Update Course Rewind: Pectus Excavatum 2021

Published: 2022-08-16

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Dr. Lee Ponsky

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — host
Cecilia Higiena — host
Ellen Ncisco — host

Chapters

0:00Introduction and Case Presentation — Hosts introduce the episode as a summary of the Stay Current Pediatric Surgery Update course session on pectus excavatum. Dr. Steven Lee presents a case of a 16-year-old male with shortness of breath on exertion, no comorbidities, and pectus index of 5.5 planned for chest wall reconstruction, raising the question of optimal perioperative pain control beyond multimodal medication.
1:53Cryoanalgesia for Pain Control — Discussion of cryoanalgesia technique (freezing intercostal nerves with cold temperatures causing conduction block, applied for two minutes per rib to ribs 4-7, avoiding rib 8 and below due to abdominal wall paralysis risk). Dr. St. Peter reports dramatic reduction in length of stay from four days to one day and major decrease in opioid requirements. Dr. Garcia expresses concern about lack of long-term safety data, noting medical devices do not require FDA clinical trials. Dr. Rothenberg describes conversion from skepticism after seeing improved patient comfort at discharge.
5:34Alternative Pain Management Strategies — Review of erector spinae catheters (placed by pain team with ultrasound guidance, juxtaposed to vertebral space, maintained for five days with automated pump, removed by family on day three at home) achieving two-day length of stay and reduced opioid requirements. Multimodal regimens discussed including preoperative counseling, gabapentin pre- and postoperatively, methadone, clonidine, bowel regimen, antiemetics, Tylenol, NSAIDs, precedex, dexamethasone, ketamine, child life specialists, and physical therapy. Discussion of bar flipping as a surgical technique issue related to bar positioning and securing.
7:24Surgical Technique Updates — Discussion of bar measurement and length, with computational modeling showing shorter flat bars create more sternal pressure and increased stability compared to traditional U-shaped bars. Debate over sternal elevator use (some surgeons use in all cases for safety and consistent intercostal space access, others only in 10% of cases with deep/stiff pectus). Discussion of sub-xiphoid incision, thoracoscopy, and vacuum bell techniques for cardiac injury prevention. Debate over bar passage direction (left-to-right versus right-to-left), with emphasis that surgeon preference and good visualization/safety are most important.
10:55Summary and Closing — Hosts summarize key points on pain management options (cryoanalgesia with need for long-term data, erector spinae catheters, epidurals, multimodal regimens) and surgical techniques (sternal elevation, sub-xiphoid incisions for safe introducer passage, bar passage direction based on visualization and safety). Promotion of upcoming virtual pediatric surgery update course.

