Category: Genel

Nuss surgery is a minimally invasive (closed) surgical method used in the treatment of shoemaker’s chest (pectus excavatum).

It is considered the gold standard today due to the fact that it is performed with much smaller incisions than traditional open surgeries and the speed of the healing process.

We have brought together the technical details, operation process and recovery stages that patients and families are most curious about this procedure in 10 basic questions.

Top 10 Questions About Nuss Surgery

1. What is the Best Age for Nuss Surgery?

The ideal age range for surgery is usually between 12-18 years old.

During this period, the rib cage is still flexible and bone development responds best to surgical correction.

However, with the developing technology, this method can also be successfully applied to adult patients who are deemed suitable.

2. How is Post-Surgery Pain Management Provided?

The first few days after Nuss surgery are the most critical period for pain management.

Epidural analgesia or patient-controlled pain relief (PCA) systems are used in the hospital.

In recent years, pain transmission in the surgical area has been temporarily stopped with the “Cryoanalgesia” (nerve freezing) method, which allows patients to have a much more comfortable recovery period.

3. How long should bars on the ribcage stay?

The placed bars usually remain in the rib cage for 2.5 to 3 years.

This time is necessary for the breastbone to be permanently shaped in its new position.

At the end of the period, the bars are removed with a closed and short-term procedure.

4. Can You Do Sports While There Are Bars?

Heavy physical activities should be avoided for the first 3 months after surgery.

However, after the 3rd month, sports such as swimming, jogging and fitness can be started gradually.

It is recommended to avoid contact sports where there is a risk of impact to the ribcage, such as taekwondo, karate, or football, while the bars are on the body.

5. Will There Be Any Surgical Scars?

Since Nuss surgery is a minimally invasive method, only small incision scars of 2-3 centimeters remain on the sides of the chest.

When viewed from the front, no surgical scars are visible, which provides a great cosmetic advantage.

6. What is the success rate of the surgery?

The success rate of the Nuss procedure is over 95% with proper patient selection and an experienced surgical team.

The vast majority of patients are highly satisfied with both functional (reduced shortness of breath) and aesthetic results.

7. Do Bars Sing at Airport Security Gates?

The bars used can often trigger metal detectors.

For this reason, patients are given a signed surgical ID card or epicrisis report stating that they have a medical implant in their body.

8. What are the Risks and Complications of the Surgery?

As with any surgical procedure, Nuss surgery has low risks such as bar slippage, infection or air collection between the lung membranes (pneumothorax).

However, with advanced fixing techniques, the risk of bar slippage has decreased to less than 1%.

9. When can I return to daily life after surgery?

Patients are usually discharged after 5 days of hospitalization.

The time to return to school or office work is usually 2-3 weeks.

Full recovery and transition to normal physical activity takes about 3 months.

10. Is Nuss Surgery Covered by Insurance?

Cases with a Haller Index of 3.25 and above, whose heart or lung compression has been proven by medical tests, are considered “medical necessity”.

Patients who meet these criteria are usually eligible for SSI and private health insurance coverage.

Prof. Dr. Levent Alpay: The most important rule after Nuss surgery is patience. It is vital to avoid sudden body movements and heavy lifting, especially during the first 6 weeks, so that the bars fully adapt to the texture. Our preference for the cryoanalgesia method in pain management allows our patients to walk comfortably even on the second day after surgery.

Comparison of Nuss Surgery and Other Methods

Post-Surgery Recovery Tips

• Posture: Trying to stand upright distributes the pressure of the bars more evenly.
• Breathing Exercises: The use of Triflo should not be neglected to maintain lung capacity after surgery.
• Sleeping Position: It is recommended to lie on your back for the first few months to keep the bars in place.

This information is for general informational purposes only; It is recommended to consult a healthcare provider for your condition.

