title: A simple and safe technique for manipulation of retrosternal dissection in the nuss procedure.
abstract: 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.
  
  
  CONCLUSIONS
  We believe every surgeon can easily apply this procedure to patients with pectus excavatum, and this procedure can reduce the stress during the dissection.
authors.affiliation: Department of Plastic and Reconstructive Surgery, Nagano Children's Hospital, Toyoshina, Azumino, Japan ; Department of Plastic and Reconstructive Surgery, Shinshu University School of Medicine, Matsumoto, Japan.
authors.forename: Masahiko
authors.initials: M
authors.lastname: Noguchi
authors.affiliation: Department of Plastic Reconstructive Surgery, Ina Central Hospital, Ina, Japan.
authors.forename: Shoji
authors.initials: S
authors.lastname: Kondoh
authors.affiliation: Department of Plastic and Reconstructive Surgery, Nagano Children's Hospital, Toyoshina, Azumino, Japan.
authors.forename: Kenya
authors.initials: K
authors.lastname: Fujita
keywords: Nuss procedure; pectus excavatum; prevent life-threatening complication; safe dissection; the layer of the dissection level