Nuss Procedure Research Articles

Biomechanical validation of novel Nuss procedure simulations for patients with various morphological types of pectus excavatum.

A novel Nuss procedure simulation was developed for patients with pectus excavatum considering the displacement of a metal bar and a chest wall model, including the intercostal muscles. However, this simulation was developed for a typical symmetrical patient among the various morphological types of pectus excavatum. Accordingly, this study aimed to validate and confirm the novel simulation for patients with eccentric and imbalanced types, which are severe types of pectus excavatum, considering factors such as depression depth and eccentricity among others. Three-dimensional models of chest walls and metal bars were created for three different types of patients. The rotation-equilibrium displacement and chest wall with intercostal muscles were set according to the methods and conditions of the novel Nuss procedure simulation. The anterior sternal translation and the Haller index derived from the simulation results were compared and verified using medical data from actual postoperative patients. Additionally, maximum equivalent stresses and strains were derived to confirm the suitability of the novel Nuss procedure for each patient type. The severe types had similar precision to the typical type when compared to the actual postoperative patient. Relatively high maximum equivalent stresses and strains were observed on the metal bars and sternum in the severe type, thereby predicting and confirming the biomechanical characteristics of these types. In conclusion, a novel Nuss procedure simulation for severe types was numerically validated. This underscores the importance of biomechanical evaluation through a novel Nuss procedure simulation when planning actual surgeries for severe types of cases.

Combined Ravitch and Nuss procedure for pectus excavatum with dyspnea following scoliosis repair

Abstract Pectus excavatum (PE) is often associated with scoliosis and can elicit cardiovascular disturbances under rare conditions. Here we report a patient who was treated with a combined Ravitch and Nuss procedure for PE with dyspnea following scoliosis repair to improve her symptoms. The patient was a 49-year-old woman with a history of PE and scoliosis. Right inferior pulmonary vein stenosis was caused by posterior spinal fusion for scoliosis prior to the PE repair. We could safely correct the chest wall deformity and treat dyspnea by performing a modified Ravitch repair in combination with the Nuss procedure.

Should There be a Surgical Revision of the Axillary Incisions Prior to a Nuss Bar Extraction?

The minimally invasive Nuss procedure is currently the preferred surgical approach for treatment of pectus excavatum. During this procedure, a retrosternal bar is inserted which instantly corrects the deformity. The bar typically remains in place for 2 to 3 years, during which time the chest is considered to have adopted its new shape. Removal of the bar is generally considered to be a nondemanding procedure. Notwithstanding, it is associated with rare but potentially life-threatening complications.

Caring for the Pediatric Patient Post-Nuss Procedure

Background Surgical correction for pectus excavatum (PE) is often performed during adolescence for patients exhibiting cardiac and respiratory problems. The surgery to correct PE is a thoracoscopic-assisted minimally invasive repair of PE or Nuss procedure. The postoperative clinical management is largely related to addressing pain from the constant pressure from the bar(s) on the sternum. A quality improvement project was developed to improve nurses' knowledge of appropriate postoperative care for the pediatric patient undergoing a Nuss procedure. Method A literature search was conducted using CINAHL and MEDLINE (ProQuest) to identify research studies that have evaluated nurses' knowledge of postoperative care for patients undergoing surgical correction for PE. Six studies were identified that investigated nurses' knowledge and attitudes of postoperative pain management in the pediatric patient and the effectiveness of enhanced recovery pathways to improve patient outcomes. A pretest and posttest were developed from the findings of the literature review along with an educational intervention. The educational presentation focused on the postoperative care of the pediatric patient who undergoes a Nuss procedure. A complete supplemental care plan is provided, which includes an enhanced recovery after surgery pathway, recommended pain treatment plan, exercises, medication recording sheet, home management tips for pain control, and patient discharge information. Results Implementation of a targeted educational program for the care of the pediatric patient who undergoes a Nuss procedure improved the clinician's knowledge and attitudes, resulting in a positive impact on pain management practice and patient outcomes. Conclusion Targeted educational interventions to improve pain management knowledge in nurses can result in increased understanding of appropriate postoperative pain management. This increased knowledge has the possibility to improve pain management and significantly improve the nurse and patient experience.

