Needle Entry And Contrast Injection

The site for the first T-fastener is selected. The location should be a reasonable distance from the G tube site (2-3cm if possible). The needle (with T fastener inside) is placed through the skin under fluoro and directed to the gastric wall. As the needle pushes on the wall the indentation will be seen on fluoro if the c-arm is RAO 20-30 degrees. The needle is then advanced into the lumen of the stomach with a short controlled burst of pressure. Once the tip is in the lumen contrast is dripped through the needle under fluoro. The contrast should normally be seen to drip to the stomach wall and the rugal folds will be appreciated. DOI: https://doi.org/10.17797/48sxirkbwp

Endoscopic Management of a Duodenal Web

From the APSA 2016 Annual Meeting proceedings ENDOSCOPIC MANAGEMENT OF A DUODENAL WEB Lauren Wood, BS1, Zach Kastenberg, MD2, Tiffany Sinclair, MD2, Stephanie Chao, MD2, James Wall, MD2. 1Stanford School of Medicine, Palo Alto, CA, USA, 2Lucile Packard Children’s Hospital Stanford, Palo Alto, CA, USA. Introduction: Surgical intervention for duodenal atresia most commonly entails duodenoduodenostomy in the neonatal period. Occasionally, type I duodenal atresia with incomplete obstruction may go undiagnosed until later in life. Endoscopic approach to dividing intestinal webs has been reported in rare select cases. Methods: A two-year old female with a history of trisomy 21 and tetralogy of Fallot underwent laparoscopic and endoscopic exploration of intestinal obstruction as visualized on upper gastrointestinal series for symptoms of recurrent emesis and weight loss. After laparoscopy confirmed a duodenal web as the cause of intestinal obstruction, endoscopic division of the membrane was carried out with a triangle tip electrocautery knife followed by dilation with a 15 mm balloon. Results: The procedure took 210 minutes and the patient tolerated it well. Post-op Upper GI showed rapid passage of contents without leak and a diet was started. The patient was discharged on post-operative day 2 without narcotics. The patient had gained 2 pounds at 4 week follow-up and remains asymptomatic six months after the procedure. Conclusions: Endoscopic management of a duodenal web is feasible in children. Pediatric surgeons are ideally suited to offer the hybrid approach including laparoscopy to confirm no extraluminal obstructive process or complication from endoscopy. Endoscopy enables minimal recovery time and should be embraced as another tool in the minimally invasive toolbox of pediatric surgeons. DOI: https://doi.org/10.17797/pknxvd91zf

FNA Bx Thyroid

Contributors: Geoff Blair Sedation is given even in youths as an FNA biopsy fully awake can be frightening for young patients and it affords a still target. An anesthetist is present to monitor and maintain the airway. A surveillance US is performed based on the images of the detailed previous US. In our institution and in many others the FNA biopsy is performed by qualified interventional radiologists as opposed to pathologists or pediatric surgeons. The field is prepped and draped. Local anesthesia, usually two percent lidocaine with epinephrine is injected with a small 25 gauge needle. The fine needle is then passed and seen on US to enter a solid component of the nodule to be biopsied. It is moved rapidly in and out and then swiftly aspirated to gather an appropriate sampling of cells. This is then expelled onto a waiting glass slides and spray fixative is applied. It is helpful to have the pathology technician on hand to ensure proper plating and fixation of the samples. US guidance may allow for a number of samples from different sites to be obtained safely. Biopsies of suspicious nodal tissue may be obtained as well in the same manner. Samples of nodal aspiration may also be sent for thyroglobulin determination; a marker of probable nodal thyroid carcinoma metastases. A simple bandage is applied at the needle entry sites and the child is allowed to recover from the procedure and sedative in a semisitting position to lessen the chances of postbiopsy bleeding. Discharge home within an hour or two is usual.

T Fastener Deply

Contributors: Marcus Jarboe, MD T-fasteners (pre-loaded into a slotted 18 G needle and fixed to nylon suture) are sequentially advanced using the introducer needle under endoscopic visualization into the stomach. A total of 3-4 concentric T-fasteners are deployed and secured to the skin externally, leaving a central area large enough to accomodate the G-tube. A skin incision is then made in this space between the T-fasteners, and an 18 G needle is inserted into the stomach under endoscopic visualization. A guidewire (preferrably stiff such as Amplatz superstiff -Boston Scientific) is passed through the needle and sequential dilation is performed using Seldinger technique to the diameter of the intended tube. A balloon-based G-tube is then inserted over the guidewire and the balloon is inflated with water per manufacturer guidelines. The external bumper is pulled down against the skin to secure the tube at an appropriate depth.

THORACOSCOPIC DIVISION OF A DOUBLE AORTIC ARCH AND TEF REPAIR THROUGH THE LEFT CHEST IN A PATIENT WITH A DOMINANT RIGHT ARCH

Contributors: Steven S. Rothenberg, MD This video depicts a thoracoscopic division of a double aortic arch and repair of a Tracheo-esophageal fistula (TEF) in a infant with a type 3 TEF and a dominant right arch.

THORACOSCOPIC REPAIR OF ESOPHAGEAL ATRESIA WITH DISTAL TRACHEOESOPHAGEAL FISTULA AND A PROXIMAL TYPE-H TRACHEOESOPHAGEAL FISTULA

A 2,045-gram, ex-35 week female with a history of CHARGE syndrome in mild respiratory distress underwent thoracoscopy for what was preoperatively believed to be a Gross type C tracheoesophageal fistula. After ligation of the distal fistula, ventilation remained challenging and intraoperative flexible bronchoscopy through the endotracheal tube revealed a proximal fistula. The proximal fistula was in an H-type configuration high in the thoracic inlet. The video describes the surgical technique used to repair both fistulae and the esophageal atresia thoracoscopically.

