children usually have this surgery as teenagers. Surgeons usually don’t do this operation on children younger than 14 years old. There is no upper age limit. Adults can have a Nuss procedure also.

Why is a Nuss procedure done?

A Nuss procedure makes a sunken chest, called pectus excavatum, look better right away. The bar pushes your breastbone forward to flatten your chest. While the bar is in place, it helps your breastbone grow in the right way. This procedure can help your heart or lungs work better than they do prior to surgery.

The Nuss procedure can help with:

How long do Nuss bars stay in?

Your child will have a Nuss procedure bar in their chest for three years. When a surgeon removes the bar, your child will be asleep for the procedure. However, they usually won’t need to stay overnight in the hospital.

What does a Nuss procedure treat?

A Nuss procedure treats pectus excavatum, a condition in which your chest bones didn’t develop right. This is a congenital condition or one you’ve had since birth. One in 1,000 people will develop pectus excavatum.

With pectus excavatum, your breastbone, or sternum, looks sunken or hollow. Also, your ribs may not look even.

Procedure Details

What happens before a Nuss procedure?

Your child will need several tests a few days before their surgery. Tests may include:

How long does a Nuss procedure take?

A Nuss procedure can take up to four hours.

What happens during a Nuss procedure?

Your child will receive general anesthesia so they’ll be asleep during the operation.

Your pediatric surgeon will follow these steps:

  1. Make a small cut on each side of your child’s chest.
  2. Put a small camera into one of the cuts so they can see inside.
  3. May perform cryoablation, or freezing of the chest nerves, for pain control after surgery.
  4. Place a metal bar through the incision and attach it to your child’s chest wall with stitches. This curved bar, made to fit your child, goes under their breastbone to lift it.
  5. Insert a second or third bar if the first one isn’t enough to fix the problem.
  6. Remove the camera.
  7. Close the incisions they made.

What happens after a Nuss procedure?

Usually, your child will stay at the hospital overnight (rarely longer if necessary).

The day after surgery, a healthcare provider will ask your child to sit up in bed and breathe deeply. They may also ask them to walk down the hallway, even if it’s a short distance with a walker. This basic exercise, which your child can slowly increase day by day, helps with healing.

Your provider will advise your child to take laxatives or stool softeners to prevent constipation.

How painful is a Nuss procedure?

A Nuss procedure is painful enough that your child will need several different kinds of pain relievers. Some of these may be strong prescription medicines.

Your child may receive these for pain relief while in the hospital and for two weeks after going home:

  • Nerve cryoablation: freezing the nerves near your child’s ribs.
  • Oral medication: acetaminophen, ibuprofen, gabapentin and limited opioids.

Risks / Benefits

What are the advantages of a Nuss procedure?

A Nuss procedure straightens your child’s chest wall. Most children who have this procedure get a normal chest shape that’s visible right after surgery. After a Nuss procedure, most people can breathe and exercise better.

Other benefits include:

  • Low complication rates.
  • Low risk of the breastbone sinking again.

What are the risks or complications of a Nuss procedure?

Risks of a Nuss procedure include:

  • Bleeding.
  • Infection.
  • Pain.
  • Bar(s) moving out of place.

To help keep the bar(s) from moving around during the first four weeks, ask your child to:

  • Sit up straight.
  • Bend at their hips.
  • Not roll over on their sides.

Recovery and Outlook

How long does it take to recover from a Nuss procedure?

It takes about six months for full recovery from the Nuss procedure, but most people are back to usual activities (except for heavy lifting and contact sports) much sooner. Activities that involve twisting your body or raising your arms a lot can move the bar out of place. This is why your child will need some time to recover from surgery before returning to physical activities.

Your surgeon will review the gradual return to activities with you in detail.

When can my child go back to school?

Most children who have a Nuss procedure can go back to school within a month after their operation.

When to Call the Doctor

When should I see my healthcare provider?

Contact your child’s provider if your child is experiencing any of these:

  • Fever.
  • Redness around the wound.
  • Swelling or bleeding from the surgical cuts.
  • Chest pain.
  • Shortness of breath.
  • A feeling that the bar has moved out of place.

You’ll follow up with your child’s surgeon at regular intervals after surgery where they will evaluate:

  • How the wounds are healing.
  • How the chest shape looks.
  • Whether the bar is in the right place.

Your child will need to keep going to these checkups until the surgeon removes the bar.

A note from Cleveland Clinic

If your child’s healthcare provider recommends a Nuss procedure for pectus excavatum, don’t be afraid to ask questions about it.

Last reviewed by a Cleveland Clinic medical professional on 03/09/2022.

References

  • American Pediatric Surgical Association. Conditions P-Z. (https://apsapedsurg.org/parents/learn-about-a-condition/p-z/) Accessed 3/9/2022.
  • Frantz FW, Goretsky MJ, Shamberger RC. Pectus Excavatum. In: Ziegler MM, Azizkhan RG, Allmen D, Weber TR. Operative Pediatric Surgery, 2e. McGraw Hill; 2014. Accessed 3/9/2022.
  • Pilegaard HK. Short Nuss bar procedure. (https://pubmed.ncbi.nlm.nih.gov/27747185/) Ann Cardiothorac Surg. 2016 Sep;5(5):513-518. Accessed 3/9/2022.

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