Pediatric Tracheostomy

Paediatric Tracheostomy Position the child with chin extension appropriately Drape the child as shown in the video Mark the incision line Use 15 number blade for skin incision Remove the excessive subcutaneous fat tissue Find the median raphe and strap muscles Retract the strap muscles laterally Identify the tracheal ring Create the impression of tube for appropriate size incision Place the stay sutures as shown in the video incise the trachea with 11 number blade Secure the maturation sutures Insert the tracheostomy tube Confirm the position and then inflate the cuff Secure the ties and dressing at the end.

Stapler-assisted Loop Ileostomy Stoma Prolapse Repair

Stoma prolapse is an increase in the size of the stoma secondary to intussusception of the proximal bowel segment. Strangulation and ischemia of the prolapsed segment have been reported as complications. This is the case of a 58-year-old man with multiple comorbidities who was diagnosed with an adenocarcinoma of the ascending colon with hepatic metastasis. He was considered unable to start conversion chemotherapy because of his cardiovascular comorbidities and was therefore under paliative chemotherapy. Patient came into emergency room with an acute bowel obstruction and underwent a loop ileostomy as a diversion procedure. Following up the procedure, the patient developed an acute on chronic kidney failure because of dehydration from high output ileostomy. In the postoperative day 17, patient presented with an acutely incarcerated prolapsed afferent limb of the loop ileostomy. Attempts at reduction were unsuccessful. Herein we present a simple, safe, and fast approach for correcting a prolapsed loop or terminal stoma using a step-wise application of linear staplers. When laparotomy and/or stoma reversal is not appropriate, local revision of stoma prolapse provides a low-risk and high-benefit alternative solution.

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. 

A Novel Technique for Reconstruction of Right and Left Hepatic Arteries in Pancreaticoduodenectomy

A 55yo lady undergoing open pancreaticoduodenectomy for duodenal adenocarcinoma was intra-operatively found to have macroscopic tumour involvement of the proper hepatic artery and its bifurcation. The diseased segment was resected and a novel technique for reconstruction was performed- the remnant common hepatic artery was anastomosed to the remnant right hepatic artery, and the left gastric to the remnant left hepatic artery. Doppler ultrasound confirmed  patency of all anastomoses prior to closure. Synthetic function of the liver and bilirubin recovered to appropriate levels postoperatively, and the patient was planned for adjuvant chemotherapy.

Two Layered End-to-side Duct to Mucosa Pancreaticojejunostomy

Contributors: David Caba-Molina, MD and Mark S. Talamonti, MD The following video depicts our technique for performing a two layered end-to-side duct to mucosa pancreaticojejunostomy without the use of a pancreatic duct stent, following the resection phase of a standard Whipple operation. DOI: http://dx.doi.org/10.17797/wvi4b33r6r Editor Recruited By: Jeffrey Matthews, MD

Robotic Abdominoperineal Resection with en Bloc Prostatectomy

Rectal cancer with local invasion presents a particular operative challenge. The standard procedure for locally advanced rectal cancer is a total pelvic exenteration (TPE), which is a highly morbid procedure. For select patients, the literature has demonstrated that bladder-sparing techniques involving en bloc resection of the prostate are safe and oncologically acceptable.1 Additionally, case studies have demonstrated the success of combined approaches using laparoscopic techniques.2,3 However, little has been published concerning the combined robotic-assisted approach of an abdominoperineal resection (APR) and en bloc prostatectomy with vesicourethral anastomosis. Robotic assistance offers several advantages for pelvic surgery, including better visualization using 3D technology and wristed instruments. Furthermore, research has shown the advantages of robotic surgery for rectal cancer resections.4,5 Our video presents a case of T4N0M0 rectal cancer, 1 cm from the dentate line, in a 63 year old male with invasion anteriorly into the prostate. After completing chemotherapy and radiation, a combined approach with a colorectal surgeon and a urologist was done using the daVinci Xi robot (Intuitive Surgical Inc, Sunnyvale, CA). The important steps of the procedure are demonstrated in the attached video. Pathology revealed a 5 cm mucinous adenocarcinoma with treatment effect and negative margins. The patient did well post-operatively with no complications. He was discharged on post-operative day 5. Robotic-assisted procedures offer the advantage of precision and visualization for pelvic operations. For locally invasive rectal cancer, robotic surgery allows the opportunity to create novel techniques for select patients in order to reduce the number of TPEs.

