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

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

ThoracoscopyThoracoscopy

• 5 mm trocar; 0° telescope

• 2 ICS below the intended position of the bar

• 4 mmHg CO2 pneumothorax

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

Prepare The BarPrepare The Bar

• Use a malleable Template:

– Check the length– Mold the contour of

the corrected chest– Choose the

appropriate Pectus Bar

• Using the template as a guide

• Remain symmetrical

• Final adjustments after insertion

INSERT THE PECTUS BARINSERT THE PECTUS BAR

• Under direct vision from one side at least.

• Minimize the manipulation

Flipping the Bar !!!Flipping the Bar !!!

• 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

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

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

ComplicationComplication

Remove the bar in about 2 yearsRemove the bar in about 2 years

Question?Question?

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