Scientific Bibliography

• Nuss Procedure for Pectus Excavatum – PubMed
• Cryoanalgesia in Nuss Procedure – Journal of Pediatric Surgery
• The Nuss Procedure: 20 Years Later – Lancet

Shoemaker’s chest, known as Pectus Excavatum in the medical literature, is a rib cage deformity characterized by the collapse of the sternum bone, known as the sternum, towards the spine.

In society, it is generally perceived as a cosmetic defect that concerns only appearance.

However, from a surgical perspective, the mechanical stress of this condition on vital organs and the implications for a patient’s quality of life extend far beyond aesthetic considerations.

As the depth of the collapse increases, the volume in the rib cage narrows and this can restrict the functions of the heart and lungs.

Physiological Effects and Health Risks of Pectus Excavatum

The rib cage is a lattice structure that protects vital organs and provides the necessary volume for their functioning.

In cases of shoemaker’s chest, the inward collapse directly narrows the internal volume of this cage.

Pressure on the Heart (Compression) and Rhythm Disorders

The inward collapse of the sternum creates direct pressure on the right ventricle (right ventricle) part of the heart.

This mechanical compression can restrict the heart’s capacity to fill with blood.

In advanced cases, it is observed that the heart is displaced (shifted to the left).

Patients may experience complaints such as palpitations, rhythm disturbances or chest pain during exertion due to this pressure.

Complaints of Decreased Lung Capacity and Shortness of Breath

The collapsed bone structure prevents the lungs from fully expanding.

This condition, which causes a restrictive lung pattern, leads to a decrease in respiratory capacity (vital capacity).

This limitation, which is not noticed at rest, occurs as shortness of breath when the body’s oxygen demand increases.

Exercise Intolerance: Physical Causes of Fatigue

Individuals with pectus excavatumtend to tire more quickly in sports activities compared to their peers.

This is mainly due to the fact that both the amount of blood pumped by the heart in one beat (stroke volume) and the oxygen intake capacity of the lungs are at the limit.

Exercise intolerance is an important medical indication that negatively affects a patient’s physical development and overall fitness.

Medical Evaluation Criteria: Aesthetic or Functional?

Objective measurement methods are used to understand whether a patient’s condition is just a visual defect or a disease that needs to be treated.

Haller Index: How to Measure the Severity of Collapse?

The Haller Index calculation made on computed tomography (CT) or MRI images is the most reliable parameter.

It is obtained by dividing the transverse diameter of the rib cage from the inside by the depth of the sternum at the point where it is most collapsed.

• Normal Value: It is at the level of approximately 2.5.
• Surgical Margin: Values of 3.25 and above indicate that heart-lung compression is significant and surgical intervention should be considered.

The Role of Echocardiography (ECHO) and Pulmonary Function Tests

With the ECHO test, whether the heart is under pressure and the functioning of the valves (especially the risk of Mitral Valve Prolapse) are examined.

Pulmonary function tests (PFT) numerically reveal the loss of lung volumes.

The results of these tests determine the point at which the decision for surgery evolves from aesthetic concerns to medical necessity.

The Effect of Rib Cage Deformity on Posture Disorders

In patients with pectus excavatum, it is often accompanied by the appearance of “slumped shoulder”, “hunchback” (kyphosis) and “dislocated abdomen”.

These posture disorders develop as a result of an effort to hide the deformity in the rib cage and can lead to chronic back and lower back pain over time.

Prof. Dr. Levent Alpay: The ‘introverted shoulder’ posture we see in young people with pectus excavatum is not just a posture disorder, but a physical reflection of the psychological burden created by the deformity. In cases with a high Haller Index, surgical correction improves not only the chest, but also the patient’s entire spinal health and self-confidence.

Psychological and Social Dimensions of Shoemaker’s Chest

As well as the physical effects, the effects of the deformity on the mental health of the individual should be evaluated within the scope of “medical necessity”.

Loss of Self-Confidence and Social Isolation in Adolescence

The deformity often becomes more pronounced during the rapid growth period in adolescence.

To hide this difference in their bodies, young people may exhibit behaviors such as avoiding swimming, wearing loose clothes and withdrawing from social environments.