Laparoscopic Pancreatico-Jejunostomy

Critical elements of the technique for Laparoscopic Pancreatic anastamosis for MIS Whipple procedure are demonstrated. This shows a 2 layered duct to mucosa anastamosis. DOI:http://dx.doi.org/10.17797/xe556mv1e9

Laparoscopic Adjustable Gastric Band Removal and Conversion to Sleeve Gastrectomy

Contributors: Melissa Beitner and Christine Ren-Fielding This video shows the one-stage conversion of an adjustable gastric band to a sleeve gastrectomy. DOI: http://dx.doi.org/10.17797/ygruogodll

Endoscopic Anterior Cricoid Split with Balloon Dilation for Failed Extubation

This is done in infants who have had failed extubation and had maximal medical treatment(steroids,epinephrine etc). This procedure done with careful patient selection will help avoid tracheostomy. The Larynx is suspended using a Lindholm Laryngoscope with patient spontaneously breathing with ventilating through the side port. The airway is first completely assessed to make sure there is no other lesion to explain the failure. The larynx is then suspended with a laryngoscope(Lindholm). With direct visualization a micro laryngeal sickle knife is used to divide the anterior cricoid with palpation of the neck from outside to feel the cut being made. Care is taken not to injure the anterior commissure. Once this is achieved a 5-7 mm balloon is used in an infant to dilate the sub glottis for 30-60 seconds. The patient is either extubated on the table or in a day.Further 24 hrs of steroids is given. For further reading: Laryngoscope. 2012 Jan;122(1):216-9. http://dx.doi.org/10.1002/lary.22155. Epub 2011 Nov 17. Endoscopic anterior cricoid split with balloon dilation in infants with failed extubation. Horn DL, Maguire RC, Simons JP, Mehta DK. DOI: http://dx.doi.org/10.17797/1y99qiqe93

Laparoscopic repair of Morgagni hernia in infant.

Laparoscopic repair of Morgagni hernia in infant.

Chylous pericarditid in infant

Thoracoscopic pericardial window creation for chylous pericarditis in infant. 15 days old baby admitted on NICU for tachypnea. Rt hydrothorax was identified and pleural drainage was inserted. 3 weeks later thoracoscopic lymphatic duct ligation performed due to lack of conservative management. 1 month later he was admitted due to pericardial effusion and pericardial drainage was inserted. But 2 weeks later thoracoscopic pericradial window creation procedure was done because pericardial effusion continuously drained though pericardial tube. Uneventful recovery and there was no any complications during 1 year long-term follow-up.

Superior Rectus Recession

Introduction 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. Methods 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. Results 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. Conclusion 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 mhuynh@uams.edu Surgeons: Brita Rook, MD Arkansas Children’s Hospital – Department of Ophthalmology, Little Rock, Arkansas, USA BSRook@uams.edu Joseph Fong, MD Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA JFong@uams.edu Video was performed at Arkansas Children’s Hospital, Little Rock, AR, USA.

Robotic Inferior Mesenteric Artery, Common Iliac Artery, and Retroperitoneal Lymph Node Dissection

David Schwartzberg MD, Tushar Samdani MD, FASCRS, Mario M. Leitao MD, FACOG, FACS, Garrett M. Nash MD, MPH, FACS, FASCRS Recent data has shown an improved survival with metastasectomy for metastatic rectal cancer. Metastasectomy on a minimally invasive plateform (robotic) can be used for an R0 resection in patients who have retroperitoneal metastasis from rectal cancer after control of the primary tumor. DOI # http://dx.doi.org/10.17797/wd7d09sjgc

Robotic Assisted Right Hemicolectomy with Intracorporeal Anastomosis

Contributors: Nell Maloney Patel We present a case of a seventy-two year old female found on colonoscopy to have multiple polyps and an ascending colon mass that was biopsy proven adenocarcinoma who underwent a robotic assisted right hemicolectomy with intracorporeal anastomosis. DOI# http://dx.doi.org/10.17797/54hba94993 Editor Recruited by: Vincent Obias

