Case Report

A Simple and Safe Technique for Manipulation of Retrosternal Dissection in the Nuss Procedure

Masahiko Noguchi, MD, PhD; Shoji Kondoh, MD, PhD; Kenya Fujita, MD, PhD

Disclosures

ePlasty. 2014;14 

In This Article

Case Report

The patient was a 9-year-old boy with a symmetric chest wall deformity. As the first step, the insertion point of the dissector on the right thoracic wall was determined using a CT image taken in the axial plane where the Nuss bar was to be inserted. On this image, a line was drawn from the insertion point of the Nuss bar on the left thoracic wall (Figure 1, white arrow) along the retrosternal plane (Figure 1, red arrow). The point at which this line extended to meet the lateral portion of the right thoracic wall was the insertion point of the dissector. The depth between the body surface and the insertion point was 7.5 cm in this case (Figure 1*). From this evaluation, the dissector was inserted from the sixth intercostal space near the mid-axillary line (Figure 2a↑) and therefore skin incision was set up dorsally from the usual position. In dissection of the retrosternal space, we dissected just above the pericardia not just beneath the sternum to preserve sufficient tissues around both cardiac and internal thoracic vessels to protect them from damage (Figures 2b and 2c). The dissection manipulation was smooth and the bar was placed at the fourth intercostal space. A good result was obtained (Figure 2d).

Figure 1.

A 9-year-old boy with symmetric chest wall deformity. The insertion point for the dissector was determined by CT examination. The insertion point of the Nuss bar on the left thoracic wall (↑). The depth between the body surface and the insertion point (*) was 7.5 cm.

Figure 2.

Intraoperative view of the same patient shown in Fig 1. (a) Intraoperative design. The dissector passed through from the same skin incision where the Nuss bar was to be inserted. (b) The right side of the mediastinum. Dissection of the mediastinum. The layer of the dissection was just above the pericardium (*). (c) The left pleura (*) and internal thoracic vessels (↑). Sufficient tissues were left in place to protect the internal thoracic vessels from damage. (d) Postoperative view.

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