Reduction in the duration of postoperative fever following NUSS surgery during the COVID-19 pandemic

BackgroundOur study aimed to compare the prevalence of postoperative fever during the COVID-19 pandemic period with that of the preceding non-pandemic period.MethodsA retrospective analysis was conducted on patients with pectus excavatum (PE) undergoing minimally invasive repair (also called NUSS procedure) at Nanjing Children’s Hospital from January 1, 2017 to March 1, 2019 (Group 2019), and from January 1, 2020 to March 1, 2021 (Group 2021). Data from a total of 284 patients, consisting of 200 (70.4%) males and 84 (29.6%) females with an average age of 9.73 ± 3.41 (range, 4 to 17) years, were collected. The presence of post-operative fever (defined as a forehead temperature of 37.5℃ or above within 72 h post-surgery), as well as the time of operation, duration of postoperative mechanical ventilator and urinary catheter use, and length of hospitalization were all assessed in admitted patients from Group 2019 (n = 144) and Group 2021 (n = 140). Postoperative white blood cell (WBC), C-reactive protein (CRP) levels, and prevalence of postoperative complications (i.e., pneumothorax, pulmonary atelectasis, pneumonia, wound infection, and dehiscence) were also determined.ResultOur results showed a statistically significant decrease in the incidence of postoperative fever within 24 to 72 h of surgery in patients admitted from Group 2019 as compared to Group 2021 (p < 0.001), as well as a decrease in peak body temperature within 72 h (p < 0.05). Meanwhile, no significant differences were observed in age and body mass index (BMI), time of operation, or duration of postoperative mechanical ventilator and urinary catheter use between the two groups (p > 0.05). The average hospitalization length of Group 2021 was significantly shorter than Group 2019 (12.49 ± 2.57 vs. 11.85 ± 2.19 days, p < 0.05). Furthermore, while the WBC count between the two groups 24 h after surgery showed a statistical difference (p < 0.05), no differences in CRP levels or the incidence of postoperative complications were observed (p > 0.05).ConclusionThe prevalence of postoperative fever within 72 h of surgery and the length of hospital stay for patients with PE undergoing NUSS surgery were both decreased in Group 2021. We propose that the above phenomenon may be related to increased used of personal protection equipment (such as surgical masks and filtering facepiece respirators (FFRs)) by physicians, nurses, and the patients themselves.

A novel in silico Nuss procedure for pectus excavatum patients

The purpose of this study is to suggest a novel in silico Nuss procedure that can predict the results of chest wall deformity correction. Three-dimensional (3D) geometric and finite element model of the chest wall were built from the 15-year-old male adolescent patient’s computed tomography (CT) image with pectus excavatum of the mild deformity. A simulation of anterior translating the metal bar (T) and a simulation of maintaining equilibrium after 180-degree rotation (RE) were performed respectively. A RE simulation using the chest wall finite element model with intercostal muscles (REM) was also performed. Finally, the quantitative results of each in silico Nuss procedure were compared with those of postoperative patient. Furthermore, various mechanical indicators were compared between simulations. This confirmed that the REM simulation results were most similar to the actual patient’s results. Through two clinical indicators that can be compared with postoperative patient and mechanical indicators, the authors consider that the REM of silico Nuss procedure proposed in this study is best simulated the actual surgery.

1136 Modified Nuss Bar Procedure for Pectus Excavatum – Our Experience in Patients Aged 20 and Over

Abstract Background Pectus excavatum (PE) is a common congenital anterior chest wall deformity characterized by a sunken appearance. The incidence rate is approximately 0.1% with a male to female ratio of 4:1. It is associated with connective tissue disorders, neuromuscular diseases, and linked with some genetic conditions. In 1987, the Nuss procedure was invented by Dr Nuss and his colleagues as a minimally invasive procedure to correct PE. This is a two-staged procedure and involved lesser hospital stays, smaller incisions, and early mobilisation. Applying this procedure to video-assisted thoracoscopic surgery (VATS), we present our experience on insertion as well as removal of the Nuss bar in patients aged 20 and over with PE. Method This is a single centre, retrospective study carried out in a tertiary cardiothoracic centre. A total of 104 patients, aged 20-57 years, who underwent Nuss bar insertions and removals between 2016 and 2021 (5 years) were included in our study. All the procedures were performed by a single consultant cardiothoracic surgeon using biotech stainless steel bars. Results A total of 24 bar insertions, 79 bar removals and 1 bar revision were performed between 2016-2021. The data included 95 male and 9 female patients. The average hospital stay was 2.5 days. Postoperative complications for the procedure included pleural effusions (3%), pericardial effusion (0.9%), post-operative bleeding requiring re-operation (0.9%), bar dislodgement (0.9%) and wound infection (4%). Conclusions We can conclude that VATS-Nuss procedure is a safe procedure for adult patients resulting in shorter hospital stays and reduced post-operative complications.