Reoperative Laparoscopic Anti-Reflux Surgery

Contributors: Marco P. Fisichella 65 year old man who underwent a laparoscopic Nissen fundoplication in August 2015. Preoperative manometry was normal and DeMeester score was 25. Two months later he began to experience difficulty of swallowing solid foods, then liquids. After 2 dilatations, dysphagia persisted. DOI#: http://dx.doi.org/10.17797/egw2097cpq Referred By: Jeffrey B. Matthews

Per Oral Endoscopic Myotomy (POEM) for Zenker's Diverticulum

In contrast to major thoracic operations, per oral endoscopic myotomy for Zenker's diverticulum offers the possiblity to resect a symptomatic Zenker's under monitored anesthesia care (MAC) for patients to ill to undergo general anesthesia. Patients have similar functional results when compared to small Zenker's treated with traditional operative approaches. DOI# http://dx.doi.org/10.17797/f3gyzc3k95

Nasal Encephalocele: Endoscopic Surgery

Contributors: Vincent Couloigner We describe the excision of a nasal encephalocele obstructing the left nasal fossa with an anterior subcutaneous portion deforming the nasal pyramid in a four-year-old girl using endoscopic surgery combined to a Rethi approach. The anterior skull base defect was reconstructed using autologous conchal cartilage and temporal fascia. Editor Recruited By: Sanjay Parikh, MD, FACS DOI: http://dx.doi.org/10.17797/udewjr2ge7

Microdebrider Assisted Lingual Tonsillectomy

Microdebrider Assisted Lingual Tonsillectomy Adrian Williamson, Michael Kubala MD, Adam Johnson MD PhD, Megan Gaffey MD, and Gresham Richter MD The lingual tonsils are a collection of lymphoid tissue found on the base of the tongue. The lingual tonsils along with the adenoid, tubal tonsils, palatine tonsils make up Waldeyer’s tonsillar ring. Hypertrophy of the lingual tonsils contributes to obstructive sleep apnea and lingual tonsillectomy can alleviate this intermittent airway obstruction.1,2 Lingual tonsil hypertrophy can manifest more rarely with chronic infection or dysphagia. A lingual tonsil grading system has been purposed by Friedman et al 2015, which rates lingual tonsils between grade 0 and grade 4. Friedman et al define grade 0 as absent lingual tonsils and grade 4 lingual tonsils as lymphoid tissue covering the entire base of tongue and rising above the tip of the epiglottis in thickness.3 Lingual tonsillectomy has been approached by a variety of different surgical techniques including electrocautery, CO2 laser, cold ablation (coblation) and microdebridement.4-9 Transoral robotic surgery (TORS) has also been used to improve exposure of the tongue base to perform lingual tonsillectomy.10-13 At this time, there is not enough evidence to support that one of these techniques is superior. Here, we describe the microdebrider assisted lingual tonsillectomy in an 8 year-old female with Down Syndrome. This patient was following in Arkansas Children's Sleep Disorders Center and found to have persistent moderate obstructive sleep apnea despite previous adenoidectomy and palatine tonsillectomy. Unfortunately, she did not tolerate her continuous positive airway pressure (CPAP) device. The patient underwent polysomnography 2 months preoperatively which revealed an oxygen saturation nadir of 90%, an apnea-hypopnea index of 7.7, and an arousal index of 16.9. There was no evidence of central sleep apnea. The patient was referred to otolaryngology to evaluate for possible surgical management. Given the severity of the patient’s symptoms and clinical appearance, a drug induced sleep state endoscopy with possible surgical intervention was planned. The drug induced sleep state endoscopy revealed grade IV lingual tonsil hypertrophy causing obstruction of the airway with collapse of the epiglottis to the posterior pharyngeal wall. A jaw thrust was found to relieve this displacement and airway obstruction. The turbinates and pharyngeal tonsils were not causing significant obstruction of the airway. At this time the decision was made to proceed with microdebrider assisted lingual tonsillectomy. First, microlaryngoscopy and bronchoscopy were performed followed by orotracheal intubation using a Phillips 1 blade and a 0 degree Hopkins rod. Surgical exposure was achieved using suspension laryngoscopy with the Lindholm laryngoscope and the 0 degree Hopkins rod. 1% lidocaine with epinephrine is injected into the base of tongue for hemostatic control using a laryngeal needle under the guidance of the 0 degree Hopkins rod. 1. The 4 mm Tricut Sinus Microdebrider blade was set to 5000 RPM and inserted between the laryngoscope and the lips to resect the lingual tonsils. Oxymetazoline-soaked pledgets were used periodically during resection to maintain hemostasis and proper visualization. A subtotal lingual tonsillectomy was completed with preservation of the fascia overlying the musculature at the base of tongue. She was extubated following surgery and there were no postoperative complications. Four months after postoperatively the patient followed up at Arkansas Children's Sleep Disorders Center and was found to have notable clinical improvement especially with her daytime symptoms. A postoperative polysomnography was not performed given the patient’s clinical improvement.

