What to Expect: Surgery

Preparing for surgery

• Around one month prior to surgery, you will have a telehealth visit with a provider from the chest wall team.
• To prevent constipation after surgery, your care team will give you instructions for a bowel preparation and special diet the day prior to surgery. You will receive this information at your preoperative visit.
• We will review special cleaning wipes to use on the skin prior to surgery.
• Once surgery is scheduled, you will be provided with specific information about when and where to arrive for surgery. You will also be contacted for by our anesthesia department to discuss your child’s anesthetic plan and answers any questions you may have. Your child will be given an incentive spirometer (a device used to help keep the lungs healthy after surgery) to practice deep breathing exercises prior to surgery.
• You will receive a phone call from the PARC team the day prior to surgery to tell you when to arrive at the hospital and when to stop eating and drinking.
• Please have your child use the incentive spirometer twice daily as directed until the surgery date and upon returning home from surgery. You will be given antiseptic wipes to clean your child’s chest the night before and the morning of surgery to help reduce the risk of infection.

The hospital stay

For most pectus excavatum or pectus carinatum surgical repairs, patients should expect to stay in the hospital for one to two days. Patients will be able to eat and move around immediately after surgery. During the hospital stay, the goals of care will be to:

• Optimize pain control
• Work with physical therapy to develop strategies to transfer and move around comfortably
• Monitor the incisions to ensure proper healing
• Practice taking deep breaths using the incentive spirometer to help fully re-expand the lungs after surgery and prevent fluid or mucus buildup that could lead to the development of pneumonia

Pain control methods

We offer a wide variety of pain control options during and after surgery, some not available in most other children’s hospitals.

Target-based care pathway. We offer a wide variety of pain control options during and after surgery, some of which are unique to Stanford Children’s:

• Cryotherapy. Cryotherapy, or freezing of the chest nerves, is done at the time of surgery to decrease pain after surgery and speed up recovery time.
• Intercostal nerve block. A numbing medicine is injected around the intercostal nerves at the time of surgery to decrease pain after surgery.
• Multimodal pain control. We target nerve pain, muscle pain, and inflammation with our multimodal pain management protocol to minimize narcotic use after surgery. Your chest wall team will detail the medications we use after surgery at your consultation visit.
• Goal-directed care. Your multidisciplinary care team shares the same goal of getting you home and back to your daily activities as safely and quickly as possible.

At Stanford Medicine Children’s Health, our Pain Management program continually explores new and better ways to manage pain. These often balance traditional methods with complementary medicine, including physical therapy, occupational therapy, intravenous patient-controlled analgesia, acupuncture, biofeedback, cognitive behavioral techniques, yoga exercises, and much more.

Nuss procedure:

The most commonly performed surgical treatment for pectus excavatum is the Nuss procedure. This is a minimally invasive surgical procedure. During this procedure, small incisions are made on each side of the chest to allow the surgeon to insert a metal support bar underneath the sternum to reverse the depression in the chest. Minimally invasive surgical techniques result in reduced blood loss and shorter operating times that lead to a smoother, faster recovery. Managing your child’s pain is very important to us. That’s why we offer state-of-the-art pain control techniques, including cryoablation and others to reduce pain and recovery time after surgery.

Our surgeons use a new, innovative, state of the art pectus bar set that uses a connector bar to stabilize them in place. This makes the bars more secure and does not require them to be sutured to the ribs.

• Surgery is performed using general anesthesia under the care of pediatric anesthesiologists. A special breathing tube called a double lumen endotracheal tube will be placed during surgery to allow single lung ventilation during the minimally invasive Nuss procedure.
• Learn more about our specialized Pediatric Anesthesia team.

Ravitch procedure:

Surgical correction of pectus carinatum is an option for severe cases and for cases that do not respond to bracing therapy. For pectus carinatum and severe cases of pectus excavatum, we perform a surgery called the Ravitch procedure. Our skilled surgeons remove and reshape cartilage and reposition the sternum into a more natural position. The surgery requires that your child spend a few days at the hospital, where our pain management team uses the most innovative and leading-edge techniques to manage your child’s pain, including a combination of conventional medicine and complementary approaches.

A temporary bar and a small drain are placed during surgery to help the cartilage regenerate. Your child will have daily movement limitations for about six weeks after surgery, and sport and activity limitations until healing is deemed complete. The bar typically remains in place for six months or until your child builds up adequate cartilage and fully recovers.

Recovery after surgery

Your child will be discharged home once their pain is well controlled and he/she can move around independently. Your child will be provided with exercises to help aid in your child’s recovery at home. There will be minimal required care for incisions. We will typically see your child for follow-up one month, three months, six months, and one year after discharge. We will then arrange for annual follow-up after surgery to evaluate your child’s progress and discuss optimal timing for bar removal.

• Your team will review all instructions for medications to take during your recovery at home.
• You will continue to use the incentive spirometer after discharge to help expand your lungs and prevent pneumonia.
• It is important to be up and moving frequently after surgery. Your child should be walking, preparing meals, changing clothes, and showering independently after surgery.
• Your care team will review any activity limitations with you prior to leaving the hospital.
• Most patients stay home from school or work for two weeks following surgery. If your child feels ready to return to school sooner than two weeks following surgery, that is safe to do.
• You will follow up with your care team one month after surgery and then yearly until the bars are removed. Your care team may request an additional clinic visit at three months after surgery.