Introducer director: A new tool to extract the introducer from the contralateral chest during Nuss procedure

One of the technical difficulties encountered during a Nuss procedure is the extraction of the Introducer instrument once it has crossed the anterior mediastinum. Sometimes, this maneuver is done with brute force and without precision. Therefore, a creation of a surgical tool to facilitate precise extraction of the Introducer would benefit the surgeon and optimize the surgical result. Introducer Director (ID) is made of curved steel with a hollow tip and a handle. It has a curved tip appearance like the Introducer. Once the Introducer has traversed the anterior mediastinum, another Introducer is used to enter the contralateral chest at the desired exit site on the chest. Contralateral Introducer is withdrawn and replaced with the ID. A videoscope is used to visualize the joining of the two instruments. While keeping the two instruments mated by applying opposing forces, the Introducer is pushed with a greater force to exit the contralateral chest following the tract created by the ID. ID facilitates the Introducer to exit the contralateral chest at the precise location with ease. Guess work or brute force is no longer needed.

Consumer Wearables Define a Normative Recovery Trajectory Following the Modified Nuss Procedure

IntroductionThe modified Nuss procedure is an elective procedure associated with a lengthy recovery, uncontrolled pain, and risk of infrequent, yet life-threatening complications. The absence of objective measures of normative postoperative recovery creates uncertainty about the postdischarge period, which remains highly dependent on the patients' and their caregivers’ expectations and management of recovery. We aimed to describe an objective-normative, physical activity recovery trajectory after the modified Nuss procedure, using step counts from the Fitbit. MethodsThis observational study enrolled children ≤18 y with pectus excavatum who underwent the modified Nuss procedure from 2021 to 2022. The Fitbit was worn for 21 postoperative days. Postdischarge outcomes and health-care utilization were evaluated. For patients without postoperative complications, piecewise linear regression analysis was conducted to generate a normative recovery trajectory model of daily step counts. ResultsOf 80 patients enrolled, 66 (86%) met eligibility criteria (mean age, 15.1 ± 1.3 y; 89.4% male, 62.1% non-Hispanic White). The mean number of telephone and electronic message encounters regarding concerns with the patient's recovery within 30 d postoperatively was 2.1 (standard deviation = 2.7). Ten patients (15.2%) returned to the emergency department (ED) within the 30-d postoperative period. Seven patients (10.6%) presented to the ED one time, and three patients (4.5%) presented to the ED twice. Thirty-day readmission rate was four patients (6.0%). Piecewise regression model showed that patients without complications steadily increased their daily step count on each postoperative day and plateaued on day 18. ConclusionsWe have developed a normative recovery trajectory following the modified Nuss procedure using step count data collected by a consumer wearable device. This offers the potential to inform preoperative patient expectations and reduce avoidable health-care utilization through informed preoperative counseling, thus laying the ground work for the use of consumer wearable devices as a postdischarge remote monitoring tool.

Discussion to: A case of living-donor segmental lung transplantation and concomitant Nuss procedure in a pediatric patient with pectus excavatum.

Discussion to: A case of living-donor segmental lung transplantation and concomitant Nuss procedure in a pediatric patient with pectus excavatum.

Evaluation of Analgesic Practice Changes Following the Nuss Procedure in Pediatric Patients

IntroductionPectus excavatum repair by the Nuss procedure results in severe postoperative pain. Regional blocks and intercostal nerve cryoablation (INC) have emerged as potential strategies to manage analgesia. This study compares pain-related outcomes following these perioperative interventions. MethodsWe reviewed charts of patients <18 y who underwent the Nuss procedure at Duke Children's Hospital from July 2018 to June 2022. Patients were divided into three groups by analgesic strategy: no block, regional catheters, or INC, representing the chronologic change in our practice. The primary outcome was total and daily in-hospital opioid utilization measured by oral morphine equivalents (OMEs). Secondary outcomes included average daily pain scores, length of stay, opioid refills after discharge, and complications. ResultsTwenty-one patients were included and analyzed: no block (n = 6), regional catheters (n = 7), and INC (n = 8). INC-treated patients required significantly lower total postoperative, in-hospital OMEs (64 ± 47 [mean ± standard deviation]) than those with no block (270 ± 217, P = 0.04) or those with regional catheters (273 ± 176, P = 0.03). INC was associated with longer average operative times (161 ± 36 min) than no block (105 ± 21 min, P = 0.005) or regional catheters (90 ± 11 min, P < 0.001). INC-treated patients had shorter hospital length of stays (median 68 h) than those with regional catheters (median 74 h, P = 0.006). ConclusionsINC was associated with longer operative times but decreased in-hospital OMEs when compared to bilateral regional block catheters and multimodal analgesia alone.