LINX Procedure for GERD

This video depicts the procedure for the implantation of a LINX implant for augmentation of the LES for refractory GERD. DOI:http://dx.doi.org/10.17797/69av5w723r Editor Recruited by: Dr. H. Leon Pachter

Laparoscopic Paraesophageal Hernia Repair

Contributors: Reza Salabat and Marco P. Fisichella Preoperative work-up and surgical technique of laparoscopic paraesophageal hernia repair. DOI#: http://dx.doi.org/10.17797/c2kvm64ru5

Laparoscopic Portal Vein Resection

Key aspects of vascular isolation and control for en bloc PV resection during laparoscopic whipple. Xenograft vein patch is used for reconstruction DOI: http://dx.doi.org/10.17797/ee9p182opy Editor Recruited by: H. Leon Pachter

Laparoscopic Adrenalectomy

Laparoscopic adrenalectomy (LA) was first described by Gagner et al. in the early 1990s, and has since become the gold standard for removal of small and medium sized adrenal tumors. Most commonly, LA is performed for unilateral benign adrenal lesions, however the minimally invasive technique is also routinely used for bilateral disease, as well as myelolipomas, adrenal cysts, adrenal hemorrhage and androgen-secreting tumors.  Compared with the open approach, LA offers shorter hospital stay, improved patient satisfaction, decrease post-operative pain and markedly improved cosmesis.  Even more, the difficulty in obtaining adequate open surgical exposure, combined with the diminutive size of the adrenal gland make laparoscopy an especially attractive option. Given this, we decided to proceed with LA approach for our patient who presented with NSCLC metastasis to his right adrenal. DOI# http://dx.doi.org/10.17797/4ek02iupxd Mellon MJ, Sethi A, Sundaram CP. Laparoscopic adrenalectomy: Surgical techniques. Indian Journal of Urology : IJU : Journal of the Urological Society of India. 2008;24(4):583-589. doi:10.4103/0970-1591.44277. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing's syndrome and pheochromocytoma. N Engl J Med. 1992;327:1033.

Irreversible Electroporation for Treatment of Locally Advanced Pancreatic Cancer

Contributors: Robert C.G. Martin, II Locally advanced pancreatic cancer (Stage 3) is defined by encasement or abutment of vital venous and arterial structures.  Irreversible electroporation (IRE) represents an effective local non-thermal ablation modality for treatment of solid tumors involving critical vascular and biliary structures.  Electroporation creates pores in the cell membrane and disrupts the ionic gradients while sparing the extracellular matrix, resulting in preservation of blood vessel and biliary scaffolding. DOI: http://dx.doi.org/10.17797/yonbav6fdz Editor Recruited by: Jeffrey B. Matthews

Gastric Sleeve Obstruction From Adjustable Gastric Band Capsule

The field of metabolic and bariatric surgery has recently switched from laparoscopic gastric banding (LGB) to laparoscopic sleeve gastrectomy (LSG) as the procedure of choice for weight loss surgery. As LGB has been replaced with LSG many patients who had complications with LGB or failed to loose a satisfactory amount of weight with LGB have had a conversation from their band to a sleeve gastrectomy. Meticulous dissection takes place when removing a band, as the fibrotic scar capsule that surrounds the band must be resected in its entirety to avoid staple firings across fibrotic tissue rather than healthy gastric tissue. In addition to ensuring a healthy staple line by resecting the fibrotic capsule, we present a case where the band capsule was thought to be removed however was incompletely dissected and caused a postoperative strictured proximal stomach with complete PO intolerance. For this reason, we routinely perform intra-operative endoscopy to ensure the lumen of the stomach is patent prior to staple firing to complete the sleeve gastrectomy in band to sleeve patients. DOI#: http://dx.doi.org/10.17797/19tn2xjdda

