Contributors: Andrew Weaver and Kumar Patel, PA-C

18 y.o. female with Treacher-Collins syndrome (patients have micrognathia, underdeveloped facial bones, particularly the cheek bones, and a very small jaw and chin. She is only able to open her mouth to 20mm due to the interference of her coronoid process with her zygoma/

DOI: http://dx.doi.org/10.17797/959yiezvoo

Contributors: Marco P. Fisichella

65 year old man who underwent a laparoscopic Nissen fundoplication in August 2015. Preoperative manometry was normal and DeMeester score was 25. Two months later he began to experience difficulty of swallowing solid foods, then liquids. After 2 dilatations, dysphagia persisted.

DOI#: http://dx.doi.org/10.17797/egw2097cpq

Referred By: Jeffrey B. Matthews

Contributors: Josephine Czechowicz and Sanjay Parikh

Removal of a bronchial foreign body with a smooth surface can be challenging with standard optical forceps. The fogarty arterial embolectomy catheter is a suitable alternative, particularly in the setting of a bead or other hollow object.

DOI: http://dx.doi.org/10.17797/7gq2gil0v3

Editor Recruited by: Sanjay Parikh

Contributors: Vincent Couloigner

We describe the excision of a nasal encephalocele obstructing the left nasal fossa with an anterior subcutaneous portion deforming the nasal pyramid in a four-year-old girl using endoscopic surgery combined to a Rethi approach. The anterior skull base defect was reconstructed using autologous conchal cartilage and temporal fascia.

Editor Recruited By: Sanjay Parikh, MD, FACS

DOI: http://dx.doi.org/10.17797/udewjr2ge7

Contributors: Reza Salabat and Marco P. Fisichella

Preoperative work-up and surgical technique of laparoscopic paraesophageal hernia repair.

DOI#: http://dx.doi.org/10.17797/c2kvm64ru5

Transcanal endoscopic tympanoplasty is illustrated with steps explained. This is a “realistic” case with bleeding and middle ear adhesions; tips to overcome these hurdles are discussed.

DOI# http://dx.doi.org/10.17797/atpw43so2e

Editor Recruited by: Ravi N. Samy

Contributors: M. Nathan Nair and Timothy Deklotz

For patients with basilar invagination, an odontoidectomy may be necessary to decompress the brainstem, before further correction and stabilization of the craniocervical junction can be achieved. The open-mouth odontoidectomy procedure is associated with significant moribdity, and the endoscopic endonasal approach may be a better option. In this video, we provide a step-by-step demonstration of the endoscpic endonasal approach for odontoidectomy.

DOI:http://dx.doi.org/10.17797/6mx9qe789f

Rib cartilage is the workhorse autogenic material for laryngeal airway expansion surgery.  Most usually one will use the right-sided 5th or 6th rib as the donor site.  A 2.5 cm incision is made directly over the rib, in the inframammary crease from the lateral aspect of the nipple to the sternal xyphoid process.  Subcutaneous fat is removed.  The overlying intercostal muscles are dissected up away from the rib, divided, and retracted– effectively exposing the rib.  Perichondrium is sharply incised on the superior and inferior borders of the rib.  A posterior tunnel is elevated in asub-perichondrial plane using blunt instruments, just medial to the osseocartilagenous (OC) junction.  A Doyen elevator is inserted into the tunnel and the rib is transected right at the OC junction.  The rib is then elevated from lateral to medial in the subperichondrial plane.

Such a manuever ensures that the plueral space will not be entered, protecting the pleural membrane from injury.

Once the rib has been elevated to the sternal attachment, it is completely released.  The pleura is inspected directly to confirm it has not been injured.  The wound is filled with normal saline and 30 cm of water pressure valsalva is applied by the anesthesiologist for 30 seconds, to ensure no air is escaping the lung.  The wound is closed in layers over a rubber band drain placed in a dependent position.

One should be able to harvest 2.5-3 cm of cartilage. Post-operatively a chest radiograph is obtained to rule out pneumothorax

DOI: http://dx.doi.org/10.17797/2jra6vjlud

Contributor: Ciro Andolfi (University of Chicago), Marco G. Patti (University of Chicago)

We describe our preoperative work-up and the surgical technique of Laparoscopic paraesophageal/hiatal hernia repair.