Single Incision non-thoracoscopic Nuss procedure for children with pectus excavatum: protocol for a multicenter, non-masked, randomized controlled trial.

Nuss procedure is the most common method of surgical treatment to pectus excavatum (PE). A significant percentage of surgeons choose to use thoracoscopic assistance during the Nuss procedure (TNP) to avoid cardiac injury. However, our previous findings confirm the safety of single incision Non-thoracoscopic Nuss Procedure (SINTNP). Hence, Further studies, particularly prospective randomized controlled trials, are necessary to assess the value of SINTNP for PE. This study is a prospective, superiority, multicenter, non-masked, randomized controlled trial that investigates the outcome and hospitalization medical expense of SINTNP compared to TNP for PE. A total of 320 eligible patients according to sample size calculation by retrospective data will be randomly assigned to the SINTNP group or the TNP group at a 1:1 ratio using stratified blocked randomization and the zone length was set as four. Patients aged between 3 and 18 years old for the first surgery and without combination of complex anomalies such as Marfan syndrome and congenital heart disease will be considered for the study. The co-primary endpoint is thoracic related complications and medical expense during hospitalization. Thoracic related complications were defined as pneumothorax, pleural effusion, pneumonia and incision infection. The secondary endpoints include surgery duration and length of hospital stay.The registration number for this study protocol is ChiCTR230073081 (Chinese Clinical Trial Registry, A Primary Registry of International Clinical Trial Registry Platform, World Health Organization).

Intercostal Nerve Cryoablation for Postoperative Pain Control in Pediatric Thoracic Surgery: A Scoping Review.

Background: Cryoanalgesia uses the application of cold temperatures to temporarily disrupt peripheral sensory nerve function for pain control. This review outlines the principles of cryoablation, clinical applications, and clinical data for its use in pediatric thoracic surgery. Methods: A comprehensive PubMed search was performed using the principal terms and combinations of cryoablation, cryoanalgesia, Nuss, Nuss repair, pectus, pectus excavatum, thoracic surgery, thoracotomy, and chest wall. Pediatric articles were reviewed and included if relevant. Adult articles were reviewed for supporting information as needed. Reference lists of included articles were reviewed for possible additional sources. Discussion: The scientific and clinical principles of cryoablation are outlined, followed by a focused review of current clinical application and outcome data. Conclusion: Postoperative pain is a major challenge following thoracic surgery. Cryoanalgesia is emerging as an adjunct in pediatric thoracic surgery, particularly for the Nuss procedure or minimally invasive repair of pectus excavatum. It effectively controls pain, decreasing postoperative opioid use and hospital length of stay with few short-term complications. Although more long-term studies are needed, early evidence suggests there is reliable return of sensation to the chest wall and long-term neuropathic pain is rare.

Customized Three-Dimensional Printed Nuss Bar Molds for Repair of Pectus Excavatum

BackgroundThe minimally invasive Nuss procedure has emerged as the standard of care for correction of pectus excavatum. The site of chest wall insertion and bar shape are currently contoured on the basis of the surgeon's judgment. To optimize and individualize Nuss bar configuration, we aimed to create a virtual surgical planning workflow and 3-dimensional (3D) printed Nuss bar molds customized to each patient’s defect. MethodsStandard thin-section chest computed tomography images were imported into the planning software, and segmentation was used to extract anatomically relevant features including ribs, cartilage, sternum, and skin surface. Curves representing the ideal Nuss bar contour are splined on axial imaging. Molds designed from the Nuss bars are created within medical computer-aided design software and then 3D printed with a biocompatible sterilizable photosensitive resin, labeled with the correct orientation. ResultsVirtual surgical planning and 3D reconstruction were used to create patient-specific sterilizable Nuss bar molds in 9 patients presenting with pectus excavatum. The Nuss bar was bent in the operating room to the optimized curve and fitted to the mold. Six male patients with a median age of 26 years underwent customized Nuss bar placement with no intraoperative complications and a procedural time of 126 minutes. The median length of stay was 4 days. No early postoperative revisions were required. ConclusionsAlthough further prospective studies are warranted, this initial pilot demonstrates a replicable technique for virtual surgical planning workflows and patient-specific customizable Nuss bar molds for patients with pectus excavatum.