Thyroid Histopathology Examples

The thyroid gland has two capsular coverings. There is an outer fibrous covering that is contiguous with the pretracheal and deep cervical fascia. Beneath this is the true glandular capsule that has involutions on its surface and sends incomplete septae deeper into the substance of the gland that accompanies its blood supply and lymphatics. The thyroid’s microscopic unit is the follicle - an irregularly shaped cell lined structure that surrounds collections of colloidal thyroglobin. Most of a follicle’s lining cells are low cuboidal epithelial cells. Intermixed with the follicular cells, but not abutting the follicles, are the parafollicular C-cells. Thyroid histopathology can be confusing and in some cases to some degree interpretive. It is important that the pediatric thyroid surgeon become conversant with the generalities of thyroid pathology

ULTRASOUND-GUIDED LATERAL APPROACH TO INTERNAL JUGULAR CATHTER PLACEMENT

Contributors: Marcus Jarboe, MD The approach to the internal jugular vein is started adjacent to the clavicle, just lateral to the sternocleidomastoid muscle on the the right side. The ultrasound probe is placed in a transverse fashion cephalad and adjacent to the clavicle. The needle trajectory is in-line with the probe. The lateral approach enables clear and simultaneous visualization of the entire needle and key anatomic structures such as the edge of the lung, the internal jugular vein, and the carotid artery. Second, the approach allows a gentle curve on the catheter when tunneling, avoiding kinks and avoiding tendency of catheter movement in the tunnel pocket when the neck moves. Third, in cases of internal jugular occlusion, the lateral approach makes it possible to access the brachiocephalic vein.

Vascular Video

For a lateral tunneled catheter approach, the hockey-stick linear transducer is placed low, directly above the clavicle. The handle of the transducer is held medially, exposing the lateral end of the transducer for needle alignment, parallel to the clavicle. The internal jugular vein is seen via US, with the carotid artery lying medially. The needle is inserted in-line, beginning just lateral to the sternocleidomastoid (SCM) while being careful not to injury the nearby external jugular vein. The needle is advanced medially, below the SCM, directly into the internal jugular vein, while maintaining in-line full needle visualization throughout.

What are T Fasteners - Enteral Access

The C-arm is then placed in a right anterior oblique (RAO) position of about 20-30 degrees. This allows the stomach wall to be visialized as the needle pushes on and then punctures the gastric wall. The appropriate position for the G tube is selected on the skin surface and marked. Three T-fasteners are then prepared for placement. The T-fasteners will be deployed into the lumen of the stomach and then pulled up to keep the stomach against the anterior abdominal wall while the G tube site is dilated and the tube is placed. DOI https://doi.org/10.17797/qrto4chmgs

Walk Down Down

o safely gain intravascular access using the transverse orientation, the needle is placed at an approximately 45-degree angle perpendicular to the transducer at the midway point. As the needle is advanced, the US probe is used to “walk” down the needle by finding the tip at regular intervals. The ultrasound is slowly moved down the shaft of the needle until just past the tip. At this point the ultrasound will be beyond the tip and the bright needle will disappear from the ultrasound screen. Then to confirm what is be ing seen the ultraosund probe is brought back to the needle and it will again appear as a bright spot on the ultrasound screen. In this way the tip location is knonw and confirmed at all times. Once the tip loaction is assured the needle is advances a small amount and the tip is then found and confirmed again. In this way you can walk the needle down to and well into the vessel lumen in a very precise and reproducible manner

Shadow Clip Over Radial

When using the transverse orientation during needle insertion, extra care must be taken to ensure proper localization of the needle tip. The exact needle entry site can be obtained by placing the needle flat on the skin under the ultrasound probe with a layer of gel in between. This will result in seeing the needle at the top of the screen on ultrasound with a shadow directly below. If the shadow is lined up with the target the needle is in the correct position. That position can then be marked.

RESECTION OF DUODENAL WEB USING HYBRID NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES)

Contributors: Maria Carmen Mora, MD1 We performed an incisionless resection of the duodenal web via the existing gastrostomy site. Initially the plan was to use the endoscope for visualization and the gastrostomy site for instrumentation; however, the endoscope visualization was inadequate. The gastrostomy site was dilated and an extra small wound protector was placed with a sterile glove over it allowing insufflation and access via the fingers for the laparoscope and 3mm instruments. A 70-degree laparoscope was used for visualization. The opening of the web was cannulated using a Fogarthy catheter prolapsing the web towards the stomach. A 3mm hook cautery and then the LigaSure were used to incise and excise the anteriolateral aspect of the duodenal web. Intraoperative CXR ruled out free air. A 1cm 14-French Mickey button was placed at the completion of the procedure. The length of the operation was 100 minutes.

PA Catheter Removal

Many suggest that the catheter fragment is safe to leave in place. However, this is not universally true by any means and catheters do, on occasion, embolize to the pulmonary artery. This has obvious dangers but also makes retrieval more difficult and dangerous. Retrieving the fragment in the SVC is generally a straight-forward procedure for an interventional radiologist and does not leave a foreign body in the SVC.

OPERATIVE VIDEO: ANORECTAL MALFORMATION. RECTOPERINEAL FISTULA WITH VAGINAL AGENESIS

Contributors: Victoria A. Lane, MBChB The video demonstrates the initial examination findings of a vestibular fistula, with a normal vaginal introitus, however on closer inspection the vagina was found to be atretic. Standard mobilization of the rectum was performed in the prone position, followed by a lower midline laparotomy in order to examine the internal gynecological structures. A uterus and cervix were identified, but there was agenesis of the distal vagina. The operative technique for rectal pullthrough and simultaneous vaginal replacement, completion of the neo-vaginoplasty, and anoplasty is shown in the operative video.

