A brief patient history is provided, followed by preoperative imaging, intraoperative repair, and postoperative imaging.
School: University of Arkansas for Medical Sciences College of Medicine
Inferior Oblique Myectomy
Inferior oblique myectomy is a type of strabismus surgical procedure that aims to weaken an extraocular muscle by transecting it. The patient is a four old with a history of inferior oblique overaction and vertical strabismus, which can be corrected by resection of the inferior oblique muscle.
The ointment was applied to the cornea. Forced ductions were performed and identified restriction of the inferior oblique. A conjunctival incision is made in the fornix. Tenon’s capsule is dissected to expose the Inferior Oblique. The inferior oblique muscle is isolated using a Stevens tenotomy hook followed by Jameson muscle hooks. The inferior rectus was identified on a steven’s hook medially to the inferior oblique. The lateral rectus was then identified on a steven’s hook laterally to the inferior oblique. This was done to ensure that neither muscle was incorporated with the portions of the inferior oblique muscle to be cut. Wescott scissors were used to cut both ends of the muscle. Bipolar cautery forceps were used to cauterize the resected proximal and distal ends of the inferior oblique muscle. The two ends were released and the remaining muscle ends were allowed to retract into the orbit. The conjunctiva was closed using a plain gut suture.
No complications arose during the procedure. Postoperatively, the patient had a subconjunctival hemorrhage, injection, and pain that decreased over the following week. Neomycin-polymyxin-dexamethasone drops were applied daily to prevent infection and inflammation. At the one follow-up, the redness and pain had resolved.
Inferior oblique myectomy effectively treats inferior oblique overaction and vertical strabismus associated with this condition.
Repair of a Non-coronary Sinus of Valsalva Aneurysm Rupture
A brief patient history is given, followed by preoperative imaging, intraoperative repair, and postoperative imaging.
Minimal incision Partial Sternotomy ASD Repair
This video showcases a minimal incision, partial sternotomy exposure for complete ASD patch repair performed at Arkansas Children’s Hospital.
Pulmonary Valve Replacement
This video highlights a pulmonary valve replacement in a patient with Tetralogy of Fallot.
RV-PA Conduit Replacement in d-TGA
Replacement of a stenotic/irregular right ventricle to pulmonary artery Gore-Tex trileaflet graft with a novel KONECT RESILIA Aortic Valved Conduit. This is the only tissue valved conduit currently in use. This patient has d-transposition of the great arteries along with ASD, VSD, pulmonary stenosis, bovine left arch and aberrant right subclavian arteries.
His previous operations include MBTS 4mm Gore-Tex graft, urgent shunt revision secondary to thrombosis and subsequent conversion to a 4mm central shunt, right atrial thrombectomy secondary to indwelling right atrial catheter, takedown of central shunt, primary pledgeted closure of pulmonary valve, Gore-Tex patch closure of ASD/VSD, Rastelli procedure with 24mm Gore-Tex trileaflet with bulging sinuses graft.
Superior Rectus Recession
Muscle recession is a type of strabismus surgical procedure that aims to weaken an extraocular muscle by adjusting its insertion posteriorly closer to its origin. The patient is a 14-year-old with dissociated vertical deviation, which can be corrected with recession of the superior rectus muscle.
A conjunctival incision is made in the fornix. Tenon’s capsule is dissected to expose the superior rectus muscle. The superior rectus muscle is isolated using a Stevens tenotomy hook followed by a Jameson muscle hook. After the remaining Tenon’s attachments are cleared, the muscle is secured at both poles with a double-armed 6-0 VicrylTM suture and double-locking bites. The muscle is then disinserted from the sclera with Manson-Aebli scissors. A caliper is used to mark the predetermined distance of muscle reinsertion. Next, the muscle is reattached to the sclera with partial thickness bites and then tied down to its new location. The conjunctival incision is closed with 6-0 plain gut sutures.
No complications arose during the procedure. Postoperatively, the patient had subconjunctival hemorrhage, injection, and pain that decreased over the following week. Neomycin-polymyxin-dexamethasone drops were applied daily to prevent infection and inflammation. At the three-month follow up, the redness had resolved. The dissociated vertical deviation had improved.
Superior rectus recession is a safe procedure that can effectively treat vertical strabismus.
By: Michelle Huynh
College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
Brita Rook, MD
Arkansas Children’s Hospital – Department of Ophthalmology, Little Rock, Arkansas, USA
Joseph Fong, MD
Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
Video was performed at Arkansas Children’s Hospital, Little Rock, AR, USA.
Redo Posterior Fossa Decompression with Duraplasty for the Treatment of Chiari Type I Malformation
Chiari decompression is a common neurosurgical procedure. Chiari malformations present with a number of symptoms including Valsalva-induced headaches, swallowing dysfunction, and sleep apnea. Chiari malformations can also cause syringomyelia and syringobulbia. Surgical procedures used for the treatment of Chiari malformation include bone-only decompression (posterior fossa craniectomy +/- cervical laminectomy), craniectomy/laminectomy with duraplasty, and craniectomy/laminectomy/duraplasty with shrinkage or resection of the cerebellar tonsils. The procedure used depends on the specifics of the patient’s condition and the preference of the surgeon.