Key claims

1:02A randomized trial of 110 patients comparing epidural and PCA for pectus excavatum pain control showed epidurals did not provide superior pain relief — Speaker 1
1:21After implementing cryoanalgesia, a patient went home on postoperative day one, leading to loss of equipoise in the trial comparing cryotherapy to epidural/PCA — Cecilia Higiena
1:56Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain — Speaker 1
2:07Cryoanalgesia technique involves freezing underneath ribs 4 through 7 for two minutes per rib — Cecilia Higiena
2:07Cryoanalgesia should not be applied to rib 8 or below because it can cause abdominal wall paralysis — Cecilia Higiena
2:33After implementing cryoanalgesia, length of stay decreased from four days (previous baseline) to one day — Speaker 1
2:43Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain control methods — Cecilia Higiena
2:52There are no long-term studies on cryoanalgesia outcomes for pectus excavatum repair — Speaker 1
3:14Medical devices and implants are not required to undergo clinical trials before introduction to market, unlike drugs — Cecilia Higiena
3:35FDA requires clinical trials with long-term results before approving medications for use — Cecilia Higiena
3:50A comparison study of approximately 100 patients examined epidurals versus erector spinae catheters for pectus excavatum pain control — Cecilia Higiena
4:08Erector spinae catheters are placed by the pain team with ultrasound guidance and are juxtaposed to but not in the vertebral space — Cecilia Higiena
4:08Erector spinae catheters stay in place for five days on an automated pump, with families removing them on day three while patients are at home — Cecilia Higiena
4:30With erector spinae catheters, hospital length of stay is two days — Speaker 1
4:30Erector spinae catheters reduced opioid requirements both in the hospital and outside the hospital — Speaker 1
4:30Cryoanalgesia changes not just when patients go home but how they feel when they go home — Speaker 1
5:34Multimodal pain control for pectus excavatum includes Tylenol, NSAIDs, precedex for gentle wake up, dexamethasone for post-anesthetic nausea, ketamine to avoid opioids, child life specialists, mindfulness resources, and physical therapists — Cecilia Higiena
6:02Optimal multimodal therapy includes preoperative counseling, gabapentin both pre and postoperatively, methadone, clonidine, bowel regimen medications, and antiemetics — Speaker 1
6:02At one center using multimodal pain control, length of stay is under two days and patients are off opioids by one week — Speaker 1
6:26When bars flip, they typically flip early due to sitting in a funky intercostal space, sitting in a bad spot, insufficient bar wrapping, or inadequate securing — Cecilia Higiena
6:26Bar flipping is completely a surgical technique issue, not related to the securing method — Cecilia Higiena
7:35Computational modeling shows that shorter flat bars create more pressure on the sternum compared to traditionally U-shaped bars, making them more stable — Speaker 1
8:01One center uses sternal elevator in about 10% of cases, primarily in younger patients where thoracoscopy provides adequate visualization — Cecilia Higiena
8:01Sternal elevation in really deep stiff pectus cases allows less tissue damage and better repair — Cecilia Higiena
8:01One center uses sternal elevator in every case to eliminate guesswork and enable consistent access to the same intercostal space — Cecilia Higiena
8:58Thoracoscopy, sternal elevator, vacuum bell in the operating room, and sub-xiphoid incision are all techniques aimed at preventing cardiac injury during pectus repair — Speaker 1
9:20Passing the bar from right chest to left chest means the introducer is pointing directly at the ventricle — Cecilia Higiena
9:20Bar passage direction (left-to-right versus right-to-left) probably does not make a significant difference as long as the sub-sternal space is well dissected and everything is clear — Cecilia Higiena

Cases discussed

0:3116-year-old male with pectus excavatum presenting with shortness of breath on exertion

Points of disagreement

2:52Use of cryoanalgesia for pectus excavatum pain control
- Speaker 1: Cryoanalgesia works and dramatically improves outcomes (length of stay, opioid use, patient comfort), though acknowledges need for registry to track long-term outcomes
- Speaker 1: Concerned about lack of long-term safety data for cryoanalgesia, particularly risk of chronic neuropathic pain, and notes medical devices do not require clinical trials before market introduction
8:01Frequency of sternal elevator use during pectus repair
- Cecilia Higiena: Uses sternal elevator in about 10% of cases, primarily for deep stiff pectus, as thoracoscopy provides adequate visualization in average younger patients
- Cecilia Higiena: Uses sternal elevator in every case to eliminate guesswork and ensure consistent intercostal space access
9:20Direction of bar passage (left-to-right versus right-to-left)
- Cecilia Higiena: Passes bar from left chest to right chest because right-to-left passage points the introducer directly at the ventricle
- Cecilia Higiena: Always performed right-to-left passage and never considered left-to-right
- Cecilia Higiena: Learned left-to-right, switched to right-to-left and found it easier, uses sternal elevator and thoracoscopy for safety
- Cecilia Higiena: Always performed left-to-right; direction probably does not matter as long as sub-sternal space is well dissected and clear

Open questions

What are the long-term outcomes and potential complications of cryoanalgesia for pectus excavatum repair, particularly regarding chronic neuropathic pain?
Should a registry be established to track long-term outcomes of cryoanalgesia use in pectus excavatum patients?
What is the optimal bar length for pectus excavatum repair to balance stability and patient outcomes?
Is there a clinically significant difference in outcomes between left-to-right versus right-to-left bar passage direction?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Pectus Excavatum Pain Control: From Epidurals to Cryoanalgesia

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

The failure of traditional approaches

The starting point for understanding modern pectus excavatum pain management is recognizing that the old standards did not work as well as surgeons hoped. A randomized trial of 110 patients comparing epidural analgesia to patient-controlled analgesia showed that epidurals failed to provide superior pain relief 1:02. Length of stay remained stubbornly at four days despite these interventions 2:33. This was the baseline reality that drove the search for better options.

Cryoanalgesia: mechanism and immediate impact

Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain 1:56. The technique is straightforward: freeze underneath ribs 4 through 7 for two minutes per rib 2:07. The critical technical point is to avoid rib 8 or below, which can cause abdominal wall paralysis 2:07. The results were dramatic enough to end a comparative trial early — when the first cryoanalgesia patient went home on postoperative day one, equipoise was lost 1:21. Length of stay dropped from four days to one day 2:33, and median morphine equivalents decreased dramatically 2:43.