On Table Contrast Enema

On initial fluoroscopy, the transverse colon can usually be seen as it contains air. If the colon cannot be visualized, a water-soluble contrast enema can be performed by inserting a Foley catheter into the rectum and infusing contrast by gravity. DOI: https://doi.org/10.17797/a3x82z0hrb

Manipulation of Wire Past Pylorus

Once the wire is in the stomach a 5Fr Kumpe catheter is placed over the wire and the catheter and the wire are manipulated past the pylorus and to the ligament of trietz. If the pylorus is difficult to locate air or contrast can be injected through the catheter to delineate the anatomy. This contrast/air injection can be done throughout the procedure to confirm anatomy and guide in the direction of the course of the bowel. Once the ligament of treitz is reached the wire is exchanged through the catheter for a stiff wire hydrophilic wire. The appropriate GJ tube is selected and placed over the wire into the jejunum. Both the wire and lumen of the tube should be very wet to ensure that friction does not cause problems in tube placement. Balloon should be inflated with diluted contrast (half and half) and pulled back to the anterior abdominal wall and grommet synched down appropriately. Contrast should be injected into the jejunal port and gastric port to confirm the tube is in the appropriate position DOI: https://doi.org/10.17797/wgqh4fbxe3

LNAR Technique

Contributors: Andre Hebra, MD

Lpm Bovie Cut

Contributors: Joe Iocono, MD

LPM Check For Leak

Contributors: Joe Iocono, MD

LPM Spreader

Contributors: Joe Iocono

Lymphatic Malformation around the Airway of Fetus

DOI#: https://doi.org/10.17797/9be9m8q9ca

LAPAROSCOPIC REPAIR OF BILATERAL FEMORAL HERNIAS IN A CHILD

Contributors: Robert J. Vandewalle, MD During the initial laparoscopic examination, hernia defects were noted bilaterally, inferior to the inguinal ligaments and medial to the iliac veins, which was diagnostic for femoral hernias. The hernia sacs were everted and excised with electocautery. Care was taken to identify and preserve the Vas deferens and the iliac vein. The femoral hernia defects were then obliterated by approximating the inguinal and pectineal (Cooper’s) ligaments with 2-0 braided nylon suture. The patient tolerated the procedure well and was discharged home the same day. Operative time was approximately 60 minutes for each hernia defect, for a total time of around 120 minutes.

LAPAROSCOPIC REPAIR OF DIAPHRAGM EVENTRATION

Contributors: Oliver B. Lao, MD, MPH We demonstrate the use of an endostapler in a minimally invasive eventration repair in a pediatric patient. In contradiction to most other reported repairs, we approach the repair in a minimally invasive fashion through the abdomen. We invert the redundant diaphragm downward for our plication given this approach. We feel that this allows for better visualization of the intra-abdominal organs, avoids the pain and thoracostomy tube associated with a thoracoscopic procedure and gives a much more reliable and reproducible result. In addition the procedure can be done, on average, in less than 30 minutes, and it can be done as an outpatient procedure.

LAPAROSCOPIC ASSISTED PSARP FOR RECTO-BLADDERNECK AND HIGH PROSTATIC FISTULA

Contributors:  Andrea Bischoff A video was recorded highlighting the important technical details of a laparoscopic assisted posterior sagittal anorectoplasty for recto-bladderneck fistula. The distal rectum is identified near the peritoneal reflexion, and the peritoneum around it is divided, remaining as close as possible to the rectal wall in order to avoid injuries to vas deferens, ureters, and nerves. The dissection continues circumferentially and distally to the point where it narrows down and meets the bladderneck. The fistula is divided and an endoloop is used to ligate it. Cauterization and division of avascular attachments of the rectum allows gaining of rectal length. The center of the sphincter is determined with the use of an electric stimulator and a minimal posterior sagittal incision is made with the legs elevated. A plane of dissection and a space in front of the sacrum is created, immediately behind the urethra, up to the peritoneal cavity. A laparoscopic dissection is carried out behind the bladder to meet the perineal dissection. The distal rectum is pulled down, assuring the correct orientation. When further rectal dissection is required, selective ligation of the peripheral branches of the inferior mesenteric vessels is performed. The bowel wall should be kept intact to preserve its intramural blood supply. The posterior sagittal incision is closed in layers. The posterior edge of the muscle complex is tacked to the posterior rectal wall which helps to avoid prolapse and the anoplasty is performed.

LAPAROSCOPIC ASSISTED RESECTION OF A TYPE IV SACROCOCCYGEAL TERATOMA IN A 6-MONTH-OLD GIRL

Contributors: Hans Joachim Kirschner, MD A three port technique was used for the minimal invasive approach in supine position. After abdominal dissection of the teratoma, the child was repositioned in a prone jack-knife position. A posterior longitudinal midline incision was carried out to remove the tumor completely.

Lap Distal Panc- Surg Endosc

Laparoscopic distal pancreatectomy is most often performed with four trocars. A hand assist port can be useful in some settings but its use may be limited in younger children with less abdominal domain. Subcostal and perixiphoid trocar positions are modified according to the size of the child. Working ports should accept 5 mm instruments and at least one port should accept endosurgical stapling devices. After achieving pneumoperitoneum, the lesser sac is entered through the gastrocolic ligament and omentum. The pancreas is then explored through the lesser sac. If the spleen is to be preserved, the short gastric vessels are preserved. To gain further exposure of the pancreas, the short gastric vessels can be taken up to the level of the gastroesophageal junction, however splenectomy will then be required if the splenic vessels are sacrificed. The splenic flexure is than mobilized to expose the inferior edge of the tail of the pancreas. The pancreas is then mobilized out of the retroperitoneum by incising the peritoneum from the inferior edge of the pancreas to the inferior pole of the spleen.The pancreatic tail is then mobilized and retracted medially. This dissection allows the splenic artery and vein to be isolated and divided with a vascular stapler or between clips.

Intussusception Reduction

This video shows air being injected into the colon via the rectal tube. It meets the intussusceptum in the transverse colon and reduces it completely. Towards the end of the video you can see air reflux into the terminal ileum

HYDROCOLPOS DRAINAGE IN CLOACA

Contributors: Andrea Bischoff, MD A video was recorded highlighting the important technical details of hydrocolpos drainage in two cloaca patients that had previously underwent a colostomy opening and were left with an undrained hydrocolpos. In one patient, a vesicostomy was also previously performed in an attempt to drain the hydrocolpos, which in retrospect was unnecessary.With an infra-umbilical midline laparotomy or with a left lower quadrant oblique incision used for the colostomy opening, the hydrocolpos can be found behind the bladder. When opening the posterior vaginal wall at the dome, special emphasis should be placed on identification and protection of the uterus. When two hemivaginas are present a window can be created within the vaginal septum to allow for a single tube to drain both hemivaginas. The draining tube should remain in place until the time of the definitive cloacal reconstruction.