Body Image Disorder and Its Effects on Quality of Life

Dissatisfaction with body image can pave the way for depression and social anxiety.

Many cases consult a physician because of this psychosocial pressure rather than their physical complaints.

Studies around the world prove a dramatic increase in quality of life scales after surgical correction.

When is Treatment Necessary? Functional Indications

Not every pectus patient is operated on. However, certain situations necessitate intervention.

Severe Collapses Restricting Daily Activities

Panting while climbing stairs, inability to participate in sports classes, or a constant feeling of pressure in the chest area are all signs of functional limitation.

Deformity Levels Threatening Heart and Lung Health

Treatment should not be delayed in patients with a clear crushing of the right ventricle of the heart or a murmur on CT images.

Treatment Options Comparison Table

Frequently Asked Questions

1. Does shoemaker’s chest improve on its own over time?

Unfortunately, pectus excavatum is not a self-resolving deformity. On the contrary, with rapid growth during adolescence, the depression tends to deepen.

2. What is the best age for surgery?

The ideal age range is usually between 12-18 years old. The rib cage is still flexible and the healing rate is high. However, today it can also be successfully applied to older adults.

3. Will there be a lot of pain after Nuss surgery?

Pain management in the first few days after surgery is provided with an epidural catheter or patient-controlled analgesia (PCA). Pain has been minimized with modern techniques and cryoanalgesia (nerve freezing) applications.

4. Do pectus bars prevent sports?

Heavy sports should be avoided for the first 2-3 months after surgery. However, after the recovery is completed, patients can safely do sports such as swimming, fitness and jogging even when there are bars. Only combat sports (kickboxing, karate, etc.) are not recommended.

5. Does insurance cover this surgery?

Cases with a Haller Index above 3.25 and whose heart-lung compression is proven by medical tests (ECHO, PFT) are generally covered by insurance because they are considered within the scope of “medical necessity”, not aesthetics.

This information is for general informational purposes only; It is recommended to consult a healthcare provider for your condition.

Scientific Bibliography

• Management of Pectus Excavatum – The Lancet
• Chest Wall Deformities and Cardiac Function – PubMed
• Nuss Procedure for Pectus Excavatum – Journal of Pediatric Surgery

Lung nodules are detected much more frequently by chance today, thanks to developing radiological imaging techniques. Although the expression “lung nodule” seen in radiology reports causes serious concern among patients, the majority of these formations are benign. However, there are certain criteria that determine the potential of a nodule to be malignant. These criteria are; The radiological characteristics of the nodule are evaluated based on the patient’s personal health history and the rate of change over time.

Basic Criteria Determining the Risk of Cancer in Lung Nodules

To understand whether a lung nodule indicates cancer, physicians first analyze the morphological structure of the nodule. Although a feature alone does not make a diagnosis, the combination of certain features increases the risk scoring.

The Importance of Nodule Size and Millimetric Measurements

The diameter of the nodule is directly related to the risk of cancer. In the general medical literature, the risk of cancer in nodules under 5 mm is less than 1%, while this risk can exceed 60% in formations over 20 mm (2 cm). In particular, formations exceeding 30 mm (3 cm) are no longer called nodules but “masses” and are considered malignant until proven otherwise and require further examination.

Edge Structure: Is It Uniformly Bounded or Spiculate?

Benign nodules usually have sharp and smooth borders. On the other hand, if there are radial extensions called “spicular” or an irregular, serrated structure on the edges of the nodule, this may suggest that the nodule is trying to infiltrate the surrounding tissue. The “lobulated” (gnarled) margin structure is also among the radiological findings that increase the risk of cancer.

Density of the Nodule: Solid and Ground Glass (Subsolid) Appearance

Nodules are divided into three groups according to their radiological density:

• Solid Nodules: They contain completely dense tissue.
• Ground Glass Nodules: They are translucent views in which the vascular and bronchial structures under the lung tissue can be distinguished.
• Semi-Solid Nodules: They are structures with both frosted glass and dense solid components. Statistically, semi-solid nodules constitute the highest risk group for early-stage adenocarcinoma, especially if the solid component increases over time.