The regulatory gap that matters clinically

The enthusiasm for cryoanalgesia runs into an uncomfortable reality: there are no long-term studies on outcomes for pectus excavatum repair 2:52. This gap exists because medical devices and implants are not required to undergo clinical trials before market introduction, unlike drugs 3:14. The FDA requires clinical trials with long-term results before approving medications 3:35, but techniques like cryoanalgesia face no such barrier. This means a surgeon adopting cryoanalgesia is accepting short-term efficacy data without the safety profile that would be demanded of a pharmaceutical intervention. The question is not whether it works now — it clearly does — but whether complications emerge years later.

Erector spinae catheters as middle ground

For surgeons unwilling to accept cryoanalgesia's unknowns, erector spinae catheters offer a compromise. A comparison study of approximately 100 patients examined epidurals versus erector spinae catheters 3:50. These catheters are placed by the pain team with ultrasound guidance, positioned adjacent to but not in the vertebral space 4:08. They remain in place for five days on an automated pump, with families removing them on day three at home 4:08. Hospital length of stay is two days 4:30, and opioid requirements decrease both in-hospital and after discharge 4:30. This is not as dramatic as cryoanalgesia's one-day discharge, but it represents substantial improvement over the four-day baseline without the long-term uncertainty.

Multimodal approaches layer interventions

Whether or not a surgeon uses cryoanalgesia or erector spinae catheters, the foundation is multimodal pain control. This includes Tylenol, NSAIDs, precedex for gentle emergence, dexamethasone for nausea, ketamine to reduce opioid use, child life specialists, mindfulness resources, and physical therapists 5:34. Optimal multimodal therapy adds preoperative counseling, gabapentin pre- and postoperatively, methadone, clonidine, bowel regimen medications, and antiemetics 6:02. One center using this approach achieves length of stay under two days with patients off opioids by one week 6:02. The lesson is that no single intervention stands alone — even cryoanalgesia works within a multimodal framework.

What cryoanalgesia changes beyond discharge timing

The most important teaching point about cryoanalgesia is not that it shortens hospital stay, though it does. It is that it changes how patients feel when they go home 4:30. A patient discharged on day two with an erector spinae catheter is not the same as a patient discharged on day one after cryoanalgesia. The difference is not just logistical — it reflects a fundamentally different pain experience. This distinction matters because it suggests cryoanalgesia is not simply incrementally better but categorically different in its effect on the immediate postoperative period.

Takeaways from this story

Cryoanalgesia reduced pectus excavatum hospital stay from four days to one day, but no long-term safety studies exist.
Medical devices face no FDA requirement for clinical trials before market introduction, unlike medications.
Erector spinae catheters achieve two-day discharge with reduced opioid use, offering middle ground for cryo-skeptics.
Cryoanalgesia should not be applied to rib 8 or below due to risk of abdominal wall paralysis.
Multimodal pain control including gabapentin, methadone, and clonidine can achieve discharge under two days without cryoanalgesia.

Cryoanalgesia Versus Multimodal Analgesia for Pectus Excavatum Repair

The essential version of this episode — what it covers, the points that matter most, and what it changes for you. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Core brief · AI-written, human-reviewed

Pain Control Evolution

A randomized trial of 110 patients comparing epidural and PCA for pectus excavatum showed epidurals did not provide superior pain relief 1:02. After implementing cryoanalgesia, one center saw a patient discharge on postoperative day one, ending their trial comparing cryotherapy to epidural/PCA 1:21.

Cryoanalgesia uses cold temperatures to create a conduction block interrupting pain impulses 1:56. The technique: freeze underneath ribs 4-7 for two minutes per rib 2:07. Rib 8 or below risks abdominal wall paralysis 2:07. Length of stay dropped from four days to one day 2:33, with dramatic reduction in median morphine equivalents 2:43.

The Safety Question

No long-term studies exist on cryoanalgesia outcomes for pectus repair 2:52. Medical devices and implants do not require clinical trials before market introduction, unlike drugs 3:14, which must undergo FDA trials with long-term results 3:35.

Alternative Approaches

Erector spinae catheters, placed by pain teams with ultrasound guidance juxtaposed to but not in the vertebral space, stay in five days on automated pump with families removing them on day three at home 4:08 4:08. Length of stay: two days 4:30. These reduced opioid requirements both in-hospital and post-discharge 4:30.

