preparing for pectus excavatum surgery

1. FMLA paperwork
   • If you need any FMLA paperwork completed, please ask us before your child's surgery.
2. Insurance checks
   • Check for pre-certification, second opinion and pre-existing clauses that may be in your policy.
   • Check to see if your child's surgery is a covered procedure.
   • We will call your insurance company to check if pre-certification is necessary for your child's surgery. If it is required, we'll attempt to get that authorization.
3. Your surgeon (the doctor who will do the procedure) will refer you to physical therapy to get a pre-surgical evaluation. This will help understand your child's physical mobility and will be an important piece in your child's recovery after surgery.
4. Watch the video below and join Riley as he prepares for a procedure at Dayton Children's! 
   
   

   preparing for surgery at Dayton Children's

    Surgery can be a scary time for children, but Riley will walk you through what to expect when coming to Dayton Children's for a surgery or procedure.

5. Pre-surgery tour
   • If you would like to do a pre-surgery tour to help make you and your child more comfortable, call 937-641-4532.

• Avoid these medications two weeks before surgery:
  • No aspirin (including Pepto Bismol)
  • No ibuprofen (Advil, Motrin)
  • No anti-inflammatory medications (Aleve, Naprosyn)
  • No products containing Gingko Biloba or St. John's wort
• One of the surgery nurses will call to discuss your child's medical history. Please let the nurse know if there is a family history of bleeding tendencies or your child tends to bruise easily.
  • Your child's medical history will be shared with the pediatric anesthesiologist (the doctor who gives medicine to make your child sleepy) who will use it to plan for your child's care.
  • You will also meet one of the nurse practitioners from the pain team who will discuss pain control after surgery.
• It is important to prepare your child for the procedure. Explain as much as you feel they can understand. View our tips for preparing your late elementary schooler to teenager for surgery.

• If your child does not need to arrive at the hospital early, your child's surgery time will be confirmed the day before surgery. If you haven't heard from us by 4:00 pm the day before surgery, call 937-641-4269.
  • If you cannot make the scheduled surgery, call 937-641-5020, option 5, right away to let our office coordinator know. We will reschedule the surgery.
  • We will do our best to keep your child's surgery at the scheduled time. Sometimes a need arises, and we will need to change your time. For example, another patient may cancel, and we may move your time up. Or cases may need to be moved ahead of you to meet the requirements of our operating room. We will let you know as soon as possible if we need to change your time.
• Eating/drinking instructions before surgery
  • It is very important to follow these instructions. If they aren't followed, we may have to delay or cancel your child's surgery. Even a small amount of food or drink in your child's stomach during surgery can cause very serious problems.
  • No solid foods, candy, chocolate, chewing gum, or any form of tobacco products 8 hours before arrival time. Examples include:
    • Crackers
    • Bread
    • Meat 
    • Milk products, including yogurt
    • Fruits
    • Vegetables
    • Applesauce
  • Clear liquids are permitted until 2 hours before arrival time. Examples include:
    • Water
    • Apple juice
    • White grape juice
    • Sprite
    • Pedialyte
    • Gatorade
    • Avoid any red-colored liquids
  • The following beverages are not clear liquids and should not be given after midnight the day before your child's surgery:
    • Orange juice
    • Banana juice
    • Pineapple juice
    • Grapefruit juice
    • Purple grape juice
    • Mountain Dew
    • Broth
    • Milk
  • Nothing is to be taken by mouth eight hours or less before arrival time.
• Your child can bathe and wash their hair the night before surgery.
• Bring the names and amounts of any medications your child is taking.

getting to the surgery center

Please arrive 1 hour before your surgery time. Your surgeon and anesthesiologist will meet with you, and we will complete any needed lab work or IVs.

• Main campus: Park in the free parking garage and come in the main entrance. Your first stop will be the welcome center in the main lobby. They will guide you to the surgery center on the second floor.

checking in and meeting your care team

• When you check-in at the registration desk, you and your child will get an ID bracelet. This is for your child's safety, so please leave it on and make sure your child leaves it on.
• Then you and your child will be taken to your room to prepare them for their procedure.
• You will meet with your child's care team, including a nurse, the anesthesiologist and surgeon.
• The surgeon will talk to you about the procedure and answer any questions you have.
• Please leave your cell phone number so we can call you when your child is waking up. You can also track your child's progress during surgery by looking at the TV monitors in the waiting area. If you leave the waiting area, please let us know.

the Nuss procedure

• This minimally invasive procedure is performed using general anesthesia and cryoablation.
• Cryoablation is a new approach to pain management, using extreme cold to freeze nerves and prevent pain. Using this approach, patients will be virtually pain-free following surgery without the use of opioids or other traditional pain medicines.
• The typical surgery lasts 1 to 2 hours.
• After surgery, your child will be admitted for observation for 3 to 5 days. The length of stay depends on your child's recovery.

school note

• Please ask for a school note after your child's surgery before you are discharged.
• If you don't receive a school note upon discharge, please call the surgery clinic at 937-641-5020, option 5.

