Chapters Transcript Video Bar Removal after Nuss Procedure Frazier Frantz, MD, completes the hardware removal on a male patient who has previously undergone a 2 bar minimally invasive pectus excavatum repair. This video depicts hardware removal. In a patient who has previously undergone two bar, minimally invasive practice excavatum repair Pettus bar removal typically occurs three years after practice repair. The procedure is performed in a hospital setting where thoracic and cardiac surgery capabilities are available if necessary. The procedure is typically performed as outpatient surgery. The most common complications encountered our wounds, aroma and pneumothorax, significant bleeding from intra thoracic vessels is a rarely reported complication. Standardized equipment for practice. Bar removal includes instrumentation for dissection and flattening of the practice bars. Specialized equipment that should be available in the operating room includes osteo tomes and Ron jurors for sharp dissection and removal of hetero topic bone. A thoracotomy and stern autonomy tray should be available for control of hemorrhage if encountered. For practice bar removal. The patient should be placed in the supine position with the arms outstretched. The chest area should be prepped generously to allow for a thoracotomy or stern. Ah To me if necessary. Prior to operation, the hardware configuration is verified by palpitation or chest X ray. If necessary, bilateral incisions are made through the previous surgical scars. Attention is first focus to the bar and stabilizer complex. The section continues down to the fibrous capsule overlying these structures. The capsule is released to expose the bar and stabilizer. The fiber, wire tie attaching the bar and stabilizer is removed. The exposed stabilizer is then disengaged from the bar. In this case a bone tamp and mallet is being utilized for this purpose. The end of the bar previously attached to the stabilizer is flattened. In this case, an orthopedic plate. Bender is being utilized for this purpose. The fibrous capsule overlying the medial aspect of the bar is exposed and incised. Yeah, attention is next directed to exposure and release of the free end of the lower bar on the left side. After incision of the scar capsule. The bar is flattened after exposure and flattening of the left sided hardware, attention is focused to the right side. The scar capsule overlying the lower bar on the right side is incised to expose the bar and stabilizer complex. The stabilizer is subsequently disengaged from the bar. Mhm. The lower bar is flattened and removed by applying downward force with a bone hook through the eyelet in the bar. The free end of the upper bar on the right side is exposed by in sizing the scar capsule and removed in similar fashion. Meticulous homeostasis is achieved at the incision sites and the scar capsules are re approximated with interrupted absorbable sutures. The incisions are closed in multiple layers. For practice bar removal. The following techniques are utilized. The bilateral thoracic incisions are opened where multiple bars have been placed. Attention should first be directed to the incision overlying the stabilized bar, the fibrous attachments over the stabilizer and end of the bar are dissected free and the stabilizer is disengaged from the bar, The lateral aspect of the bar is then flattened. Multiple devices are available for this purpose. The fibrous capsule over the bar is incised immediately as far as can be visualized the fibrous attachments over the side of the bar without stabilizer are dissected and the capsule overlying the bar is incised immediately. Hetero topic bone if present should be removed. The lateral aspect of this side of the bar should then be flattened Before attempting bar removal. Adequate mobility of the bars within the scar capsules should be insured by applying lateral traction manually or with a bone hook through the eyelet in the bar. The bars are removed by applying steady lateral traction. A positive pressure breath is held by the anesthesiologist to minimize the risk of pneumothorax. After bar removal. Manual pressure is applied over the fibrous tracks and subsequent assessment for the presence of air leak or hemorrhage is undertaken. Multi layer wound closure is undertaken. A compression dressing can be applied if appropriate. Postoperative chest x ray is undertaken to assess for the presence of pneumothorax or other abnormalities. Follow up after practice. Bar removal includes a wound. Check at 2-3 weeks post operatively and a one year assessment to verify permanent chest wall remodeling. There are several considerations which may affect the optimal timing of pecker's bar removal, consideration for delaying the procedure for an additional year or more is appropriate in the setting of ongoing rapid puberty growth because of the potential risk of recurrence. Earlier hardware removal should be considered when sternal overcorrection has occurred, especially if it is progressive in this setting. The earliest timing of removal would typically be at two years, post up hetero topic calcification and bone formation represents the formation of excessive bone around the practice bars and typically involves the unstable ized aspect of the bars. This can completely encase the practice bar, making identification of the exact bar position difficult. In this setting, intra operative flora. Skopje may be a useful adjunct for bar localization. It is difficult to predict the presence of hetero topic classification pre operatively. It is more common when the hardware is tight when encountered. This requires complete removal with sharp dissection to ensure that the petrus bar slides through the capsule easily. As this represents extra bone superior to the underlying rib. There is no need for rib resection. The rib will remodel with time after hardware removal. Created by Related Presenters
