Hybrid Nuss Procedure for Pectus Excavatum With Severe Retrosternal Adhesions After Sternotomy

Background. The most striking feature of pectus excavatum (PE) after previous congenital heart disease (CHD) surgery through a median sternotomy is the postsurgical adhesions between the sternum and heart. For patients with severe adhesions, passing the introducer can be difficult and hazardous when performing a Nuss repair. We describe a hybrid Nuss procedure using a small subxiphoid incision for blunt and sharp anterior mediastinal dissection and using a thoracoscope to ensure the whole process of dissection is under direct visualization. Methods. A retrospective case review was conducted of PE patients (previous CHD operation) who had undergone the hybrid Nuss procedure between January 2012 and June 2015. Demographic, treatment, and outcome variables were recorded. Results. Eleven patients were included. The mean age was 4.7 +/- 1.7 years (range, 3.2 to 8.9). The mean Haller index based on computed tomography was 4.15 +/- 0.78 (range, 3.2 to 5.8). All cases were the symmetric type. Mean operating time was 95.5 +/- 8.4 minutes (range, 80 to 110); mean blood loss was 15 +/- 2.3 mL; and mean length of hospitalization was 6.0 +/- 1.4 days (range, 4 to 8). There was no pneumothorax, cardiac injury, wound infection, discomfort requiring removal, or bar rotation at the average 27-month (range, 9 to 50) follow-up. Two patients had the bars removed. No reoperations were performed owing to recurrence. Conclusions. The hybrid Nuss procedure is a safe, simple modification of the Nuss repair for patients with severe retrosternal adhesions. This procedure achieves dissection with direct visualization. Hence, the risk of death due to cardiac perforation can be prevented. (C) 2017 by The Society of Thoracic Surgeons