Your child will still have some pain after surgery. The acute pain service (anesthesiologist and nurse practitioners) will work with your surgeon to come up with a pain plan. The pain might be around the incision, on the sides or center of the chest, or sometimes even the back. Pain is managed with opioid and non-opioid medicines. Cryoablation during surgery will significantly decrease pain and will lessen the need for pain medicines. Cryoablation will cause numbness in the chest that can last up to 3 months.

Your child's hospital pain plan will include Tylenol, Toradol, ibuprofen, muscle relaxers and opioids. During surgery, the anesthesiologists may use numbing medicine that will help until the cryoablation is working.

Your child may be sent home with the following medicines (this can vary based on your child's overall condition at the time of discharge):

1. Tylenol and Ibuprofen - over the counter
   • Your child should take this around the clock during the first few weeks for the post-surgical inflammation. The dose will depend on your child's age and size.
   • Your child may need to take this medicine for up to 3-4 weeks as needed.
   • Your child should take this medicine with food to prevent stomach upset.
2. Robaxin (Methocarbamol) - prescription
   • Your child should take this in the morning when they wake up and at night before they go to bed. This schedule will help with muscle stiffness.
   • This may also be taken for backaches and sudden spasms that feel like a charley horse or cramp.
3. Opioid medication - prescription
   • We expect that your child will need to take this for just a few days post-discharge and that they'll take less each day. Follow the recommendations provided by your surgeon and care team. Again, cryoablation will significantly decrease the need for any type of opioid medication after surgery.
   • This medication is to be taken only for severe pain and only as needed.
   • This medicine also causes constipation so your child must take Senna (or equivalent) while they are taking opioids.
4. Valium (Diazepam) - prescription
   • Your child may need to take this for 1-2 weeks as a muscle relaxant and to help them sleep. It helps relax muscles and decrease tension. The dose depends on your child's age and size.
5. Colace (stool softener) - over the counter
   • Must be taken while taking opioids to prevent constipation.
6. Senna (laxative) - over the counter
   • Must be taken while taking opioids to prevent constipation.
   • Discontinue if stool becomes loose, but continue Colace as directed.
7. Zofran (Ondansetron) - prescription
   • Used as needed for nausea and vomiting.
8. Zantac (Ranitidine) - over the counter
   • Continue taking while on any type of non-steroidal anti-inflammatory medicine like Motrin.
9. Gabapentin (Neurontin) - prescription
   • Used after surgery for 7 to 21 days.
   • Used to reduce chronic nerve pain.
10. In some cases, we may recommend these medicines:
    • Lidocaine Patch 4% - over the counter
      • Used for pain around the incision.
      • Leave on for 12 hours, then off for 12 hours.
      • Discontinue when no longer needed.
      • Use only one patch per day. Cut the one patch. Place above and below the incisions. Do not place directly on the incision. Use gloves when handling the patches. Use care when disposing of the old patches to prevent any pets or children from handling/ingesting.
    • Scopolamine patch - prescription
      • Used for nausea.
      • Place behind the ear.
      • Leave on for 3 days then remove.

Please note: Your child will probably not need all the medicines that have been prescribed. They also do not need to finish all the medicines. We also strongly advise that you do not set an alarm during the night to wake up and take any medication. It is very important to get a good night's sleep. Have the medication ready and available if your child wakes up having pain.

• No driving for 4-6 weeks depending on your child's mobility and need for pain medications. Teens and young adults with a driver's license are allowed to start driving after 4 weeks. No driving is allowed if taking any opioid pain medication.
• No lifting anything greater than 5 pounds for about 1 to 2 months.
• No carrying backpacks or satchels on their shoulders for 3 months. The weight of the backpack or satchel will pull on their chest and cause unwanted strain and stress.
• No stomach or side sleeping. Your child should sleep on their back for about 4 to 8 weeks. Patients often say that sleeping in a recliner is more comfortable - if available. Your child can slowly transition to sleeping on their side as tolerated.
• No activities for the first 4 weeks following surgery except the ones provided by their physical therapist. Deep breathing with breath holding and walking are encouraged.
• No physical education/gym class for school-aged children.
• No contact sports.
• No working out at a gym until your child received clearance from their physician and/or surgeon. This includes aerobics, Pilates, yoga classes, biking, running, swimming, elliptical machine, sit-ups, or weightlifting.
  • For working out with weights: Most patients can start exercising with small weights less than 5 pounds after about 4 to 8 weeks. Many patients will be followed by physical therapy.
• No twisting at the waist for 4 weeks. Flexing is acceptable but it must be done slowly and very carefully the first 4 weeks.
• No slouching or slumping - good posture is important.

If you need a note indicating physical restrictions please call orthopedic rehab at 937-641-4384.

All goals and timelines are subject to change based on your child's recovery.

Physical therapy appointments will also be determined based on your child's initial physical therapy assessment and recovery.

