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.

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

Pulmonary Valve Replacement

This video highlights a pulmonary valve replacement in a patient with Tetralogy of Fallot.

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.

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.

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

Pulmonary Valve Replacement

This video highlights a pulmonary valve replacement in a patient with Tetralogy of Fallot. 

Robotic-Assisted Right Middle Lobectomy of Central Lung Tumor

Contributors: Inderpal S Sarkaria This is a video of a 61 year old female with a history of smoking, TIA, and DVT undergoing robotic-assisted right middle lobectomy for a central and FNA-proven lung adenocarcinoma. DOI: http://dx.doi.org/10.17797/235p3c90cc

Robotic Pelvic Lymph Node Dissection

Contributors: Kristina Butler, MD and Javier Magrina, MD Pelvic lymphadenectomy is part of most gynecologic malignancy staging procedures. Knowledge of the retroperitoneal anatomy is key to safely completing this procedure. DOI: http://dx.doi.org/10.17797/5xzrp8fuk3 Editor Recruited By: Dennis S. Chi, MD, FACOG, FACS

Video Assisted Thoracoscopic Thymectomy Langerhans Cell Histiocytosis

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

Thoracoscopic Division of a Vascular Ring in a Child

Contributors:Curt S. Koontz This video details the thoracoscopic division of a vascular ring in a child presenting with dysphagia. This is a safe and effective technique that minimizes the potential complications and cosmetic issues associated with a thoracotomy. DOI#: https://doi.org/10.17797/ohknzpzkwi

Ultrasound Guided Thoracoscopic Dental Extraction

Contributors: Rodrigo Ruiz and Adele Brudnicki We present a minimally invasive approach for removal of an aspirated tooth that was not extractable via rigid / flexible bronchoscopy. The multimodal technique results in a successful extraction via non-anatomic wedge resection of the affected portion of the lung and thereby obviates the need for a formal lobectomy.

Total Calvarial Reconstruction for Increased Intracranial Pressure and Chiari Malformation

This procedure is a total calvarial vault expansion to correct pansynostosis in a three-year-old child. Total calvarial reconstruction is an open procedure that consists of removing bone flaps with an osteotome, outfracturing the skull bone edges with a rongeur to allow for future expansion, shaving down the bone flap inner table with a Hudson brace to create a bone mush for packing the interosseus spaces, and modifying then reattaching the bone flaps with absorbable plates and screws. This patient is status post craniofacial reconstruction for earlier sagittal synostosis. Second operations are uncommon after correction of single-suture synostosis, so this more aggressive technique represents an attempt to definitively correct the calvarial deformity and resolve the signs and symptoms of the attendant intracranial hypertension. Indications for surgery include cosmetic and neurologic concerns, here including a Chiari malformation and cervicothoracic syrinx. This educational video is related to a current research project of the Children’s National Medical Center Division of Neurosurgery regarding single-suture craniosynostosis and the factors that place children at risk for surgical recidivism in the setting of intracranial hypertension. Kelsey Cobourn, BS - Children's National Medical Center Division of Neurosurgery and Georgetown University Owen Ayers - Children's National Medical Center Division of Neurosurgery and Princeton University Deki Tsering, MS - Children's National Medical Center Division of Neurosurgery Gary Rogers, MD, JD, MBA, MPH - Children's National Medical Center Division of Plastic and Reconstructive Surgery and George Washington University School of Medicine Robert Keating, MD - Children's National Medical Center Division of Neurosurgery and George Washington University School of Medicine (corresponding author)

Robotic-Assisted Posterior Mediastinal Mass Resection

A 34-year-old non-hypertensive, obese female with a history of smoking, asthma, fibromyalgia presented at the ED with hemoptysis, dyspnea, and emesis for two weeks. At presentation the patient was afebrile, vital signs were stable and labs showed unremarkable CBC and BMP. Chest X-ray showed an abnormal soft tissue density within the subcarinal region. A follow-up chest CT with contrast revealed a posterior mediastinal mass measuring 5.4 cm x 3.6 cm in size with well-circumscribed borders. The patient was referred to cardiothoracic surgery for complete excision of the mass. She underwent robotic-assisted posterior mediastinal mass resection.