DOI: http://dx.doi.org/10.17797/56by9lqzf5

Editor Recruited By: Dr. Jeffrey Matthews

The procedure shown in this video is a pediatric ansa to recurrent laryngeal nerve reinnervation. It is performed with a concurrent laryngeal electromyography and injection laryngoplasty.

Editor Recruited By: Sanjay Parikh, MD, FACS

DOI: http://dx.doi.org/10.17797/7jjbn56ca3

Contributor: Tyler McElwee

Choanal atresia describes the congenital narrowing of the back of the nasal cavity that causes difficulty breathing in neonate. Choanal atresia is often associated with CHARGE, Treacher Collins and Tessier Syndrome. It is a rare condition that occurs in 1:7000 live births, seen in females twice as often as males, and affects bilaterally in roughly 50% of cases.  Bilateral choanal atresia is usually repaired in the newborn period. Unilateral CA repair is often deferred until age 2-3 years. Stent placement has become optional as stentless repair is gaining popularity because this technique decreases foreign body reaction in the nasopharynx which in term decreases granulation formation.  Transnasal endoscopic choanal atresia repair is performed by opening the atresia bilaterally, drilling out pterygoid bone as needed, and removal of the posterior septum and vomer. Normal mucosa is preserved as much as possible by elevating a lateral based mucosal flap to prevent scarring and restenosis. Postoperatively, these patients are treated with antibiotic, reflux medications and steroid nasal drops; a second look procedure is planned 4-6 weeks postop for debridement and possible removal of granulation tissue & scar.

DOI: http://dx.doi.org/10.17797/9s5ty2f7yv

Editor Recruited By: Sanjay Parikh, MD, FACS

Contributor: Tyler McElwee

Congenital dacryocystocele describe the distended lacrimal sac in neonates with or without associated intranasal cyst.  The prevalence is about 0.1% of infants with congenital nasolacrimal duct obstruction and a slight prevalence in female infants.  It refers to cystic distention of the lacrimal sac as a consequence of the nasolacrimal drainage system obstruction.  It typically presents as a bluish swelling inferomedial to the medial canthus in the neonates.  Unilateral congenital dacryocystocele is more common but 12-25% of patients affected have bilateral lesions.  Ultrasound, CT scan or MRI can be used for diagnosis.  About half of the patient with acute dacryocystitis can be management with conservative management such as digital massage of lacrimal sac or in-office lacrimal duct probing.  The other half of patients will require surgery under general anesthesia for removal of the dacryocystocele.   Endoscopic excision of the intranasal cysts has been used successfully as a treatment option with Crawford stent placement.  Post-operatively patients are treated empirically with antibiotics and nasal saline.  No second look is usually planned unless patients develop significant nasal obstrctuion.

Editor Recruited By: Sanjay Parikh, MD, FACS

DOI: http://dx.doi.org/10.17797/16rnuq8n0y

This video shows a KTP laser assisted endoscopic excision of a myofibroblastic lower tracheal tumour.

Editor Recruited By: Sanjay Parikh, MD, FACS

DOI: http://dx.doi.org/10.17797/jt8idqw53j

Contributors:

Chris Streck (MUSC)

Aaron Lesher (MUSC)

Robert Cina (MUSC)

Step-by-step demonstration on how to perform the laparoscopic needles assisted repair (LNAR) of inguinal hernias in infants and young children.

This fairly new technique for laparoscopic repair of inguinal hernias in infants and children is now well accepted among many pediatric surgeons. Because of the very small skin incisions, it is associated with minimal pain and has great cosmetic appeal. The operation is indicated in the treatment of inguinal hernias and communicating hydroceles in children less than 12 years of age. Preliminary results reported by the authors have suggested a similar recurrence rate as reported for the open technique. Interestingly, the recurrence rate is lower in small and premature infants compared to open surgery. The authors prefer the use of non-absorbable suture (like Prolene) in order to minimize the risk of recurrence. Our experience has demonstrated that the laparoscopic needle-assisted repair of inguinal hernia is safe with a 4% rate of minor complications. The most common complication is the development of a suture granuloma at the site of the suture placement for closure of the internal inguinal ring. It usually can be treated medically. In rare occasions, it might be necessary to remove the suture. Other less common reported complications include infection, residual hydrocele, hernia recurrence, and injury to the spermatic vessels or vas.