Combined erector spinae plane block with surgical intercostal nerve cryoablation for Nuss procedure is associated with decreased opioid use and length of stay

Background and objectivesPain management for patients undergoing the Nuss procedure for treatment of pectus excavatum can be challenging. In an effort to improve pain management, our institution added bilateral single...

Comparative Study Between Intravenous Patient-Controlled Analgesia Morphine and Computerized Ambulatory Delivery Device Epidural Morphine for Post Operative Analgesia for Nuss Procedure in Pectus Excavatum: A Retrospective Analysis.

Pectus deformities are commonly seen in chest wall deformities among the pediatric age group. Pectus deformities occur due to defective growth of the sternum and its surrounding cartilage. The Nuss procedure is the technique of choice for correcting the deformity surgically which includes placing a convex bar under the sternum without resection or injury to costal cartilages. Adequate pain control is utmost to improve wound healing, patient satisfaction, short hospital stays, and decrease the financial burden on attendants. Therefore, it is necessary to investigate which analgesic method is more advantageous for the Nuss procedure. To compare the analgesic effects of intravenous patient-controlled analgesia (IVPCA) morphine versus computerized ambulatory delivery device (CADD) epidural morphine on acute post-operative pain management in Nuss procedures. A retrospective study was done at Rajiv Gandhi Cancer and Research Hospital, New Delhi from 2015 to 2020 to assess the efficacy and safety between IVPCA morphine and CADD epidural for post-operative analgesia following pectus excavatum repair. A total of 34 cases of Nuss procedures were taken with 17 cases in each group. Group 1 (intravenous PCA morphine) was given 39 ml normal saline + 6 ml morphine (total 45 ml, 2 mg/ml morphine), set at demand dose 0.5 ml, i.e. 1 mg, lockout interval 7 minutes, doses per hour was six and Group 2 (CADD epidural morphine) was given 42 ml normal saline + 3 ml morphine (1 mg/ml morphine) with continuous infusion at the rate of 0.5 ml/hr. Demand dose 0, lockout interval nil. Visual analog pain scores using a scale of 0-10 and Ramsay Sedation Score (RSS) scores were obtained on arrival at the post-anesthesia care unit, at 12, 24, 48, and 72 hours throughout the subsequent hospital stay. This study yielded positive information about our experience with the pectus post-operative pain management. The mean visual analogscale (VAS) score was lower in Group 1 compared to Group 2 but significantly different at 12 and 72 hours only. The mean RSS score was comparable between groups. The mean hospital stay (days) and requirement of rescue analgesia doses were 3.47±0.51 and 0.12±0.33 in Group 1 and 4.76±0.44, 0.59±1.12 in Group 2. Both IVPCA morphine and CADD morphine were effective in controlling post-surgical pain in the Nuss procedure, but IVPCA morphine was better as compared to CADD morphine in this regard because it was noninvasive, safe, and cost-effectivewith non-significant complications.

Comparing postoperative analgesia of bilateral serratus anterior plane block and thoracic paravertebral block for children following the Nuss procedure: protocol for a randomised, double-blind, non-inferiority clinical trial

IntroductionThe Nuss procedure, despite being a minimally invasive surgery, is regarded as one of the most painful surgical procedures in children, and postoperative pain control remains a major clinical issue...

Application of an ultrasound-guided bilateral erector spinae plane block after the Nuss procedure for pectus excavatum in children: a retrospective cohort study with propensity score matching.