Open Tracheotomy in Ventilated COVID-19 Patients

Authors Carol Li, MD1*, Apoorva T. Ramaswamy, MD1*, Sallie M. Long, MD 1 , Alexander Chern, MD 1 , Sei Chung, MD 1 , Brendon Stiles, MD 2 , Andrew B. Tassler, MD 1 1Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY 2Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY *Co-First authors Overview The COVID-19 pandemic is an unprecedented global healthcare emergency. The need for prolonged invasive ventilation is common amid this outbreak. Despite initial data suggesting high mortality rates among those requiring intubation, United States data suggests better outcomes for those requiring invasive ventilation. Thus, many of these patients requiring prolonged ventilation have become candidates for tracheotomy. Considered aerosol generating procedures (AGP), tracheotomies performed on COVID-19 patients theoretically put health care workers at high risk for contracting the virus. In this video, we present our institution’s multidisciplinary team-based methodology for the safe performance of tracheotomies on COVID-19 patients. During the month of April 2020, 32 tracheotomies were performed in this manner with no documented cases of COVID-19 transmission with nasopharyngeal swab and antibody testing among the surgical and anesthesia team. Procedure Details The patient is positioned with a shoulder roll to place the neck in extension. The neck is prepped and draped in a sterile fashion with a clear plastic drape across the jawline extending superiorly to cover the head. An institutional timeout is performed. The patient is pre-oxygenated on 100% FiO2. A 2-cm vertical incision is made extending inferiorly from the lower border of the palpated cricoid cartilage. Subcutaneous tissues and strap muscles are divided in the midline. When the thyroid isthmus is encountered, it is either retracted out of the field or divided using electrocautery. The remaining fascia is then cleared off the anterior face of the trachea. Prior to airway entry, the anesthesiologist pauses all ventilation and turns off oxygen flow. The endotracheal tube (ETT) is advanced distally past the planned tracheotomy incision, without deflating the cuff, if possible. If necessary, the endotracheal cuff is deflated partially to advance the tube, with immediate reinflation once in position. The surgical team then creates a tracheotomy using cold steel instruments. The cricoid hook is placed in the tracheotomy incision and retracted superiorly for exposure of the lumen. The tube is withdrawn under direct visual guidance, without deflating the endotracheal cuff if possible. The tracheotomy tube is placed, and to minimize aerosolization of respiratory secretions, the cuff is inflated prior to re-initiation of ventilation. The tracheotomy tube is then sewn to the skin using 2-0 prolene suture. A total of five simple stitches are placed around the tube to prevent accidental decannulation. Indications/Contraindications Candidacy for tracheotomy was determined on a case by case basis with consideration for progression of ventilator weaning, viral load, and overall prognosis. All patients who underwent tracheotomy were intubated prior to the surgery for a minimum of 14 days, able to tolerate a 90-second period of apnea without significant desaturation or hemodynamic instability, and expected to recover. Optimal ventilator settings included FiO2

Non-fenestrated Extracardiac Fontan

This video demonstrates a non-fenestrated extracardiac fontan. This is the final step in palliation of hypoplastic left heart syndrome. Authors: Ethan Chernivec; Chris Eisenring, ACNP-BC; Lawrence Greiten, MD; Brian Reemtsen, MD. Arkansas Children's Hospital, Department of Pediatric Cardiothoracic Surgery, Little Rock, AR University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR

Closure of a Large Secundum ASD

Institution: University of Arkansas for Medical Sciences Authors: Thomas Heye - teheye@uams.edu Lawrence Greiten MD - lgreiten@uams.edu Christian Eisenring ACNP-BC - EisenringC@archildrens.org

Transannual Patch Repair of Tetralogy of Fallot

Institution: University of Arkansas for Medical Sciences Authors: Thomas Heye - teheye@uams.edu Lawrence Greiten MD - lgreiten@uams.edu Christian Eisenring ACNP-BC -EisenringC@archildrens.org

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.

Aortic Valve Replacement via the Ross Procedure

A brief patient history is provided, followed by preoperative imaging, intraoperative repair, and postoperative imaging.

Robotic Assisted Repair of Morgagni Hernia

Contributors: Thomas Bauer, MD and Glenn Parker, MD Up to 25 % of diaphragmatic hernias may be incidentally diagnosed in adulthood. If symptomatic, patients often present with epigastric pain, chest pain or persistent cough. When found, they should be repaired to prevent incarceration and strangulation. DOI #: http://dx.doi.org/10.17797/wy2y9m77gv

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.

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.