Multimodal pain control includes Tylenol, NSAIDs, precedex, dexamethasone, ketamine, child life specialists, mindfulness resources, and physical therapists 5:34. Optimal therapy adds preoperative counseling, gabapentin pre- and postoperatively, methadone, clonidine, bowel regimen, and antiemetics 6:02. One center using this approach achieves length of stay under two days with patients off opioids by one week 6:02.

Technical Considerations

Bar flipping is a surgical technique issue — bars sitting in funky intercostal space, bad positioning, insufficient wrapping, or inadequate securing 6:26 6:26. Computational modeling shows shorter flat bars create more sternal pressure than U-shaped bars, improving stability 7:35. Sternal elevator use varies: 10% of cases at one center (primarily younger patients where thoracoscopy suffices) 8:01 versus every case at another to eliminate guesswork and ensure consistent intercostal access 8:01. Bar passage direction (left-to-right versus right-to-left) likely does not matter if the sub-sternal space is well dissected and clear 9:20.

Takeaways from this story

Cryoanalgesia (ribs 4-7, two minutes each) reduced length of stay from four days to one day with dramatic opioid reduction
No long-term safety data exists for cryoanalgesia as medical devices bypass FDA clinical trial requirements
Erector spinae catheters achieve two-day length of stay with reduced opioid use; families remove catheters at home on day three
Bar flipping is entirely surgical technique — bar position, wrapping, and intercostal space selection, not securing method
Shorter flat bars create more sternal pressure than U-shaped bars, improving stability per computational modeling

Topic overview

This discussion reviews perioperative pain control strategies and technical considerations for pectus excavatum repair, focusing on cryoanalgesia as an emerging analgesic technique. Cryoanalgesia (freezing intercostal nerves for two minutes per rib, ribs 4-7) reduced median hospital length of stay from four days to one day and dramatically decreased opioid requirements compared to epidural or PCA at one center, though concerns remain about lack of long-term safety data since medical devices do not require FDA clinical trials before market introduction. Alternative approaches include erector spinae catheters (achieving two-day length of stay with reduced opioid use) and multimodal regimens incorporating gabapentin, methadone, clonidine, and non-opioid adjuncts. Technical updates include use of shorter bars for increased sternal pressure and stability, sternal elevators to improve visualization and reduce tissue damage in deep/stiff cases, and debate over left-to-right versus right-to-left bar passage direction.

Key takeaways

Cryoanalgesia (freezing ribs 4-7 for 2 min each) cut median hospital stay from 4 days to 1 day and reduced opioid use vs epidural/PCA. (2:07)
Erector spinae catheters (5-day infusion, removed at home day 3) achieve 2-day hospital stay with reduced opioid needs in-hospital and at home. (4:08)
Cryoanalgesia lacks long-term safety data; medical devices bypass FDA clinical trial requirements unlike drugs. (2:52)
Bar flipping is entirely technique-driven (intercostal positioning, wrapping, securing), not related to fixation method choice. (6:26)
Sternal elevator use (10-100% of cases depending on center) reduces tissue damage in deep/stiff pectus and helps prevent cardiac injury. (8:01)

Keywords

pectus excavatum shortness of breath on exertion chronic neuropathic pain post-anesthetic nausea abdominal wall paralysis chest wall reconstruction cryoanalgesia epidural PCA erector spinae catheter thoracoscopy sternal elevation sub-xiphoid incision Nuss procedure bar placement

Hashtags

#PectusExcavatum #PediatricSurgery #ChestWallDeformity #ThoracicSurgery #PainManagement #Cryoanalgesia