Excision of Scalp Congenital Hemangioma

Contributors: Adam Johnson, MD and Gresham Richter, MD, FACS Noninvovluting Congenital Hemangioma (NICH) is a congenital vascular lesion present at birth. These lesions do not regress, in contrast to infantile hemangioma or Rapidly Involuting Congenital Hemangioma (RICH), and may grow proportionately with age. Most lesions present in the head and neck, trunk, or limbs, and can be painful. Surgical excision is the treatment of choice. DOI #: http://dx.doi.org/10.17797/5hq5nro3j4

Combined Modality: Laparoscopic Assisted Colonoscopic Polypectomy

Laparoscopic assisted colonoscopic polypectomy aids in the safe excision of otherwise unresectable polyps with colonoscopy alone due to unfavorable locations or polyp charicteristics. A combined procedure allows for laparoscopy to assist in polypectomy by providing traction on the luminal wall, the ability to recognize a full thickness perforation and perform a segmental resection without delay and to spare the patient from multiple exposures to anesthesia. DOI# http://dx.doi.org/10.17797/d04no64kyu

Cranioplasty for Sagittal Craniosynostosis

Cranioplasty with barrel stave osteotomies to treat sagittal suture craniosynostosis.

da Vinci Total Abdominal Colectomy for Ulcerative Colitis

Contributors: Craig Rezac, MD This video demonstrates the basic steps of a Robotic-Assisted Total Abdominal Colectomy for Ulcerative Colitis using the da Vinci Xi Robotic System. DOI: http://dx.doi.org/10.17797/zr41dcfdmt

da Vinci Robot Assisted Right Hemicolectomy with Intracorporeal Anastamosis

Contributors: Jimmy Lin and Craig Rezac This procedure is a da Vinci Robot assisted Right hemicolectomy with intracorporeal anastomosis performed on a 52 year-old male who was found to have a cecal adenocarcinoma on screening colonoscopy. Metastatic work-up was negative. DOI:http://dx.doi.org/10.17797/gb6xh7cx7u Editor Recruited by: Vincent Obias

da Vinci Robot Assisted Low Anterior Resection with Diverting Loop Ileostomy

Contributors: Jimmy Lin and Craig Rezac This procedure is a da Vinci Xi Robot assisted low anterior resection with diverting loop ileostomy performed on a 64 year old male patient who on work-up of hematochezia and change in bowel habits was found to have a locally advanced rectal adenocarcinoma approximately 5-6cm from the anal verge. The patient was found to have a single subcentimeter metastatic liver lesion, which was treated with radiofrequency ablation. He was treated with neoadjuvant chemoradiation prior to undergoing surgery. DOI: http://dx.doi.org/10.17797/vk8yonl7gj Editor Recruited By: Vincent Obias, MD, MS

da Vinci Assisted Take Down of a Rectovaginal Fistula Through a Posterior Vaginectomy

A rectovaginal fistula (RVF) is an epithelial lined tract between the rectum and vagina. This can result in recurrent urinary tract or vaginal infections, but also creates a significant psychosocial burden for the patient. Unfortunately, due to the individual complexities of these patients, they are difficult to manage despite the numerous surgical options presently described.1 Generally RVFs are classified as low, middle or high, due to the location of the rectal and vaginal opening. Due to this, both low and middle RVFs may be approached via anal, perineal or vaginal routes. Where as high RVFs, which have their vaginal opening near the cervix, generally require an abdominal approach for repair.2 Traditionally for high RVFs patients underwent open surgery; however, minimally invasive surgery has recently been widely accepted as the preferred approach. Although surgeons are becoming more facile with these approaches, both pelvic surgery and a reoperative abdomen still impose significant technical difficulties.3,4 Here, we present the video of a female with a complex surgical history including a hysterectomy, bilateral salpingo-oopherectomy, creation and reversal of a Hartmann’s colostomy as well as a loop ileostomy due to a locally advanced recto-sigmoid cancer, who subsequently developed a rectovaginal fistula and was managed minimally invasively with a multidisciplinary novel approach through a posterior vaginectomy; an approach that utilized the enhanced magnification of the Robot, which improved visualization and allowed access into an uninflamed, virgin plane, resulting in minimal loss of vaginal length. Contributors: Milind D. Kachare, M.D. Osvaldo Zumba, M.D. Lorna Rodriguez-Rodriguez, M.D., Ph.D. Nell Maloney-Patel, M.D. Rutgers Robert Wood Johnson Medical School, Hackensack University Medical Center, City of Hope National Medical Center