Remember to do your breathing exercises ten times, twice a day AND your posture exercises daily until the bar is removed. This will help with recovery from surgery.

weeks 1 - 3

• Return to school if opioid pain medicine or muscle relaxants are not being taken. Remember, do not carry a book bag.
• Take normal showers.
• Gently peel off Steri-Strips or Dermabond if still on.
• Take long daily walks and move as much as possible
  • Move in slow-motion and avoid abrupt turns.
  • No running.
  • Being inactive, and spending too much time in bed or sitting, can interfere with normal recovery.
• Your child might still have pain on the sides or center of the chest. Continue to use opioid medications, as well as Tylenol and Motrin.
  • If your child received cryoablation during surgery, the use of opioids should be very limited.
• It is completely normal to feel or see the bar under the skin and soft tissues, particularly on the sides. As the swelling lessens, the bar might be more noticeable.
• You may also notice a small stitch come out through the skin from one of the incisions. This is completely normal. The sutures are absorbable material, and it should be of no major concern. It may look like a small piece of fishing wire. Cover it with a band-aid and a little antibiotic ointment. You may also snip the stitch at the level of the skin. It will be reabsorbed spontaneously.
• We will schedule an office visit with your surgeon at the time of discharge from the hospital. This visit is 2 weeks after surgery.

week 4

• Your child can sleep on their side and stomach if pain allows.
  • Some patients may not be able to achieve side and stomach sleeping at week 4. This is normal. It may take up to 8 weeks before they can do so comfortably.
• Arms can be raised above the head.
  • Try a wall climbing exercise with your fingers to increase range of motion.
• Overall, your child's energy level may still feel low. This is normal.
• Your child can start driving again if they are:
  • Recovering well from surgery
  • Have no symptoms
  • Are not taking pain medications.

week 6

• Driving can resume if not taking medications or muscle relaxants.
• Using slow and controlled movements, your child may twist at the waist.
• Continue to increase your child's level of physical activity.

week 8

• Begin upper body weight training with 5-pound weights or less
• Begin cardiovascular conditioning in addition to weight training.
• Can resume non-contact sports such as tennis, swimming, running, baseball, golf, biking and volleyball.
  • If running, biking or skateboarding, be careful and avoid any falls
• Remember, exercise is the key to a strong and healthy recovery from surgery.

3 to 4 months

• Carry a backpack without limitations.
• Participate in physical education/gym class unless otherwise instructed.
• May work out with weights over 5 pounds and increase weight in intervals if desired.
• May participate in aerobic exercises/activities.
• Rollercoaster rides are permitted.

Note: Participating in any contact sport while the bar is in place may increase the possibility of the bar shifting. Check with your surgeon if your child wants to do any contact sports. Depending on your child's recovery, they could be eligible for some contact sports between 12 weeks to 1 year after surgery.

6 months

• All restrictions are lifted except for the following activities:
  • Football and other contact sports, such as soccer
  • Sparing with martial arts
  • Wrestling

1. One of our post-op nurses will call you a few days after discharge to check on your child's recovery.
2. Before you leave the hospital, we will schedule a post-surgery appointment for 2 weeks after your child is discharged from the hospital.
3. Other follow-up appointments will be made based on your child's progress after clinical evaluation at their first post-surgery visit. Many patients will also have follow-up with physical therapy.
   • Typically patients are seen in the clinic 2 weeks, 6 weeks, and then every 3 months following surgery.
4. Long term follow-up: Every 6-12 months post-surgery appointment is recommended.
5. Yearly appointments are required until the bar is removed in about two and a half to three years. If your child has any unusual problems or symptoms, please call us. We will likely schedule you to come into clinic.
6. AFTER bar removal - once the bar is removed, you will be followed in the outpatient clinic until you receive final clearance for unrestricted activities from your surgeon.

Most patients will be followed by physical therapy after surgery. Here are some basic pectus excavatum post-Nuss exercises that are commonly prescribed.

Exercise #1: Chest expansion - deep breathing and breath holding. Do this exercise in the morning and at night. Begin after surgery.

1. Stand up straight (or sitting straight in chair) with the shoulders pulled back. Breathe in as deeply as possible and hold your breath for 10 seconds.
2. Repeat 10 times.

Exercise #2: Back straightening exercise. Do this exercise ten times each morning and evening. The goal of this exercise is to straighten the back and pull the shoulders back.

1. Place your hands behind your head. Interlock your fingers.
2. Pull back your elbows as much as possible, keeping your head and neck straight. This posture causes the chest to fill out in front.
3. Bend from the hips, forward and down, to a horizontal position. Hold for 2 to 3 seconds. It is very important that the elbow, head and neck remain straight during the exercise.

Exercise #3: Strengthening the chest and back muscles. Begin 2 to 3 months after surgery.

1. Do 25 push-ups each day.
2. Another exercise to strengthen the chest muscles:
   • Lie with your back on the floor and with arms stretched out on each side. Place small weights in each hand.
   • Keeping arms straight, bring them together over the chest.
   • Do 25 each day.

Call the pediatric surgery office at 937-641-5020, option 5, immediately if your child has any of the following:

• Redness, swelling, blisters or drainage
• Severe pain that does not improve with the use of over-the-counter medications or the medications prescribed