Critical Changes Indicating Cancer in the Follow-up Process of the Nodule

The behavior of a first detected nodule becomes clear during the follow-up process. Lung cancer is a dynamic process, and it’s vital to monitor change.

Growth Rate and Volume Doubling Time (VDT)

Cancer cells multiply at a certain rate. In lung cancers, the doubling time of the nodule’s volume is usually between 20 days and 400 days. If a nodule doubles in size in less than 15 days, it is usually a focus of infection (inflammation). If its size does not change at all for 2 years, it is most likely benign.

Comparative Analysis with Old Tomography Records

The most valuable procedure that can be done for a newly detected nodule is to access the patient’s tomography or x-ray records from 5-10 years ago, if any. A formation that has been the same size since years ago is extremely unlikely to be cancerous.

Evaluation of Contrast Uptake and PET-CT Results

PET-CT may be preferred to measure metabolic activity in nodules larger than 8 mm. However, PET-CT does not always give definitive results. Tuberculosis or fungal infections may also show high involvement (SUVmax value), and some types of cancer with a slow course may give false negative results.

Prof. Dr. Levent Alpay: Do not panic just by looking at the size of a nodule detected in your lung. The ‘character’ of the nodule is much more important than its size. Especially in ground-glass-looking nodules, the follow-up process can take years; For this reason, it is critical that you stick to the control schedule determined by your doctor.

Patient-Related High Risk Factors and Clinical Manifestations

Radiological findings should be combined with the clinical profile of the patient.

• Smoking History: Long-term and intense smoking directly increases the risk coefficient of all kinds of nodules detected.
• Age Factor: In individuals under the age of 35-40, the majority of nodules are caused by infection; however, the risk of malignancy increases with age.
• Occupational Exposure: Nodule follow-up should be done more aggressively in those who work in business lines exposed to asbestos, radon gas or heavy metal fumes.

Distinguishing Features of Benign Nodules

Not every nodule is scary. Some images carry “comforting” signs for the surgeon:

1. Diffuse Calcification: If the entire nodule is calcified, it is usually a remnant of an old tuberculosis or infection.
2. Popcorn Appearance: It is the typical form of calcification of benign tumors called hamartimas.
3. Oil Content: Detection of adipose tissue in the nodule is an important finding that proves that the formation is benign.

Lung Nodule Risk Analysis Table

Diagnosis and Intervention Process in Risky Lung Nodules

If the nodule is considered in the “high risk” category, there are three main ways to follow:

Advanced Imaging and Interventional Procedures

The metabolic rate of the nodule is controlled with thin-section dynamic CT or PET-CT. Needle biopsy (TTIB) can be tried in appropriately located nodules; However, the risk of deflation of the lung and the small size of the nodule sometimes limit this method.

Definitive Diagnosis with Surgical Biopsy (VATS)

The most reliable method for suspicious nodules is complete removal of the nodule by closed surgery (VATS). The type of nodule is determined within minutes with the “Frozen” (Rapid Pathology) examination performed during the surgery. If the result is cancer, the necessary surgical treatment is completed in the same session and the patient regains his health with a single operation.

Frequently Asked Questions

1. I have a 3 mm nodule in my lung, what should I do?

Generally, nodules under 5 mm are considered low risk. If you do not have a known history of cancer, annual follow-ups are usually sufficient. However, your doctor may order a control CT in the 6th or 12th month, depending on your smoking history.

2. Is ground glass nodule dangerous?

These nodules grow very slowly. However, this slowness should not be misleading; Because this appearance can sometimes be the beginning of early-stage cancers called “adenocarcinoma in situ”. They require long-term follow-up.

3. Does a lung nodule cause shortness of breath?

No, millimetric nodules located deep in the lung usually do not cause any symptoms. Symptomatic formations (pain, cough, bloody sputum) are usually very large masses close to the main bronchi.