DOI: http://dx.doi.org/10.17797/bdmv3e7y2c

Editor Recruited By: Robert Shamberger, MD

Contributors: David A Geller

Laparoscopic left lateral sectionectomy performed for a 14 cm hypervascular left lobe liver mass which is hypervascular during arterial phase and isodense to liver during venous phasem consistent with giant Focal Nodular Hyperplasia.

DOI: http://dx.doi.org/10.17797/yjare8xwt2

Editor Recruited By: Jeffrey B. Matthews, MD

Contributors: Noemie Rouillard-Bazinet, MD and Deepak Mehta, MD

Endoscopic repair of tracheoesophageal fistula using electrocautery and fibrin glue.

DOI: http://dx.doi.org/10.17797/uq9ifhudgd

Editor Recruited By: Sanjay Parikh, MD, FACS

Surgical removal of suprastomal granuloma is a procedure performed prior to the probable decannulation of a tracheostomy. There are several ways of achieving this objective, but in certain cases, a KTP laser on a flexible delivery system offers a precise and controlled method to successful debulking of the granuloma with minimal risks of haemorrhage into the airway.

DOI: http://dx.doi.org/10.17797/pqzu0ns9y9

Editor Recruited By: Sanjay Parikh, MD, FACS

A five year old with conductive hearing loss due to traumatic ossicular discontinuity presents for surgical management. Ossicular discontinuity with a fibrous union of the incudostapedial joint is identified. Transcanal Endoscopic middle ear exploration with incus interposition is performed.

DOI: http://dx.doi.org/10.17797/t0il7famg9

Editor Recruited By: Sanjay Parikh, MD, FACS

Contributors: Noemie Rouillard-Bazinet and Julina Ongkasuwan

Bilateral vocal fold paralysis causes airway obstruction and, in some patients, tracheostomy dependence. Posterior cricoid split with costal cartilage grafting can open the posterior glottis and improving the airway.

DOI: http://dx.doi.org/10.17797/hyp0b3mzd5

Editor Recruited By: Michael M. Johns III, MD

Contributors: Gary Nace, Juan Calisto and Marcus Malek

Langerhans Cell Histiocytosis (LCH) is an exceedingly rare proliferative disorder in which pathologic histiocytic cells accumulate in nearly every organ. Our patient, a five-month-old, six kilogram female with mild pulmonary valve stenosis, had both thymic and lung tissue involvement. To date there has never been a report of a thymic LCH with lung metastases in an infant. She underwent a video assisted thoracoscopic thymectomy.

DOI: http://dx.doi.org/10.17797/2qbbejhisy

This video depicts several findings on the contralateral inguinal region when performing a diagnostic laparosocpy at the time of open repair of a unilateral inguinal hernia.

DOI: http://dx.doi.org/10.17797/w6xnoqy0un

Contributor: Manish Parikh

The patient is a 50 year-old man with a history of gallstone pancreatitis treated with endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct stent at an outside hospital. The patient subsequently had migration of the stent into the stomach and recurrent choledocholithiasis. This is a video demonstrating techniques used for laparoscopic common bile duct (CBD) exploration via choledochotomy with primary closure of the duct. The intraoperative cholangiogram revealed the “meniscus sign” consistent with a large stone at the ampulla.  

Attempts at transcystic CBD exploration failed due to a tortuous duct and inability to pass the fogarty balloon. A laparoscopic choledochotomy was then made for stone extraction.  A longitudinal choledochotomy was performed sharply after exposing the anterior aspect of the common bile duct.  Intraoperative choledochoscopy confirmed the stone at the ampulla.  A 4Fr fogarty catheter was used to extract the stone.  Repeat choledochoscopy confirmed clearance of the duct.  The choledochotomy was closed with 4-0 PDS  sutures in interrupted fashion. The patient’s stent was removed from the stomach via intra-operative Esophagogastroduodenoscopy (EGD) at the conclusion of the procedure.

If the surgeon confirms that the common duct is cleared, the evidence supports primary closure of the duct.  In scenarios where the duct is not completely cleared of stones or if there is doubt, closure over a 14-16Fr t-tube is performed.

A 10 Fr. JP is routinely left in the right upper quadrant when a choledochotomy is performed. 

DOI: http://dx.doi.org/10.17797/hawlc80i6c

Editor Recruited By: H. Leon Pachter, MD