Surgical insertion of a chest tube

Insertion of a chest tube is a common procedure. Indications count pneumo- and hemothorax among others; and in acute situations, a chest tube can be lifesaving. This video illustrates the surgical insertion of a chest tube in a patient suffering from hydro-pneumothorax. The video shows the identification of the anatomical structures that create the safe triangle, and a safe insertion of a chest tube into the pleural cavity. Chest tube insertion is a basic surgical procedure, often conducted by residential surgeons. It is important to know the guidelines for inserting a chest tube, in order to reduce the risk of damaging organs or neurovascular structures.

Danny Chu, MD, PhD

University of Pittsburgh Medical Center

• Director of Cardiac Surgery, Veterans Affairs Pittsburgh Healthcare System
• Associate Professor of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center Heart and Vascular Institute

Dr. Chu received his undergraduate degree from the California Institute of Technology and his M.D. degree from the Tufts University School of Medicine. He completed general surgery residency at the University of California, San Diego School of Medicine. Dr. Chu has authored over 70 peer-reviewed articles, 50 abstracts, 4 book chapters, and 4 invited editorials during his career thus far. He currently serves as an editorial board member of 13 peer-review journals and has been an invited reviewer of over 20 other journals. He has also been elected membership to the prestigious Society of University Surgeons. Currently, he is the Director of Cardiac Surgery at the Veterans Affairs Pittsburgh Healthcare System and an Associate Professor of Cardiothoracic Surgery at the University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center (UPMC) Heart and Vascular Institute.

Jonathan D’Cunha, MD, PhD

University of Pittsburgh Medical Center

• Associate Professor of Surgery in the Department of Cardiothoracic Surgery
• Surgical Director of Lung Transplantation
• Associate Program Director of Thoracic Surgery
• Vice-Chair of Academic Affairs

Dr. Jonathan D’Cunha studied molecular biology at the University of Wisconsin–Madison before he earned his PhD and then MD at the Medical College of Wisconsin. He then did his internship, residency, and fellowship at the University of Minnesota before he became an Assistant Professor of Surgery, Division of Thoracic and Foregut Surgery, Department of Surgery, at the University of Minnesota.

Dr. D’Cunha’s research interests include molecular mechanisms of non-small cell lung cancer tumorigenesis,novel therapeutics for non-small cell lung cancer, lung transplantation, and surgical education.

He serves on the editorial boards of Journal of Thoracic Disease, Annals of Surgical Oncology, and Journal of Surgical Oncology. In addition, he is a grant reviewer for the National Institute of Academic Anesthesia.

Inderpal S. Sarkaria, MD, FACS

University of Pittsburgh Medical Center

• Vice Chairman for Clinical Affairs
• Director of Thoracic Robotic Surgery
• Co-Director of the Esophageal and Lung Surgery Institute
• Department of Cardiothoracic Surgery  

Dr. Sarkaria is an expert in minimally invasive approaches to benign and neoplastic diseases of the esophagus, mediastinum, and lung. He is a recognized leader in robotic assisted approaches to these operations, and developed the minimally invasive esophageal program at Memorial Sloan Kettering Cancer Center prior to moving to UPMC. Dr. Sarkaria has one of the largest international experiences with robotic assisted minimally invasive esophagectomy (RAMIE) and other esophageal operations. Dr. Sarkaria has lectured, published, and presented his research and experience nationally and internationally and is a member of the major national and international thoracic surgical societies.

Board-certified in general surgery and thoracic surgery, Dr. Sarkaria earned his medical degree from the University of Medicine and Dentistry of New Jersey in Newark. He completed a residency in general surgery and cardiac surgery fellowship at New York Presbyterian Hospital – Weill Cornell Medical Center. He also completed fellowships in thoracic surgical oncology and cancer research at Memorial Sloan Kettering Cancer Center and in minimally invasive thoracic surgery at the University of Pittsburgh Medical Center.

Three Stage Management of the Single Ventricle

In this session our team of experts will discuss the three stages of single ventricle palliation including the Norwood procedure, the bidirectional Glenn shunt and the Fontan procedure.  Included in this webinar will be single ventricle pathophysiology, diagnostic studies/imaging, indications and contraindications for palliation, timing of surgical intervention, and overview of surgical goals and associated mortality.

Ventricular Septal Defects

As one of the most common congenital cardiac anomalies managed by pediatric cardiac teams, VSD’s often may present a challenge in optimal management.  Our team of experts will discuss pathophysiology, diagnostic studies, indications and timing of surgery, surgical management; along with the technical challenges/considerations of repairing each of the different anatomic variants of ventricular septal defects: perimembranous, conoventricular, supracristal (subpulmonary), inlet (atrioventricular canal type), and muscular.

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