MALE SPEAKER: Modifications using stabilizers, multiple bars, and additional fixation sutures have reduced the incidence of migration, but has not totally eliminated bar migration. This is an uncut video demonstrating placement of the zip tie. Once the thoracic strut has been positioned, we identify the best rib for fixation. We prefer the zip tie to be positioned near the eye of the Nuss bar.
In this particular patient, the port site used during cryotherapy was well positioned as the caudal exit site for the zip tie. As the zip tie has a blunt tip needle, creating an exit thoracostomy makes passing the tie around the rib much easier. A needle driver is positioned in preparation to grasp the needle intrathoracically. The entry site cephalad to the selected rib is identified, again near the eye of the bar, and the tie is placed under thoracoscopic visualization.
The needle is large and blunt, which requires a bit of force to puncture the intercostal muscle.
The needle is then grasped with the caudal needle driver, and the needle is withdrawn from the chest. This maneuver simplifies placement due to the heavy gauge needle.
Once the needle tip is extrathoracic, placement is aided by pushing from the back of the needle and pulling from the tip with the needle driver.
Once the zip tie is passed around the rib, the needle is removed with cable cutters. The tie is assembled as a standard zip tie.
The tie is tightened using the manufacturer's tensioner. This device limits how tight the zip tie can be tensioned per the manufacturer's recommendations. This device also cuts the excess tie flush with the locking tie head.
For demonstration purposes, the bar is tested using a clamp. The bar is well fixed to the rib and is quite stable. The procedure is then completed per routine.
