Nuss surgery: ways to reduce the frequency of postoperative complications, severity and duration of postoperative pain

Abstract

Funnel chest deformity is the most common malformation of the anterior chest wall, which in many cases leads to cardiorespiratory disorders and psychological problems. The undisputed progress in her treatment is the Nuss procedure, which is the «gold standard». However, this surgical operation and its modifications carry potential risks of severe postoperative and intraoperati. The aim is analyzation the existing variants of Nuss procedure and developing our own modification of this kind of surgery to eliminate intraoperative risks, reduce the level of postoperative complications, minimize postoperative pain. Materials and methods. In 2018–2019, the authors operated on 34 patients with funnel chest (Nuss operation in its own modification) with II and III degrees of deformity. The analysis of postoperative complications, the level of postoperative pain on the NRSP scale up to 3 months after surgery; duration of interventions, volume of intraoperative bleeding are made. Features of the proposed modification of the operation are: 1) Using of a monolithic T-shaped titanium bar with a removable stabilizer; 2) Formation of the tunnel is strictly under the muscles; 3) Rigid subperiostal fixation of bar stabilizers to two ribs on each side; 4) Using bars of different width for different age categories; 5) As a device for gradual dosed intraoperative lifting of the sternum used a turnbuckle; 6) The working port is entered through the right main access and through the right subpectoral tunnel; 7) Correction of asymmetric forms of deformation is carried out due to asymmetric rigid fixation of stabilizers and traction of the sternum by several ligaturesve complications. Results. The proposed modification of the Nuss operation reduces intra- and postoperative risks: only one postoperative complication was registered (2.9%); the method fixation of bar avoids the risks of eruption, displacement and reversal of the bar (no case has been registered), significantly reduces postoperative pain and prevents its chronicity. In all cases of correction of asymmetric forms of deformation it was possible to achieve good aesthetic results with the installation of one fixing bar. Conclusions. Gradual traction of the sternum to the position of moderate hypercorrection eliminates the risk of manipulation in the retrosternal space; subperiostal fixation of the bar to two ribs on each side guarantees reliable fixation of the plate without the risk of its displacement and reversal. Smaller bar thickness and width; fixing it as an arched structure reduces injuries of intercostal vascular nerve bundles and ribs and reduces postoperative pain. Placing the working port at the point of exit of the bar from the right pleural cavity facilitates and ensures manipulation in the mediastinum, providing sufficient elevation of the sternum. When using the proposed modification in most cases, it is sufficient to install one correction bar. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of these Institutes. The informed consent of the patient was obtained for conducting the studies. The authors declare no conflicts of interests. Key words: Nuss procedure, funnel chest, postoperative complications, postoperative pain syndrome, intraoperative lifting of sternum, turn-buckle, fixation of bar, thoracoscopy.