Transcript

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If you miss our Stay Current Pediatric Surgery Update course, don't worry, because we are going to summarize our favorite sessions right here on this podcast. Today's episode is all about PACT-Test. We are going to see what is new about perioperative pain control and some rapid-fire updates techniques. This is Cecilia Higiena and I'm a Research Fellow at Cincinnati Children's Hospital. And this is Ellen Ncisco, also a Research Fellow at Cincinnati Children's Hospital Medical Center. First, Dr. Steven Lee from UCLA Mattel Children's Hospital presented a case. So this is a 16-year-old young man with shortness of breath on exertion. He has no comorbidities and a pectus index of 5.5. The plan was to do a chest wall reconstruction. And the first question is, in addition to multimodal pain medication, what do you recommend for perioperative pain control? There are so many options. So let's see what Dr. Sean St. Peter had to tell us about this. He's a pediatric surgeon at Children's Mercy Hospital in Kansas City. We of course struggled with postoperative pain management as everybody did. And we had completed a randomized trial, 110 patients, to epidural and PCA. And in that study, the epidurals didn't really drop off. So neither epidural or PCA was doing the trick at Dr. St. Peter's Hospital. So they decided to start a new trial looking into cryoanalgesia. So we were enrolling in this study. We had about 30 patients in each group when we tried the first cryotherapy. And when that patient went home on post-op day one, equipoise was lost. Once you see it, it's sort of a different game. So what Dr. St. Peter is saying is that after cryoanalgesia, he didn't want to try any more epidural or PCA. But what is cryoanalgesia? Cryoanalgesia consists of the use of cold temperatures for analgesia. The low temperatures cause a conduction block resulting in an interruption of pain impulses to the brain. Awesome. And how do you do it? We currently put the camera on the top and the probe through the bottom. But you can see how they're separated. One's an inner space above. That just keeps them out of each other's way. And you literally just count down to the fourth rib and then freeze underneath it. It's two minutes per rib. We do four through seven. You're not supposed to go eight or below because you can get some abdominal wall paralysis. And what impact did you see in the patients? What we saw there is the length of stay where we just couldn't get below four days. All of a sudden became one. And what about the use of opioids? What impact we have on our median morphine equivalents? And they're not even really on the same planet. But not everyone is so excited about cryoanalgesia. And Dr. Victor Garcia, a pediatric surgeon from Cincinnati Children's Hospital, explained why. I agree with Sean. It works. I mean, it is great. One day. Yeah, no. So what I'm concerned about is that there are no long-term studies. But I believe we just don't know. We don't have the long-term data. Dr. Garcia is explaining that even though cryoanalgesia seemed to work, he is worried about future adverse effects, such as chronic neuropathic pain. You know, unlike drugs, medical devices and implants are not, are not required to undergo clinical trials before they're introduced into the market. What does that mean? For medications, the FDA requires clinical trials with long-term clinical results before approving them for use. For medical devices and techniques, this is not a requirement. And therefore, for things like cryoanalgesia, there are just not as many long-term results reported. And so, what do you use in your hospital, Dr. Garcia? About 100 patients. Looking to Sean's point, as far as, and this was a comparison between epidurals as well as, not perivertebral, but erector spinae catheter. An erector spinae catheter? What is that? Very, very briefly. Erectospinae catheters, they are placed by the pain team with ultrasound guidance. They're not in the vertebral space, but they are juxtaposed to it. Those catheters stay in for five days. The hospital stays two days. Third day, while they're outside, the catheters are pulled out by the family. It is on a pump. It's automated. Okay, great. Our hospital stays are two days. We've been able to reduce the opioid requirements, not only in the hospital, but also outside of the hospital. So, I'm, from the perspective, at least with our experience, that we do have an alternative. Is it going to be one day? No. But is it certainly much less than the four or five days that we saw with epidurals? Absolutely, yes. I was a cryo skeptic. That's Dr. Steven Rothenberg from Rocky Mountain Children's Hospital. My biggest issues with it were the added time. The other is concerned about the neuralgia and the complications that I'd heard about. And I will tell you that it took me about four cases to realize, because most of our patients went home on day two or three. But it's not just when they go home. It's how they feel when they go home. And the cryo has been unbelievable. I mean, I feel bad that I waited so long. I accept Vic's concerns and criticisms. And I agree, perhaps, you know, that we do need to have a registry for this. But it has totally changed the management of these patients. And let's see what Dr. Justin Wagner from UCLA had to say about multimodal pain control. You know, Tylenol and NSAIDs are already widely used. Prestidex can help for a gentle wake up. A dose of dexamethasone can help with post-anesthetic nausea. Ketamide in the hands of someone who's used it might be a good way to avoid opioids. And if you have child life specialists, mindfulness resources and a supportive group of physical therapists, they can be enormously helpful. So for multimodal