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Patient PositionPatient Position
• Supine
• 2 arms abducted– Allows access to both
axillas
• Primary access usually on the right– Left for special situation
(heart)
• Monitor on the left
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Find the appropriate Find the appropriate landmarkslandmarks
– Deepest bony pointDeepest bony point– Appropriate inter-Appropriate inter-
costal spacecostal space– Apex of deformityApex of deformity– Level of the bar in Level of the bar in
the mid axillary linethe mid axillary line
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ThoracoscopyThoracoscopy
• 5 mm trocar; 0° telescope
• 2 ICS below the intended position of the bar
• 4 mmHg CO2 pneumothorax
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TunnelingTunneling
• Mid-axillary line transverse incisions– 2-3 cm on the right
and on the left (stabilizer)
• Bilateral subcutaneous/sub-pectoral tunnel – To the apical
landmark
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Prepare The BarPrepare The Bar
• Use a malleable Template:
– Check the length– Mold the contour of
the corrected chest– Choose the
appropriate Pectus Bar
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• Using the template as a guide
• Remain symmetrical
• Final adjustments after insertion
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INSERT THE PECTUS BARINSERT THE PECTUS BAR
• Under direct vision from one side at least.
• Minimize the manipulation
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Flipping the Bar !!!Flipping the Bar !!!
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• Exsufflate the pneumothorax– Keep the trocar in place– Connect its insufflations tubing to a water seal– Inflate the lung till no more air leak– Remove the trocar
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Post-OPPost-OP
• No chest tube• Bed rest till
comfortable (2 to 4 days)
• Chest PT• Discharge 4 to 8
days• No sports for 3
months
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PitfallPitfall
• Introducer- should be done under direct vision
• Attention in case of- resistance: it has to pass smoothly to
contralateral side- ECG should be hearable
• Bar- in older adolecents/adults: consider two
bars and cartligge release on one or two side
• Stabiliser- at least on one side with wire cerclage
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ComplicationComplication
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Remove the bar in about 2 yearsRemove the bar in about 2 years
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Question?Question?
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Thank You