A TECHNIQUE TO PREVENT BAR DISPLACEMENT IN THE NUSS PROCEDURE

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Author: American Pediatric Surgical Association
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Specialties: Pediatric Surgery
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From the APSA 2017 Annual Meeting proceedings

A TECHNIQUE TO PREVENT BAR DISPLACEMENT IN THE NUSS PROCEDURE

Claire E. Graves, MD1, Andrew Phelps, MD1, Olajire Idowu, Jr., MD2, Sunghoon Kim, MD2, Benjamin E. Padilla, MD1.

1University of California, San Francisco Benioff Children’s Hospital, San Francisco, CA, USA, 2University of California, San Francisco Benioff Children’s Hospital, Oakland, CA, USA.

Purpose: Bar displacement is a serious complication of the Nuss  procedure. Three types of displacement have  been well described: lateral sliding, bar flipping and posterior disruption. We propose a simple  modification in bar placement and  fixation that safeguards against all three mechanisms of displacement.

Methods: Nuss  bar length  is chosen to extend just beyond the pectus ridge on each side.  Using the external bar bender, we make  a gentle  curve on each side  of the bar, corresponding to the peak  of each pectus ridge.  The ends of the bar are left straight. After the bar is inserted and  flipped,  a stabilizer  is placed on each end  and  slid medially, just lateral to the chest wall insertion site. After the stabilizers are in position, in situ bar benders are used to complete the curvature of the bar around the chest wall.

Results: This technique addresses all three  methods of displacement (Fig.1). Lateral sliding is prevented by locking the stabilizers in place with in situ bending just lateral to the chest exit site (A). The bar cannot move laterally as the stabilizers abut  the chest wall exit site (B). Placing  the stabilizers more  medially positions them  at the inflection point where  the ribs angle  superiorly. Thus the stabilizers straddle two ribs on the anterior chest (C). The stabilizers therefore have  a broader base of support, preventing bar flipping. Finally, placing  the stabilizers more  anterior  allows them  to directly counteract the posterior pressure on the bar from the sternum. Instead of relying on the intercostal musculature, the ribs themselves serve  to support the stabilizers and  bar from posterior dislocation.

Conclusion: We report  a technical modification of pectus bar placement and stabilization to minimize the risk of three  common mechanisms of displacement.

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