G Tube Balloon Endoscopic

For a primary low-profile (button) tube placement, the abdominal wall thickness should be measured using a sizer provided by the manufacturer and an appropriate length button selected. Furthermore, in the case of a button a 7 Fr vascular dilator can be placed through the lumen of the button to facilitate passing over the wire and entering the gastric lumen. After visual confirmation of balloon position, the endoscope can be removed. DOI: https://doi.org/10.17797/5i16tv71x0

G Tube Confirmation Injection

The G tube is then placed over the wire into the stomach. The balloon is inflated with half contrast, half saline and pulled back under fluoro to the abdominal wall and the grommet is synched down appropriately. Contrast should be injected into the G tube to confirm the tube is in the stomach and not past or against the pylorus. Air can be evacuated from the stomach. DOI#: https://doi.org/10.17797/e5fi2tvnd8

Extravasation of Contrast on Fluoroscopic Placement

Note that to make this maneuver safe and easy the stomach must be well inflated with air to allow the needle to penetrate the gastric wall easily. If the contrast is not seen to drip or appears to extravasate then remove the needle from the abdomen and start the process again. After the needle is confirmed to be in the lumen of the stomach the T-fastener is deployed and the suture portion of the T fastener is pulled snug and snapped to the drapes. Two additional T-fasteners are then placed in similar fashion around the G tube site.

ENDOSONOGRAPHY IN PERIRECTAL PROCEDURES

Contributors: Arun Thenappan Here we demonstrate the use of ultrasound in three common perirectal procedures: injection of Clostridium botulinum toxin or BoTox for internal sphincter achalasia or in Hirschsprung’s disease who are suffering from recurrent enterocolitis, sclerotherapy for rectal prolapse, and seton placement in complicated Crohn’s perirectal fistulas.

ARM Perineal Exam And Dilation

N/A

Cysto Cloaca 2 Uteri:2 Vaginas

Contributors: Uteri:2 Vaginas

Pulmonary contusion CT

This is a computerized tomography scan of a severe pulmonary contusion. Author Tony Escobar

Laparoscopic Repair of a Duodenal Atresia and Ladd's Procedure in a Neonate with Malrotation

From the APSA 2011 Annual Meeting proceedings LAPAROSCOPIC REPAIR OF A DUODENAL ATRESIA AND LADDâS PROCE DURE IN A NEONATE WITH MALROTATION Author: Steven S. Rothenberg The Rocky Mountain Hospital For Children, Denver, CO, USA Purpose To demonstrate current refinements of technique in performing a duodenal anastomosis in a neonate with duodenal atresia. This work is IRB exempt. Methods A 33 week premature infant with a prenatal diagnosis of Duodenal atresia was explored laparoscopically on day two of life for repair. The patients weight was 2 Kg. Two 3mm ports and one 4mm port were used for the procedure. The patient was also found to have malrotation at the time of surgery. The procedure consisted of a Laddâs procedure and duodenoduodenostomy. Techniques of abdominal wall retraction sutures are demonstrated. Results The procedure was completed successfully laparoscopically. The procedure took 60 minutes. An NG tube was used for 5 days and feeds were started on post-op day 6. Conclusions This video demonstrates that a laparoscopic duodenoduodenostomy and Laddâs procedure is efficacious and safe even in a small premature.

Thoracoscopic Management of Bilateral Congenital Pulmonary Airway Malformation with Systemic Blood Supply: Use of a Novel 5mm Stapler

from the APSA 2015 Annual Meeting proceedings THORACOSCOPIC MANAGEMENT OF BILATERAL CONGENITAL PULMONARY AIRWAY MALFORMATION WITH SYSTEMIC BLOOD SUPPLY: USE OF A NOVEL 5MM STAPLER Authors: Sandra M. Farach, MD, Paul D. Danielson, MD, Nicole M. Chandler, MD. All Childrenâs Hospital Johns Hopkins Medicine, Saint Petersburg, FL, USA. Purpose: Congenital pulmonary airway malformations (CPAM) and bronchopulmonary sequestrations (BPS) are two commonly discussed congenital lung malformations (CLM). We present a case of bilateral thoracoscopic lobectomy in a patient with bilateral, combined CPAM and BPS and report the novel use of a 5 mm linear stapling device. Methods: This is a retrospective review of a 9-month-old female patient with bilateral, combined CPAM and BPS who underwent bilateral thoracoscopic lower lobectomy. Results: The left lower lobectomy is demonstrated in this video. This was performed via a modified lateral position with the left side up using two 3 mm ports and two 5 mm ports. The lower lobe was resected cephalad. The systemic vessel was identified and secured. Polymer clips were placed, and the vessel was divided with a 5 mm stapling device. The pulmonary artery was divided with a vessel sealing instrument. The pulmonary vein was identified and was divided with the 5 mm stapler after endoscopic clips were placed. The bronchus was then identified and was divided with the 5 mm stapler. The most inferior port was removed and the incision widened to allow for extraction of the specimen. A 12 French chest tube was inserted into the left chest cavity under direct visualization. Total operative time was 146 minutes. The patient did well and was discharged on post-operative day two. Pathology revealed intralobar pulmonary sequestration with pulmonary systemic and pulmonary artery hypertensive changes and congenital cystic pulmonary airway malformation Type I. Conclusion: The literature has reported good outcomes with thoracoscopic lobectomy for congenital airway malformations. We present a successful case of bilateral thoracocsopic lobectomy for a rare finding of bilateral, combined CPAM and BPS as well as the effectiveness and safety of using a 5 mm linear stapling device.

laparoscopic pancreatectomy Dr Laje

Laparoscopic resection of a focal lesion of congenital hyperinsulinism.