To retrospectively analyze the effect of applying an ultrasound-guided bilateral erector spine plane block (ESPB) after the Nuss procedure for surgical repair of pectus excavatum (PE) in children. The subjects of the study were patients with severe PE who received the Nuss procedure in our hospital between 1 January 2019 and 30 November 2021. According to different methods for postoperative pain management, the enrolled patients were divided into two groups, the ultrasound-guided ESPB group and the thoracic epidural analgesia (TEA) group. The primary outcome of this study was analgesic drug dosage and the secondary outcome was numerical rating scales (NRSs) between the two groups. There was no significant difference between the two groups in terms of demographic, preoperative clinical evaluation, or surgical characteristics (P > 0.05). The catheter duration in the TEA group was significantly shorter than that in the ESPB group (P < 0.05), while the hospitalization time in the ESPB group was significantly shorter than that in the TEA group (P < 0.05). In terms of oral morphine equivalent comparison, the required dose of the TEA group was lower than that of the ESPB group on the 1st and 2nd day after the operation (P < 0.05), and there was no statistical difference between the two groups on the 3rd and 4th day after the operation (P > 0.05). The number of patients with an S-NRS ≥ 7 and D-NRS ≥ 7 in the TEA group at day 1 was lower than that in the ESPB group (P < 0.05). There was no significant difference between the two groups at other time points (P > 0.05). An ultrasound-guided ESPB used in Nuss surgery for children with funnel chest can provide good analgesia for surgery and shorten the postoperative rehabilitation and hospitalization time of patients. It is a safe and effective alternative to TEA.

Postoperative Symptomatic Improvement of Pectus Excavatum Patient Following Nuss Procedure

Pectus excavatum is a funnelling of posterior chest wall. Wide depression area is seen at mid sternum, particularly from 3rd to 7thcostal cartilage. Genetic predisposition is not scientifically proved but defective embryogenesis is surely involved. Congenital pectus excavatum is a very common defect, but a congenital chest defect is very rare. Until the symptoms are not present, there is no need of its treatment. If the pectus excavatum has cardio-respiratory problem then it needs firstly, conservative treatment like supportive therapy (chest brace) and then, if supportive therapy fails, we should go for the surgical intervention. Воронкообразная грудная клетка — это деформация стенки грудной клетки, при которой ее передняя стенка имеет воронкообразную форму. В середине грудины видна вмятина на уровне 3-7-го реберного хряща. Генетическая предрасположенность научно не доказана, но, несомненно, имеет место дефектное эмбриональное развитие. Врожденная воронкообразная деформация грудной клетки — весьма распространенный дефект, но врожденный дефект грудной клетки встречается очень редко. До тех пор, пока симптомы отсутствуют, лечение воронкообразной деформации не требуется. Если при воронкообразной деформации грудной клетки имеются проблемы с сердцем и / или респираторной системой, то сначала требуется консервативное лечение, такое как поддерживающая терапия (нагрудная скоба). Затем, если поддерживающая терапия не помогает, тогда только мы должны прибегнуть к хирургическому вмешательству.

Raising the Bar: Multimodal Analgesia with Transdermal Lidocaine for Nuss Repair of Pectus Excavatum Decreases Length of Stay and Opioid Use

IntroPain management for minimally invasive (Nuss) repair of pectus excavatum (PE) is challenging, particularly as the judicious use of opioids has become a patient safety priority. Multi-modal pain management protocols are increasingly used, but there is limited experience using transdermal lidocaine patches (TLP) in this patient population. MethodsPediatric anesthesiologists and surgeons in a children's hospital within a hospital designed a multi-modal perioperative pain management protocol for patients undergoing Nuss repair of PE (IRB00068901). The protocol included use of TLP in addition to other adjuncts such as methadone, gabapentin, and NSAIDS. Following initiation of the protocol charts were reviewed retrospectively, comparing outcomes before and after implementation of the protocol. ResultsForty-nine patients underwent a Nuss procedure between 2013 and 2022, 15 prior to initiation of the protocol and 34 after. Patient demographics and operative length were similar between the two groups. Average length of stay decreased from 4.7 to 3.3 days and reported opioid use at the time of the first outpatient post-op visit dropped from 60% to 24% (p < 0.05). Morphine milligram equivalents (MME) usage was decreased following implementation during hospital admission, at discharge, and at first post-operative visit (464 vs. 169, 1288 vs. 218, and 214 vs. 56, respectfully, p < 0.05). There were no ED visits or readmissions <30 days related to post-operative pain. ConclusionPost-operative opioid usage and hospital length of stay were decreased after initiation of the protocol. Transdermal lidocaine patches may be a helpful adjunct to minimize narcotic requirements after repair of pectus excavatum. Level of EvidenceLevel II.