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


ePlasty. 2014;14 

In This Article

Abstract and Introduction


Objective. The Nuss procedure has become the first choice for repairing the pectus excavatum because of the advantages of the technique including minimal invasiveness and short operative duration. Although this technique appears simple and easy, life-threatening complications during dissection such as intraoperative cardiac perforation have been reported. We developed a new approach for safer dissection of retrosternal space.

Methods. We use a dissector that is commonly used for laparoscopic operation, instead of the Nuss introducer. The dissector goes through the same skin incision where the Nuss bar will be inserted. The major difference is the position of dissector insertion, which is set up more dorsally than usual, and the use of a laparoscopic dissector instead of the Nuss introducer. In this new approach, the direction of dissection is from dorsal toward the anterior thoracic wall, which allows us to visually follow the tip of the dissector throughout the surgery. Moreover using the dissector that has better manipulation capability enables us the fine dissection and also is able to precisely determine both the layer and the area of the dissection level.

Results. We have treated more than 150 patients using this technique without any complications since 2008. In all the cases, safer dissection of the retrosternal space was performed with good results.

Conclusion. We believe every surgeon can easily apply this procedure to patients with pectus excavatum, and this procedure can reduce the stress during the dissection.


Although the Nuss procedure is a widely used minimally invasive method for repair of pectus excavatum, some catastrophic complications have been reported, including life-threatening intraoperative cardiac perforation.[1–6] Thoracoscopic surgery was proposed for safer dissection between the sternum and the heart.[7–9] Although this method has advantages, it still does not fulfill our safety requirements. Many other supportive methods have been reported to obtain a better visual field.[10,11] In our institute, we experienced 2 cases of pericardiac perforation and 1 case of injury of the internal thoracic artery during retrosternal dissection.

Here, we introduce a new technique for safer retrosternal dissection, which involves a slight shift of the bar insertion point and the use of a laparoscopic dissector instead of the Nuss introducer. This seemingly simple modification makes a great difference in visibility of the field of operation and manipulation of surgical tools, leading the Nuss procedure to much safer technique. We believe this procedure can reduce the stress during dissection in patients with pectus excavatum.