Forced Sternal Elevation as an Adjunct to the Nuss Procedure for Pectus Excavatum

From the APSA 2016 Annual Meeting proceedings FORCED STERNAL ELEVATION AS AN ADJUNCT TO THE NUSS PROCEDURE FOR PECTUS EXCAVATUM Barry LoSasso, MD, Gerald Gollin, MD. Rady Children’s Hospital and Sharp Memorial Medical Center, San Diego, CA, USA. Purpose: During most Nuss procedures, the dissector can be passed deep to the sternum in a manner that is safe and that allows for the tip of the instrument to exit the chest wall within 2 centimeters of the sternum. In some cases, proper passage of the dissector is prohibitively difficult and forced sternal elevation has been described as an adjunct. We present a video that demonstrates forced sternal elevation using the Ruhltract retractor. Procedure: The case presented in this video is that of an adult male, but the mechanical challenges are similar to older teenagers in whom we have used forced sternal elevation. In this patient, the Haller index was 5.2 and the excavatum defect was very asymmetric. Thoracoscopy demonstrated a deep and sharply angulated sternal defect that precluded safe and effective substernal dissection. A tenaculum was carefully placed by assuring deep entry of each side into the lateral sternum. The tenaculum was slowly clamped and connected to a wire loop and then to the snap clip of the Ruhltract. The Ruhltract rachet was then slowly turned to gradually retract the sternum anteriorly. Thoracoscopy after sternal retraction demonstrated a substantial correction of the pectus deformity which allowed for wide dissection between the sternum and pericardium. The dissector was then easily passed under the sternum and pushed through the corresponding left intercostal space one centimeter from the edge of the sternum. The pectus bar was then passed through the mediastinum. Conclusions: Use of forced sternal elevation can be a useful adjunct to Nuss repair in adult patients, in adolescents with particularly deep and asymmetric defects, and in re-do cases. In addition, as a surgeon gains experience with the Nuss operation, sternal elevation can offer an extra margin of safety during substernal dissection and passage of the dissector and bar. DOI: https://doi.org/10.17797/l3k45714ep