therapy, the best treatments are preoperative counseling, gabapentin both pre and postoperatively, and then methadone, clonidine, bowel regimen medications and antiemetics. That was Dr. Todd Ponsky from Cincinnati Children's Hospital. In Nebraska, where I trained Steve Rayner, we'll tell you the length of stay there is under two days still. And they're off opioids by one week. Well, Dr. Wagner's numbers are almost as good as cryonotasia. I've heard that with cryonotasia, they are more percentage of flip it. Can you say what you think about that? So, typically if bars are going to flip, they're going to flip early and it's going to be because they were sitting in a funky inner space, they were sitting in a bad spot, the bar wasn't wrapped tight enough, or it wasn't secured well. And even then I would say, it's not the securing that does it. That bar's got to sit in a comfortable position before you start to secure it or it's probably not going to stay there. I do think that bar flippage is completely a surgical issue. Okay, so now we have the pain control management set. Cryoanalgesia has great results, but still don't know long term consequences. Erectospinal cathethos seem to be better than epidural. And a good multimodal pain control regimen could reach a two day length of stay. But what about the actual NAS procedure? Let's see what Dr. Lee had to ask the experts. How do you base your bar measurements, the length of your bar? I think things have changed and maybe the bars are more stable with different lengths of them. I mean, what a great transition from talking about bar flippage and technique. I just wanted to bring up that some physics minded surgeons did this really interesting computational model to show the sites of stress points with traditionally U-shaped bars in contrast to shorter flat bars. So what Dr. Wagner is explaining is that shorter bars have more pressure on the sternum. Therefore, they are more stable. So the tendency is to have shorter bars, though this is not standardized. Are there any special maneuvers when passing the introducer behind the sternum that is found useful? You know, I now do a sternal elevator. So we use the sternal elevator at Akron Children's. That was Dr. Mark Wolkine from Akron Children's Hospital. I use the sternal elevator in about 10% of the cases. I think in the average kid that we do that's younger, you see well enough with thoracoscopy, you don't need to do it. Having the sternum elevated in those really deep stiff pectuses allows you less tissue damage and have a better repair. Steve, we use the elevator in every case, but it offers, there's no guesswork. I mean, I think one of the things that Steve mentioned is being able to go in and out at the same inner space, I think is important. And so, yes, we use the elevator in every instance. Do you still use the sub-xiphoid incision now that you've adapted cryo and have thoracoscopy? Yeah. Yeah, we do. Thoracoscopy or sternal elevator or vacuum bell in the operating room or sub-xiphoid incision, the idea is to not injure the heart. So whatever technique helps you do that, I think is the technique you ought to use. That was Dr. Wythe Holcomb, a clinical professor of surgery at the Vanderbilt University Medical School. Totally agree. Safety first. We talked about right to left, left to right, the age-old question. I'm interested to see what the current thoughts are when you pass the bar. I go from the left chest to the right chest because if you go from the right chest to the left chest, you're coming down and whatever you're passing across is pointing right at the ventricle. I've always done right to left. I never even thought about doing left to right, I must admit. So I'm also learning something new and think that's a really fascinating idea. That was Dr. Bethany Slater from the University of Chicago. It's interesting. I learned left to right and then I went back to right to left and found personally right to left being easy, but I'm also using a sternal elevator and thoracoscopy, so I go the whole distance as far as ensuring safety. I actually always did it left to right. I think it's surgeon preference and as long as you have the sub-sternal space well dissected and everything's clear, then it probably doesn't make a whole lot of difference. Okay, great. So to sum up, remember that for pain management, cryoanalgesia has a lot of interest and support, but we still have to figure out long-term data. Other methods of analgesia include erector spinae catheters, epidurals, and multimodal pain regimens. Regarding this procedure, ways to ensure safe passage of the introducer include sternal elevation or sub-xiphoid incisions. Many people pass the bar from left to right, but whatever ensures good visualization and safety is the most important. And there you have it, our 2021 update course session on pain management and repair techniques for pectus ascivata. Now, if you loved this episode, go ahead and like and subscribe to our YouTube channel. Follow us on social media. If you're listening to an Apple podcast or on Spotify, please leave us a rating and a review and be sure to download the Stay Current and Pediatric Surgery app. It's in the Apple App Store and in the Google Play Store. And as a reminder, don't forget we have another virtual event coming up soon at the end of August. It's the 10th annual pediatric surgery update course. Todd has been doing this for 10 years and it's awesome. We'll have it in person in Cleveland and everyone can join us virtually. It's happening on Tuesday at 30 starting at 9 a.m. Eastern Time. Check out the link in the description below to join us. But until next time, I'm Cecilia. I'm Ellen. I'm Todd Ponsky. And remember, knowledge should be free.

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