4. Is biopsy required for every detected nodule?

The size and shape of the nodule and the patient’s risk factors are evaluated according to the criteria of the “Fleischner Society”. Low-risk nodules are only monitored radiologically.

5. Does the nodule disappear on its own?

If the nodule is due to an infection (pneumonia residue, etc.), it may shrink or disappear completely on its own with treatment or over time. This is the biggest proof that the formation is not cancer.

This information is for general informational purposes only; It is recommended to consult a healthcare provider for your condition.

Scientific Bibliography

• Fleischner Society Guidelines for Management of Solid Nodules – Radiology
• Diagnosis and Management of Lung Cancer – American College of Chest Physicians (CHEST)
• Lung Nodules: Evaluation and Follow-up – PubMed/NCBI

VATS (Video-Assisted Thoracoscopic Surgery), one of the most important links of technological transformation in lung surgery, has largely replaced traditional open surgeries.

This method allows the operation to be completed by entering through small holes with a camera and special surgical instruments, instead of opening the rib cage with a large incision.

However, not every lung disease or every patient profile may be suitable for closed surgery.

The clinical situations in which the VATS method is preferred are determined according to the stage of the disease, the location of the tumor and the general physiological capacity of the patient.

Situations Preferred for Closed Surgery in Lung Cancer

The main criterion of surgical success in the treatment of lung cancer is complete removal of the tumor and complete lymph node cleaning.

Current oncological protocols recommend the VATS method as the “first choice” in patients who meet certain criteria.

Early Stage (Stage 1 and 2) Lung Cancer Treatment

VATS is the primary choice in cancer surgery, especially in early-stage (Stage 1 and Stage 2) non-small cell lung cancers (NSCLC).

When the diameter of the tumor is less than 5 cm and no large vessel involvement is observed, the closed method can be safely applied.

Scientific data show that operations performed with VATS in early-stage cases give equivalent results to open surgery in terms of cancer control and survival.

Lung Lobectomy and Segmentectomy Operations

Complete removal of one lobe of the lung (lobectomy) or removal of a smaller part (segmentectomy) can be performed using the closed method.

The choice of segmentectomy, especially in ground-glass view (GGO) nodules or patients with limited lung capacity, is managed more precisely with VATS technology.

Thanks to the high-resolution and magnified image provided by the camera, texture plans are more clearly distinguished.

Lymph Node Sampling and Staging Procedures

Mediastinal lymph node dissection to understand the spread of cancer is one of the areas where the VATS method is most successful.

Some deep areas that are difficult to reach in open surgery can be reached more easily with the angled camera systems offered by the closed method.

This makes it easier to stage the patient correctly and plan additional treatments (chemotherapy/radiotherapy) that may be required after surgery.

Clinical Pictures of Preferred VATS for Diagnostic Purposes

In cases where a definitive diagnosis cannot be made by imaging methods, surgical biopsy is considered the “gold standard”.

VATS offers definitive results with low risk in cases where interventional radiology is insufficient.

Biopsy of Lung Nodules and Suspicious Masses

VATS is preferred for the removal of nodules detected in CT scan, which cannot be reached by needle biopsy or are suspicious as a result of biopsy.

In this procedure called “wedge resection”, the nodule is removed in a small piece along with the surrounding healthy tissue.

With the frozen section examination performed during the surgery, it is determined that the nodule is benign or malignant and the course of the surgery can be changed at that moment.

Diagnosing Pleural Effusion of Unknown Cause

In the case of fluid collection between the lung membranes (pleural effusion), cytological examination is sometimes insufficient.

With VATS, the pleura is directly observed by entering the chest cavity and direct biopsies are taken from suspicious areas.

This method has an accuracy rate of over 95% in diagnosing malignant (cancerous) fluids.

Use of Closed Surgery in Benign Diseases of the Lung

Not only in cancer cases, but also in structural disorders of the lung, the VATS method provides great comfort to the patient.