da Vinci Assisted Low Anterior Resection and Colovesical Fistula Repair

Contributors: Jimmy Lin and Craig Rezac Robotic surgery offers benefits to both patient and surgeon by allowing smaller incisions and faster recovery time, to better accuracy, flexibility and control.  Many procedures which had previously been conducted with laparoscopy, or open surgery, are becoming further improved upon in robotic surgery. This video demonstrates two such procedures, from different specialities, being performed; the low anterior resection and colovesical fistula repair. DOI#: http://dx.doi.org/10.17797/f1frvag53q

da Vinci Assisted Extended Right Hemicolectomy and End Ileostomy

Contributors: Jimmy Lin and  Craig Rezac Robotic surgery offers benefits to both patient and surgeon by allowing smaller incisions and faster recovery time, to better accuracy, flexibility and control.  Many procedures which have previously been conducted with laparoscopy, or open surgery, are becoming further improved in robotic surgery. This video demonstrates once such procedure, the extended right hemicolectomy. DOI# http://dx.doi.org/10.17797/rv3nkbech0 Authors Recruited By: Vincent Obias. MD. MS

Laparoscopic implantation of gastric stimulator

This is a video of a laparoscopic implantation of a gastric electrical stimulator in a 13 year old girl with severe gastroparesis and functional dyspepsia. She had a temporary trial performed the week before that was successful in improving her symptoms, and therefore we proceeded with a permanent implantation. She has done well and has been able to eat food again after over a year of just liquids and has not been admitted to the hospital since surgery.

Endoscopic Balloon Dilation of Tracheal Stenosis

A 16 year old presented with stridor three after being intubated for a week following a head injury. Endoscopy revealed a long segment tracheal stenosis in a subacute phase. The airway was sized with a uncuffed 3.5 endotracheal tube with a leak at 20cm of water.This stenosis was Grade 3 Cotton-Myer classification. A 12 mm Vascular balloon (Boston Scientific-Blue Max) was placed in the in the airway with direct visualization and was dilated at 20 atmospheres for about a minute. The patient was under general anaesthesia but spontaneously breathing throughout the procedure. The patient was sized to a 6.5 endotracheal tube with a free leak after the dilation. DOI: http://dx.doi.org/10.17797/n35d0ug41t

ND:YAG Laser Therapy of Tongue Venous Malformation

This is a visual representation of the treatment of a venous malformation within the substance of the tongue. The laser directly treats the venous malformation via selective photothermolysis while preventing injury to the tongue itself. Venous malformations infiltrate normal tissue as a birthmark but continue to grow with time and show no evidence of regression. Instead of excising the venous malformation with some of the tongue itself this is a way of controlling the lesion. As seen, the ND:YAG laser set at 25 Watts and 1.0 sec duration is used to shrink the venous malformation. The laser is fired in a polkadot fashion in order to prevent mucosal sloughing. The surface is relatively protected as the laser selective penetrates the VM. DOI: http://dx.doi.org/10.17797/938qzyj3uh