Laparoscopic Partial Splenectomy

This edited video demonstrates the techniques of splenic hilar branch vessel sealing, parenchymal transection and hemostasis along the cut surface of the retained spleen segment.  It should be inserted into the APSA NAT chapter on "Splenectomy" Courtesy of Marcus Jarboe, MD

Pediatric Cervical Spine Injury

Video courtesy of: Christoper Corkins, MD Alfred Trappey, MD Ian Mitchell, MD

Laparoscopic right adrenalectomy

Author: Brent Weil

INDOCYANINE GREEN FLUOROESCENCE CHOLANGIOGRAPHY DURING LAPAROSCOPIC CHOLECYSTECTOMY

from the APSA 2017 Annual Meeting proceedings INDOCYANINE GREEN FLUOROESCENCE CHOLANGIOGRAPHY DURING LAPAROSCOPIC CHOLECYSTECTOMY Claire Graves, MD1, Olajire Idowu, MD2, Christopher R. Newton, MD2, Sunghoon Kim, MD2. 1UCSF Benioff Children’s Hospital, San Francisco, CA, USA, 2UCSF Benioff Children’s Hospital, Oakland, CA, USA. Purpose: Laparoscopic cholecystectomy is a common procedure performed by pediatric surgeons. Though  rare, with an incidence of approximately 0.4%  in the pediatric population, bile duct  injury is a serious complication often requiring  complex reconstruction. Aberrant  or distorted anatomy often contributes to biliary injuries, and  accurate identification of the anatomy is paramount. Indocyanine Green  (ICG) fluorescence, visualized  with near-infrared (NIR) imaging,  improves visualization and provides detailed anatomical mapping of the biliary structures. Though  increasingly used in adults via intravenous administration, this video demonstrates the first human use  of ICG injected directly into the gallbladder during laparoscopic cholecystectomy. Methods: Our patient is a 17-year-old female  who presented with biliary colic. A 0.25mg/ml ICG solution  is prepared on the surgical  backtable. A laparoscopic tower with NIR imaging  capability is used. After traditional  4-port  access is obtained, a needle- tip cholangiogram catheter is used to puncture the infundibulum of the gallbladder. 9ml of bile is drained and  mixed with 1ml of the ICG solution  to create a 0.025  mg/ml ICG and bile solution. The ICG and  bile solution  is then  re-injected into the gallbladder. The pre-mixed solution  fluoresces under  NIR light immediately upon  injection  with no lag time, quickly filling the gallbladder and  extrahepatic biliary system. Results: ICG fluorescence aids  significantly  in the visualization of the gallbladder, cystic duct  and  common bile duct.  When dissecting the gallbladder from the liver bed, this technique shows a well-defined plane  and  can  be used to identify accessory bile ducts. Conclusion: We demonstrate the first case of direct  administration of ICG into the gallbladder during laparoscopic cholecystectomy. This technique is safe,  avoids radiation and  can  be easily adopted by surgeons to improve  visualization of the biliary tree.

A TECHNIQUE TO PREVENT BAR DISPLACEMENT IN THE NUSS PROCEDURE

A TECHNIQUE TO PREVENT BAR DISPLACEMENT IN THE NUSS PROCEDURE Claire E. Graves, MD1, Andrew Phelps, MD1, Olajire Idowu, Jr., MD2, Sunghoon Kim, MD2, Benjamin E. Padilla, MD1. 1University of California, San Francisco Benioff Children’s Hospital, San Francisco, CA, USA, 2University of California, San Francisco Benioff Children’s Hospital, Oakland, CA, USA. Purpose: Bar displacement is a serious complication of the Nuss  procedure. Three types of displacement have  been well described: lateral sliding, bar flipping and posterior disruption. We propose a simple  modification in bar placement and  fixation that safeguards against all three  mechanisms of displacement. Methods: Nuss  bar length  is chosen to extend just beyond the pectus ridge on each side.  Using the external bar bender, we make  a gentle  curve on each side  of the bar, corresponding to the peak  of each pectus ridge.  The ends of the bar are left straight. After the bar is inserted and  flipped,  a stabilizer  is placed on each end  and  slid medially, just lateral to the chest wall insertion site. After the stabilizers are in position, in situ bar benders are used to complete the curvature of the bar around the chest wall. Results: This technique addresses all three  methods of displacement (Fig.1). Lateral sliding is prevented by locking the stabilizers in place with in situ bending just lateral to the chest exit site (A). The bar cannot move laterally as the stabilizers abut  the chest wall exit site (B). Placing  the stabilizers more  medially positions them  at the inflection point where  the ribs angle  superiorly. Thus the stabilizers straddle two ribs on the anterior chest (C). The stabilizers therefore have  a broader base of support, preventing bar flipping. Finally, placing  the stabilizers more  anterior  allows them  to directly counteract the posterior pressure on the bar from the sternum. Instead of relying on the intercostal musculature, the ribs themselves serve  to support the stabilizers and bar from posterior dislocation. Conclusion: We report  a technical modification of pectus bar placement and stabilization to minimize the risk of three  common mechanisms of displacement.

ROBOTIC LONGITUDINAL PANCREATICOJEJUNOSTOMY (PEUSTOW) FOR CHRONIC PANCREATITIS IN AN ADOLESCENT

From the APSA 2017 Annual Meeting proceedings ROBOTIC LONGITUDINAL PANCREATICOJEJUNOSTOMY (PEUSTOW) FOR CHRONIC PANCREATITIS IN AN ADOLESCENT Anna F. Tyson, MD, MPH, Daniel A. Bambini, MD, John B. Martinie, MD. Carolinas Medical Center, Charlotte, NC, USA. Purpose: A fifteen-year-old Hispanic girl presented with a brief history of nausea, vomiting and  severe abdominal pain. She  had  no prior episodes of pain, but reported a remote history of blunt abdominal trauma from a bicycle  handle injury. Workup revealed evidence of chronic  pancreatitis with diffuse calcifications throughout the pancreas and  a dilated, tortuous pancreatic duct.  This abstract describes robotic  longitudinal pancreaticojejunostomy for management of her disease. Methods: After thorough and  appropriate preoperative workup,  the patient underwent robotic  longitudinal  pancreaticojejunostomy. This was  accomplished using  three  8mm and  two 12mm  ports. The gastrocolic omentum was  opened using  a vessel sealing device, and  the stomach was  suspended. The pancreatic duct  was  identified  using ultrasound and  opened using  monopolar scissors. A Roux limb was  created 20cm  distal to the ligament of Treitz and  brought retrocolic to form the pancreaticojejunostomy. The side-to-side jejunal enteroenterostomy was  created using  a robotic  stapler and  the common enterotomy was  sutured closed. Finally, the longitudinal pancreaticojejunostomy was  sutured using  a series of running monofilament absorbable barbed sutures. Results: The patient tolerated the procedure well. Amylase level from the surgically placed drain was  normal  after eating, and  the drain was  removed prior to discharge on postoperative day five. She  has  subsequently been seen in clinic and  is doing  well 3 months out from surgery. She  has  no pain with eating  and  has  returned to her normal activities. Conclusions: Surgical  treatment of chronic  pancreatitis in children  is rare and  is difficult to perform  using  traditional  laparoscopic techniques. We conclude that totally robotic longitudinal  pancreaticojejunostomy is a safe  and  effective  option  for management of chronic  pancreatitis with a dilated  distal pancreatic duct  in appropriately sized  children. This minimally-invasive technique allows a faster  recovery and  improved cosmesis compared to a traditional  open approach.

