This video demonstrates an epidural catheter placement on a 2-year-old, 12kg male patient presenting for left hip osteotomy. His past medical history was remarkable for congenital heart defects, bilateral congenital hip dislocations, and a sacral dimple which is sometimes associated with neurologic spinal canal abnormalities. In this case, no neurologic anatomical abnormalities were demonstrated on the neonatal spine ultrasound. The patient was placed in a left lateral decubitus position. Using anatomical landmarks like Tuffier’s line or the intercristal line corresponding to L4-L5 level, the target level for needle placement was identified and marked. The patient’s skin was sterilized and draped under sterile conditions. An 18-gauge, 5 cm length Tuohy needle was used to encounter the epidural space. A general guideline for the depth to the epidural space from the skin is approximately 1mm/kg of body weight¹. Subsequently, a 20-gauge catheter was placed through the needle to a depth of 4.5 cm at the level of the skin. Negative aspiration of blood or CSF was confirmed. A test dose was calculated at 0.5 mcg/kg epinephrine or 0.1ml/kg of lidocaine 1.5% with epinephrine 1:200,000. In this case, a 1.2 mL test dose of lidocaine 1.5% with epinephrine 1:200,000 was given without any observed cardiovascular changes (e.g. ≥ 25% increase or decrease in T wave amplitude, HR increase ≥ 10 bpm, or SBP increase ≥ 15 mmHg)¹. Finally, the catheter was secured to the back of the patient. Parental consent was obtained for the publication of this video.
School: UAMS Medical Center (University of Arkansas for Medical Sciences)
Branchial Cleft Cyst Excision
Branchial cleft cysts are a benign anomaly caused by incomplete obliteration of a primordial branchial cleft. They typically appear in childhood or adolescence, but can appear at any age. They present as a non-tender, fluctuant mass following an upper respiratory infection, most commonly at the anterior border of the sternocleidomastoid muscle. These lesions are thought to originate during the 4th week of gestation when the branchial arches fail to fuse. The second branchial cleft is the most common site (95%) and cysts from in this distribution can affect cranial nerves VII, IX, and XII.
Tetralogy of Fallot Repair
Complete repair of Tetralogy of Fallot with a transannular patch. The patient is placed on cardiopulmonary bypass in the standard fashion. An incision in made into the free wall of the right ventricle and the septal defect is exposed. A non-autologous CorMatrix patch is placed with prolene suture in a running fashion to repair the septal defect. An additional patch is used to repair the right ventricular outflow tract with a similar running suture. The patient was removed from cardiopulmonary bypass and extubated in the operating room.
A Pediatric Case of Levator Palpebrae Resection
In this video, we present a case of levator palpebrae resection in an 8-year-old patient with right eye ptosis.
In the pre-op photo, significant ptosis of the right eye can be appreciated. An incision was planned along the lid crease. 0.1 ml of 1: 100,000 epinephrine was injected. An incision was made by electro-cautery along the lid through the skin and orbicularis. Westcott scissors were used to further dissect horizontally. The septum was identified and opened. The preaponeurotic fat was identified and lifted, and the levator aponeurosis was identified. The levator was then tagged with two 6.0 Vicryle sutures, and isolated from surrounding tissues. Next, three6-0 Mersilene sutures were run from the upper tarsus to the levator. They are tightened with releasable notes. The lid elevation and contour were evaluated and adjustments were made until contour and height were equal and appropriate. The temporary surgical knots were transitioned into permanent surgical knots. Approximately 14 mm of excess levator was then excised. Next, three lid crease formation sutures were placed using 6-0 Vicryl. These were attached to the subcu-skin and levator to recreate the upper eyelid crease. Skin closure was performed with 6-0 fast-absorbing gut sutures. In this one-week post-op photo, the ptosis of his right eye was improved.
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Nasal Dermoid Cyst Excision
This is a case of an 8 month old with a midline nasal mass present since birth. Preoperative physical exam and imaging was consistent with a nasal dermoid cyst with no evidence of intracranial extension.
Medial Orbital Dermoid Cyst Removal
Dermoid cysts are the most common orbital tumor in childhood. It is a developmental benign choristoma, arising from ectodermal sequestration along the lines of embryonic fusion of mesodermal processes. It is lined by keratinized stratified squamous epithelium and expands slowly due to constant desquamation and dermal glandular elements. They are usually smooth, painless, mobile, or partially mobile lesions mostly present at the fronto-zygomatic suture with proptosis, displacement, ptosis, or diplopia, depending on depth and extent1.
Although lateral orbital dermoid cysts are common, medial orbital dermoid cysts are rare2. Our patient had a right medial orbital congenital dermoid cyst since birth. At the presentation, the patient was 2 years old. On CT, the cyst measured 5 mm at the upper lid/medial canthus of the right orbit with subtle bone remodeling. He had a mildly clogged tear duct on the left but was otherwise asymptomatic. The decision was made to surgically remove the dermoid cyst.
In this video, we present a case of removal of a medial orbital dermoid cyst in a 2-year-old patient.
An incision was planned directly over the lesion. It was marked following the natural skin tension lines of the face to give the most natural esthetic appearance.
A small amount of Local anesthetic (0.5 ml of Lidocaine and Epinephrine) was injected under the skin to promote hemostasis and postoperative pain control.
A continuous Incision was made with a #15 blade on the skin.
Westcott scissors were used to dissect further through the subcutaneous tissue to expose the cyst and slowly dissect it from the normal tissue surrounding it.
Extra care was made to protect the integrity and avoid the rupture of the cyst.
After the entire cyst was freed from the surrounding tissue, it was carefully removed from its attachments to the periosteum using Westcott scissors.
The incision was closed in a two-layer fashion.
The deeper layer was closed by 6.0 Vicryl in a vertical mattress fashion with 2 interrupted sutures.
Next, wound edge eversion was achieved by placing two interrupted, superficial 5.0 fast-absorbing gut sutures. This will minimize the scar appearance.
Dermabond was applied next and the sutures were protected by a small piece of Tegaderm. This will be left in place until it spontaneously falls off.
Phacoemulsification and IOL Implantation in an Iris Coloboma Case
We present a case of cataract extraction and intraocular lens implantation in an eye with a congenital iris coloboma.
Sinus Venosus ASD Repair
This video demonstrates a sinus venosus ASD repair with the two patch repair technique.
Authors: Emily Goodman; Brian Reemtsen, MD; Markus Renno, MD; Christian Eisenring, ACNP-BC; Lawrence Greiten, MD University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR Arkansas Children’s Hospital, Little Rock, AR
Complete Repair of Total Anomalous Venous Return
Complete repair of a total anomalous pulmonary venous return. Also shown is a primary closure of a patent foramen ovale and patent ductus arteriosus. The patient is placed on cardiopulmonary bypass (CPB) in the standard fashion. The patient is then crash cooled to 20 degrees celsius with ice placed on the head and administration of steroids. Antegrade cardioplegia is then administered. The large confluent vein (vertical vein) is dissected and an arteriotomy is made, a subsequent atriotomy is made in the left atrial appendage. A side to side anastomosis using polypropylene suture in a continuous running fashion. The right atrium is then opened and the patent foramen ovale is closed. The patient was warmed to a satisfactory temperature and once adequate hemostasis was achieved the vertical vein is ligated at its insertion into the innominate vein.
Pulmonary Valve Replacement
This video highlights a pulmonary valve replacement in a patient with Tetralogy of Fallot.