Recurrent Lung Collapse (Pneumothorax) and Bullae Surgery

In cases of lung collapse caused by the bursting of air sacs (bullae) on the lung surface, VATS is the most common treatment method.

The burst sacs are closed by stapling (stapler) method and pleurodesis (bonding) is applied to the pleura.

Compared to open surgery, the recurrence rates are similar, but the recovery process is much faster.

Bronchiectasis and Post-Infection Damage

Lung parts that have lost their function due to chronic infections and are the focus of infection in the body can be removed with VATS.

Since the tissues are usually adhered to each other (adhesion) in such patients, the experience of the surgeon plays a critical role in the success of the closed method.

Prof. Dr. Levent Alpay: The most important step in the decision of lung surgery is the right patient selection. Although closed surgery is advantageous, it is a necessity for patient safety that the surgeon reserves the option to switch to the open method when necessary for a safe operation.

Medical Reasons for Preferring the VATS Method

The answer to the question of why VATS should be preferred over open surgery is hidden in the patient’s postoperative quality of life.

• Less Pain: Since the ribs are not parted and large muscle incisions are not made, postoperative pain is significantly less.
• Immune System Protection: Major surgical trauma can suppress the body’s immune response. VATS minimizes this pressure with less trauma.
• Rapid Mobilization: Patients can stand up on the day of surgery or the next day, reducing the risk of lung collapse and clotting.

Comparison of Surgical Methods

Under Which Conditions Is Closed Surgery (VATS) Decision Made?

The surgeon decides on the operation technique by considering certain parameters when evaluating the patient.

1. Tumor Location: The distance of the tumor to the main vessels and bronchi (peripheral location) is ideal for VATS.
2. Lung Functions: It is measured whether the patient’s respiratory capacity (FEV1 values) can tolerate the surgery.
3. Previous Surgeries: In patients who have previously undergone lung or heart surgery on the same side, the closed method may be difficult due to adhesions.
4. General Health Status: VATS is primarily considered to reduce surgical trauma in elderly individuals and individuals with comorbidities (diabetes, blood pressure, heart).

Recovery Process After VATS Surgery

The biggest difference provided by closed surgery occurs during the recovery period.

Patients can usually start taking liquid food a few hours after the operation and walk around the room.

The chest tube (drain) placed in the surgical area is usually removed on the 2nd or 3rd day, depending on the air leakage and fluid discharge in the lung.

With the removal of the drain, the patient’s discharge process begins.

Continuing breathing exercises (Triflo use) in the first week spent at home is critical for the remaining lung tissue to function at full capacity.

Prof. Dr. Levent Alpay: Not interrupting shoulder and arm exercises in the postoperative period prevents the muscles in the area from hardening and minimizes the risk of chronic pain that may occur in the long term.

This information is for general informational purposes only; It is recommended to consult a healthcare provider for your condition.

Frequently Asked Questions

How long does closed lung surgery take?

Although the duration of the operation varies according to the procedure to be performed (biopsy, lobectomy, etc.) and the anatomical structure of the patient, it is usually between 1.5 and 3 hours.

Is there a risk of the surgery turning into open surgery?

Yes, in case of unexpected bleeding, severe adhesions, or when it is understood that the tumor cannot be completely removed with the closed method, the surgeon may change the surgery to the open method for patient safety. This is not a failure, but a safety measure.

Will there be any scars after VATS surgery?

Since the incisions used are very small (usually 1-3 cm), there is no obvious scar after healing. When a single port (Uniportal) VATS is applied, only a single small trace remains.

Can closed surgery be performed at every stage of lung cancer?

VATS is generally preferred in the early stages, such as Stage 1 and Stage 2. Open surgery is still a safer option in advanced stage tumors that have spread to surrounding tissues or surround the main vessels.

Scientific Bibliography

• Video-Assisted Thoracoscopic Surgery (VATS) – PubMed
• VATS lobectomy vs. open lobectomy for lung cancer – The Lancet
• Society of Thoracic Surgeons (STS) VATS Guidelines