Laparoscopic Assisted Gastric Pull-up for Long-gap Esophageal Atresia - Technical Aspects

Contributors: Kamal Dev LAPAROSCOPIC ASSISTED GASTRIC PULL-UP FOR LONG-GAP ESOPHAGEAL ATRESIA - TECHNICAL ASPECTS Hans Joachim Kirschner, MD, Joerg Fuchs, MD. University Children’s Hospital Tuebingen, Tuebingen, Germany. Purpose: We present the case of a four-month-old boy undergoing laparoscopic assisted gastric pull-up for long-gap esophageal atresia without fistula. The patient was an extremely low weight birth infant with a birth weight of 670 gr (gestational age 24 6/7 weeks). Sump suction drainage of the upper pouch and gastrostomy were performed initially. The esophageus showed no sufficient length after 4 months. Therefore, decision was taken to perform a laparoscopic assisted gastric pull-up. Methods: A three port technique was used for the minimal invasive approach. After abdominal dissection of the stomach, the midline tunnel was created laparoscopically through the hiatus window. The stomach was transferred through the extended subumbilical port incision and was prepared for the pull-up extracorporeally. A dilatation balloon catheter was inserted through the site of the gastrostomy for controlled dilatation of the pyloric muscle to avoid pyloroplasty. The upper esophageal pouch was dissected and the gastric pull-up and the anastomosis were performed through a cervical incision. Results: The postoperative course was uneventful. X-Ray contrast study and repeated esophagogastroscopy showed an adequate opening of the pylorus and absence of anastomosis stricture postoperatively. Oral feeding was uneventful after successful physiotherapy for swallowing Conclusion: Laparoscopic assisted gastric pull-up can be carried out safely in small infants. This video highlights the essential steps of the procedure. DOI: https://doi.org/10.17797/hjl4mzq5lt

Thoracoscopic Repair of a Symptomatic Congenital Cervical Lung Herniation

THORACOSCOPIC REPAIR OF A SYMPTOMATIC CONGENITAL CERVICAL LUNG HERNIATION Stephen J. Fenton, MD, Justin H. Lee, MD. University of Utah School of Medicine, Salt Lake City, UT, USA. Purpose: Congenital cervical lung herniation is an extremely rare cause of stridor and dysphagia. It more often occurs on the right and results from the disruption of Sibson’s fascia that allows for apical lung parenchyma to herniate into the neck. There is a known association with Vitamin E deficiency, cleft lip and palate, and Cri-du chat syndrome. Surgical intervention is rarely required for spontaneous pneumothorax, stridor, dysphagia, or cosmetic issues due to the incarcerated lung tissue. Methods: We report the thoracoscopic treatment of an infant with symptomatic congenital cervical lung herniation. Results: A previously healthy 9 month-old girl was evaluated with a several week history of progressive stridor and dysphagia. The stridor was more pronounced with crying and especially noted with crawling. The parents stated that she could not crawl for prolonged distances due to increased work of breathing. She was also noted to have dysphagia and would choke while feeding unless held upright. The child appeared healthy with normal vital signs and was noted to have stridor on exam. Plain films of the neck demonstrated herniation of the right lung apex into the thoracic inlet with significant displacement of the trachea. The child underwent an elective thoracoscopic repair. An opening below the Azygous vein was identified that allowed for herniation of an apical lobe into the neck. Inflation of this trapped lobe caused displacement of the esophagus and trachea to the contralateral side resulting in her symptoms. The hernia was opened by division of the Azygous vein and Sibson’s fascia. The apical lobe was resected and the area reinforced with placement of biologic mesh. She had an unremarkable post-operative course with resolution of her dysphagia and significant improvement in her stridor allowing for normal activity. Conclusions: A thoracoscopic approach to repair symptomatic congenital cervical lung herniation is feasible.

Minimally Invasive Repair of Pectus Carinatum

MINIMALLY INVASIVE REPAIR OF PECTUS CARINATUM Robert Kelly, MD1, Sherif Emil, MD, CM2. 1Children’s Hospital of the King’s Daughters; East Virginia Medical School, Norfolk, VA, USA, 2Montreal Children’s Hospital; McGill University Health Centre, Montreal, QC, Canada. Pectus carinatum is a chest wall anomaly amenable to correction by a number of surgical and non-surgical techniques. Minimally invasive repair of pectus carinatum, also unknown as the Abramson or reverse Nuss procedure, is an innovative technique that can achieve correction without major cartilage resection, large incisions, or prolonged bracing. Like other innovative techniques, the operation has gone through several technical problem-solving stages, and has yet to be adopted widely. We present a high fidelity video that illustrates the required equipment and surgical maneuvers necessary to optimize safety and outcome of this new technique. The results in two teen-age boys are demonstrated. DOI: https://doi.org/10.17797/fo5h3wx5hz

Intercostal Cryoablation: a Novel Method of Pain Management for the Nuss Procedure