The patient presented here had undergone a prior Chiari decompression at the age of 20 months. This was bone-only with posterior fossa craniectomy and C1-2 laminectomy. The dura was not opened due to the presence of a venous lake. He initially had improvement in his symptoms. However, his headaches and snoring recurred, balance worsened, and dysphagia never improved. Therefore, a repeat Chiari decompression at the age of 28 months was performed as presented here.
Laparoscopic Transposition of Lower Pole Crossing Vessels or ‘The Vascular Hitch’
Contributors: John Loomis (Texas A&M Health Science Center)
Purpose: Relief of UPJ obstruction
Instruments: da Vinci Robotic Surgical System
Landmarks: Retropertionem, ureters, kidney, lower pole crossing vessel
Procedure: The laparoscopic transposition of lower pole crossing vessels, or “vascular hitch”, has been successfully used to relieve purely extrinsic ureteropelvic junction obstruction in both adults and children. This case describes the surgical steps for successfully completing this technique. Our patient is a 7 year old female. After induction of general anesthesia, the patient is placed in the right or left lateral decubitus postion (depending on the affected kidney). Access to the abdomen is accomplished with an infraumbilical incision utilizing a Veress needle, with insufflation and saline drop test. A 12mm port is placed in this incision and 2 robotic ports are placed under direct supervision, one in the midline of the suprapubic region and the other in the midline of the epigastric region, with an additional 5mm assistant port. Release of the liver or splenic attachments, with mobilization of the right and left colon, allows for exposure. After doing so, dissection into the retroperitoneum reveals the ureter, which can then be followed to the UPJ and the vessels of interest. Careful dissection of these vessels, the ureter, and lower pole, allows for mobilization of the crossing vessels to a more cranial point on the renal pelvis. “Hitching” of the vessels to this point is accomplished with interrupted 5-0 PDS, and allows for relief of the UPJ obstruction. The lower pole of the kidney is observed throughout to ensure adequate vascularization after hitching of the crossing blood vessels. Closure of the fascia and skin is accomplished in the usual fashion.
Conflict of Interest: None
References: 1. Sakoda A1, Cherian A, Mushtaq I., “Laparoscopic transposition of lower pole crossing vessels (‘vascular hitch’) in pure extrinsic pelvi-ureteric junction (PUJ) obstruction in children.”, BJU Int. 2011 Oct;108(8):1364-1368. http://dx.doi.org/10.1111/j.1464-410X.2011.10657.x
2. Gundeti MS, Reynolds WS, Duffy PG, Mushtaq I. “Further experience with the vascular hitch (laparoscopic transposition of lower pole crossing vessels): an alternate treatment for pediatric ureterovascular ureteropelvic junction obstruction.”, J Urol. 2008 Oct;180:1832-1836. http://dx.doi.org/10.1016/j.juro.2008.05.055
3. Schneider A, Ferreira CG, Delay C, Lacreuse I, Moog R, Becmeur F., “Lower pole vessels in children with pelviureteric junction obstruction: laparoscopic vascular hitch or dismembered pyeloplasty?”, J Pediatric Urol. 2013 Aug;9(4):419-423. http://dx.doi.org/10.1016/j.jpurol.2012.07.005
Ear Tube Removal and T-tube Replacement
Contributors: Gresham T. Richter (University of Arkansas for the Medical Scienc)
1) Purpose: Untreated Eustachian Tube dysfunction can lead to retraction of the tympanic membrane (TM) and, eventually, an atelectatic middle ear. The insertion of a tympanostomy tube attempts to equalize the air pressure of the middle ear with the environment, allowing for the stabilization of the TM. Bobbin style tubes have an average extrusion time of less than a year while T-tubes remain in place longer but risk residual perforation. (1)
2)Instruments: Rigid endoscopes were used to direct and record the procedure with standard video monitoring. Straight cupped forceps were used to debride the external auditory canal. A myringotomy knife was used to make the myringotomy.
3) Landmarks: After debridement of cerumen, the handle of the malleus and the incudostapedial joint are clearly visualized as indicated with titles in the video. Note that the patient’s tympanic membrane shows an incudostapediopexy and deep retraction which is not the typical tympanic membrane position.
4) Procedure: Cerumen is debrided from the EAC. A myringotomy knife is used to enter the middle ear space which is suctioned. A t-tube is placed, and the position is confirmed.
5) Conflict of Interest and Source of Funding The authors have no financial disclosures.
6) References 1. Weigel MT, Parker MY, Goldsmith MM, Postma DS, Pillsbury HC. “A prospective randomized study of four commonly used tympanostomy tubes.” The Laryngoscope. 1989 Mar;99(3):252-6. http://dx.doi.org/10.1288/00005537-198903000-00003