From the APSA 2016 Annual Meeting proceedings INTERCOSTAL CRYOABLATION: A NOVEL METHOD OF PAIN MANAGEMENT FOR THE NUSS PROCEDURE Y. Julia Chen, MD, Benjamin Keller, MD, Jacob Stephenson, MD, Amy Rahm, MD, Rebecca Stark, MD, Shinjiro Hirose, MD, Gary Raff, MD. University of California, Davis Medical Center, Sacramento, CA, USA. Purpose: Achieving adequate analgesia in patients undergoing the Nuss Procedure for pectus excavatum is a significant determinant of postoperative recovery. Pain management strategies have evolved throughout the last decade, however there is no consensus on the optimal regimen. Practice varies according to institution and surgeon. Intercostal cyroanalgesia has been described in the literature for long-term management of post thoracotomy pain syndrome and has been established as safe and feasible in the adult population. The aim of this video is to introduce the usage of intercostal cryoablation as a novel method of pain control in children undergoing the Nuss Procedure for pectus excavatum. Methods/Results: We demonstrate operative footage and describe the technique of intraoperative intercostal nerve ablation during the Nuss Procedure. Using the cyroanalgesia probe T3-T6 are ablated bilaterally under direct visualization with the thoracoscope prior to insertion of the Nuss bar. This provides immediate and durable postoperative analgesia. Using this method, the need for thoracic epidural has been eliminated from our practice and patients are fast-tracked with decreased length of stay. There have been no complications reported related to cryoablation in the 6 months that we have used this technique. Conclusions: Intraoperative bilateral intercostal cryoablation is a safe and feasible method of pain control in children with pectus excavatum undergoing the Nuss Procedure. DOI:https://doi.org/10.17797/9s1mvk79sn

Anorectal Malformation, Rectoperineal Fistula with Vaginal Agenesis

From the APSA 2016 Annual Meeting proceedings OPERATIVE VIDEO: ANORECTAL MALFORMATION. RECTOPERINEAL FISTULA WITH VAGINAL AGENESIS Victoria A. Lane, MBChB, Richard J. Wood, MD, Carlos Reck, MD, Geri Hewitt, MD, Marc A. Levitt, MD. Nationwide Children's Hospital, Columbus, OH, USA. Purpose: We present the operative video of a female infant with a rectoperineal fistula with associated vaginal agenesis, who underwent reconstruction of the anorectal malformation and vaginal replacement. Methods: The case of a 6 month old female with a rectoperineal fistula and associated vaginal agenesis is presented. VACTERL screening identified an ASD and a dysplastic thumb. No spinal or renal anomalies were found and her sacrum was normal (Sacral ratio 1.0). At 7 months she underwent operative repair of the rectoperineal fistula and sigmoid colon vaginal replacement. The video demonstrates the initial examination findings of a vestibular fistula, with a normal vaginal introitus, however on closer inspection the vagina was found to be atretic. Standard mobilization of the rectum was performed in the prone position, followed by a lower midline laparotomy in order to examine the internal gynecological structures. A uterus and cervix were identified, but there was agenesis of the distal vagina. The operative technique for rectal pullthrough and simultaneous vaginal replacement, completion of the neo-vaginoplasty, and anoplasty is shown in the operative video. Results: One month after surgery the patient underwent an examination under anesthesia and vaginoscopy. The vaginal replacement was found to be healthy and a cervical dimple was seen. The anoplasty had healed well. Conclusions: Vaginal atresia is thought to occur in 5-10% of female patients with a rectoperineal/vestibular fistula. These patients require careful inspection of the perineum as the anomaly can be easily missed. The optimal timing of vaginal replacement has not been clearly established, but when rectal mobilization is required, there is a potential technical advantage to simultaneously completing the vaginal pullthrough.

Transanal Resection, How to Avoid Fecal Incontinence

from the APSA 2010 Annual Meeting proceedings TRANSANAL RESECTION, HOW TO AVOID FECAL INCONTINENCE Author: Alberto Pena, MD, Andrea Bischoff, MD, Marc A. Levitt, MD Cincinnati Children Hospital, Cincinnati, OH, USA Purpose: Transanal resection of the rectosigmoid is a valuable technique applicable for Hirschsprungâs disease, non-manageable idiopathic constipation, and idiopathic rectal prolapse. However, it represents a risk of producing damage to the continence mechanism. A series of important technical steps are crucial to avoid damage to the anal canal and sphincters. These are shown in a short video. Methods: In operations designed to remove the rectosigmoid and pull-through a new portion of colon it is mandatory to preserve the patientâs continence mechanism. This is achieved by avoiding damage to the sphincter and preserving the anal canal for up to 2 centimeters above the pectinate line. Damage to the continent mechanism can result from inadvertently resecting part, or the entire anal canal, leaving the patient without sensation. In addition, the striated sphincter mechanism may be resected or overstretched. Results: Over a period of ten years, 13 patients from other institutions were referred suffering from fecal incontinence following a transanal rectosigmoid resection. An examination under anesthesia demonstrated that the anal canal was non-existent or seriously damaged. During the same period of time we have done 125 transanal resections of the rectosigmoid and have made every effort to preserve intact the continence mechanism. As a result, we developed a series of technical recommendations that include: a) use of a Lone-Star retractor, b) placing and then replacing the eight hooks deeper so that the pectinate line is protected and hidden, c) placing multiple fine sutures on the rectal wall to apply uniform traction, d) starting the resection two centimeters above the pectinate line, e) avoiding overstretching of the anus using a three point exposure technique (one narrow malleable, a forceps or suction tip, and rectum; forming a triangle). Conclusions: With these technical maneuvers a transanal rectal and rectosigmoid resection can be performed preserving the continence mechanism.

Laparoscopic Nephrectomy for Wilms Tumor in a One-Year Old Girl

From the APSA 2011 Annual Meeting LAPAROSCOPIC NEPHRECTOMY FOR WILMS TUMOR IN A ONE YEAR OL D GIRL Authors:

• Guido Seitz, MD
• Steven W. Warmann, MD
• Martin Ebinger, MD
• Falko Fend, MD
• Jrg Fuchs, MD
• University Children`s Hospital, Tuebingen, Germany,
• University Hospital, Department of Pathology, Tuebingen, Germany

Percutaneous Endoscopically Assisted Repair (PEAR) of Inguinal Hernia

from the APSA 2015 Annual Meeting proceedings FROM BENCHTOP TO BEDSIDE: EVOLUTION OF THE MODERN LAPAROSCOPIC PEDIATRIC INGUINAL HERNIA REPAIR Author: Nicholas E. Bruns, MD, Todd A. Ponsky, MD. Akron Children's Hospital, Akron, OH, USA. Purpose: Laparoscopic pediatric inguinal hernia repair is an evolving procedure. We have previously shown certain maneuvers in the laparoscopic high ligation improve efficacy in the animal model. The purpose of this video presentation is to define a laparoscopic technique in children that provides equivalent efficacy of the open repair and to implement elements of the technique that were learned from an animal model. Methods: Based on animal research, braided suture and peritoneal injury have been suggested to improve durability of repair in the animal model likely by stimulating inflammation and scar tissue. We have thus modified Patkowskiâs method of percutaneous internal ring suturing to include the use of braided suture and peritoneal thermal injury. Results: This technique anecdotally has shown to be durable and effective. Conclusions: This technique is safe and efficacious for indirect inguinal hernia repair in children and may show promise in adults. Further study is needed to determine long term outcomes.

FB removal from Esophagus

Walaa Elfar, MD Upper endoscopy and esophageal FB removal chapters

Normal upper endoscopy

N/A

Laparoscopic G Tube

Author:  Karen Elizabeth Speck

Augmented Reality In A Hybrid Or For Pulmonary Nodule Localization And Thoracoscopic Resection - Feasibility Of A Novel Technique

from the APSA 2018 Annual Meeting proceedings AUGMENTED  REALITY IN A HYBRID OR FOR PULMONARY NODULE LOCALIZATION AND THORACOSCOPIC RESECTION - FEASIBILITY  OF A NOVEL TECHNIQUE John M. Racadio,  MD, Meera Kotagal, MD, Nicole A. Hilvert, RT(R)(VI), Andrew M. Racadio, BS, Daniel von Allmen, MD. Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA. Purpose:  To assess the feasibility of utilizing a novel technique of augmented reality on a hybrid operating  room C-arm system  for image-guided localization and thoracoscopic resection of pulmonary  nodules. Methods: After obtaining IACUC approval,  silicone pulmonary  nodules were created and subsequently localized in a swine model in our research lab equipped as a hybrid operating room. Four optical cameras embedded in a C-arm system  allowed video co- registration  with a C-arm cone  beam  CT. Skin marker fiducials allowed for optical tracking and motion compensation. An integrated navigation system  enabled optically guided nodule localization without the need  for fluoroscopy,  thus reducing  radiation exposure. The optical augmented reality navigation was used  to both create and localize nodules. Localization was performed with microcoils. Thoracoscopic resection of the nodules was accomplished using direct visualization and fluoroscopic guidance. Results: As demonstrated in the video, realistic pulmonary  nodules were created and imaged  using the C-arm cone  beam  CT and an optical/image guidance system  to direct placement. Lesions  were accurately localized using optical/image guidance, enabling placement of microcoils  at the nodules.  Combined  thoracoscopic and fluoroscopic guidance allowed accurate wedge  resection of the nodules. Conclusions: Injection of silicone creates a realistic pulmonary  nodule  model. Image guidance using emerging  technology combining radiographic and optical imaging is effective in creating  and localizing pulmonary  nodules.  Real-time imaging combined with thoracoscopic visualization facilitates wedge  resection of nodules marked  with microcoils. The hybrid operating  room simplifies the radiographic localization and resection of pulmonary  nodules by eliminating the need  to move the patient from radiology to the operating  room. A collaborative approach combining the skill sets  and technologies of Interventional Radiology and Surgery  offers new opportunities for image guided  surgery.

Pelvic Fracture

This video is a 3D formatted CT scan of a 14 yo girl that was ejected from a car during a motor vehicle crash. She had the following pelvic fractures: 1) Open tilt fracture of the left superior and inferior pubic rami 2) Open fracture of right superior and inferior pubic rami 3) Open anterior pubic symphysis diastasis 4) Closed displaced right sacral fracture dislocation 5) Closed displaced left sacroiliac joint fracture dislocation. Author Shannon Longshore Please place this in the Assessment section of the pelvic fracture module.

Forced Sternal Elevation as an Adjunct to the Nuss Procedure for Pectus Excavatum

From the APSA 2016 Annual Meeting proceedings FORCED STERNAL ELEVATION AS AN ADJUNCT TO THE NUSS PROCEDURE FOR PECTUS EXCAVATUM Barry LoSasso, MD, Gerald Gollin, MD. Rady Children's Hospital and Sharp Memorial Medical Center, San Diego, CA, USA. Purpose: During most Nuss procedures, the dissector can be passed deep to the sternum in a manner that is safe and that allows for the tip of the instrument to exit the chest wall within 2 centimeters of the sternum. In some cases, proper passage of the dissector is prohibitively difficult and forced sternal elevation has been described as an adjunct. We present a video that demonstrates forced sternal elevation using the Ruhltract retractor. Procedure: The case presented in this video is that of an adult male, but the mechanical challenges are similar to older teenagers in whom we have used forced sternal elevation. In this patient, the Haller index was 5.2 and the excavatum defect was very asymmetric. Thoracoscopy demonstrated a deep and sharply angulated sternal defect that precluded safe and effective substernal dissection. A tenaculum was carefully placed by assuring deep entry of each side into the lateral sternum. The tenaculum was slowly clamped and connected to a wire loop and then to the snap clip of the Ruhltract. The Ruhltract rachet was then slowly turned to gradually retract the sternum anteriorly. Thoracoscopy after sternal retraction demonstrated a substantial correction of the pectus deformity which allowed for wide dissection between the sternum and pericardium. The dissector was then easily passed under the sternum and pushed through the corresponding left intercostal space one centimeter from the edge of the sternum. The pectus bar was then passed through the mediastinum. Conclusions: Use of forced sternal elevation can be a useful adjunct to Nuss repair in adult patients, in adolescents with particularly deep and asymmetric defects, and in re-do cases. In addition, as a surgeon gains experience with the Nuss operation, sternal elevation can offer an extra margin of safety during substernal dissection and passage of the dissector and bar. DOI: https://doi.org/10.17797/l3k45714ep