Hemangioma Excision

Infantile hemangiomas are vascular tumors composed of proliferating endothelial cells. They uniquely undergo rapid expansion from birth to 6-8 months of age and subsequent slow dissolution over several years thereafter. Some hemangiomas are at risk of causing functional problems during their growth phase as seen in this upper eyebrow lesion obstructing the visual axis. Laser, surgical and medical treatment options are available for problematic hemangiomas. This patient was elected to undergo excision to completely remove the lesion and forego a long course of medical therapy (propranolol). Because of the their vascular nature, excision of hemangiomas requires careful planning and hemostasis. The hemangioma is marked in elliptical fashion along natural aesthetic facial lines along the brow. The inferior mark in incised first. Careful subdermal dissection is critical to completely excise to the hemangioma near the surface and find the appropriate plane. Control of bleeding is maintained by monopolar and bipolar electrocautery as well as dissecting the lesion from one side and alternating to the other. The plane of deep dissection is rarely below the subcutaneous layer thus protecting important nerves and vessels. Complete removal is possible. Closure is performed with dissolvable monocryl or PDS suture with dermabond superficially. A plastic eyeshield (blue) is placed at the beginning of case to protect the patient's cornea during the procedure. DOI: http://dx.doi.org/10.17797/zlvhux8afu

Laparoscopic Orchiopexy: Use of a Hitch Stitch

Contributors: John Paddack (University of Arkansas for Medical Sciences) INTRODUCTION AND OBJECTIVES: The percutaneous hitch stitch, a commonly described technique for elevation of the ureteropelvic junction during laparoscopic pyeloplasty, allows for easier dissection and suturing. We have adapted this technique to laparoscopic orchiopexy. METHODS: The technique described was used for testicular retraction during three consecutive cases of right-sided intraabdominal testicle RESULTS: There were three cases of non palpable testicle, mean age 31 months (range 22-42). Testicles were all within 3 cm of internal ring on laparoscopy. In all cases, testicle was placed in subdartos pouch in single stage, without division of the spermatic vessels. There were no complications. CONCLUSIONS: The percutaneous hitch stitch is a simple modification to the traditional laparoscopic orchiopexy. It provides atraumatic retraction of the intraabdominal testicle and facilitates dissection of spermatic vessels from the posterior peritoneum. DOI: http://dx.doi.org/10.17797/n1nnrufxpt

Robotic Assisted Pediatric Lingual Tonsillectomy

The patient is nasotracheally intubated with a regular cuffed nasotracheal tube. Using a modified McIvor mouth gag, the oral cavity is exposed with the tip of the blade just shy of the posterior 1/3 of tongue so that the tongue base is clearly visualized. The DaVinci robot is set in and using a 5 mm forceps and a mono polar diathermy the incision is made in the midline and the lingual tonsil is dissected out as it is peeled off from the tongue base muscles which is very clearly visualized. The forceps is used to gently retract the tissue while the bovie at a setting of 15 is used to remove the lingual tonsils.. At the end the operative site is irrigated to check for any bleeders. FLOSEAL is also applied to help in hemostasis. DOI: http://dx.doi.org/10.17797/q82n9gkkvs

Airway Evaluation Prior to Closure of Tracheo-Cutaneous Fistula

The patient is a five year old, ex 23 week preemie whom was successfully decannulated with the tracheotomy removed in the ICU eleven months prior. The child did not have any airway reconstruction. As the techniques around decannulation as well as closure of trachea-cuteanous fistula are varied and at times controversial, it would be most excellent to see video sequences of the various ways to decannulate. The patient underwent a direct laryngoscopy and bronchoscopy and closure of the tracheo-cutaenous fistula. He is brought to the operating room for closure of a tracheo-cutaneous fistula. Prior to closure of the fistula, the patient had an airway evaluation to ensure that the airway was safe. Note the distal secretions and otherwise normal airway evaluation. The method for the airway evaluation in the setting of a trachea-cutaenous fistula is to first ensure the patient has adequate ventilation and oxygenation. If necessary and a very large fistula, the fistula may need to be covered with gauze or a finger to allow gas exchange. The airway evaluation then proceeds with a laryngoscope to expose the larynx and an endoscopic camera via a bronchoscope is passed through the vocal folds to evaluate the airway. This video demonstrates that there is no mucosal opening where the trachea-cutaneous fistula would be expected to be found. DOI: http://dx.doi.org/10.17797/k7e0zijclp

Endoscopic Drainage of a Severe Subperiosteal Abscess - Less is More

An adolescent male presented with a few day history of right eye swelling, erythema, and edema. The eye swelling was determined to be a result of subperiosteal abscess of the medial orbit, as seen on imaging. The vision was progressively getting worse and the decision was made to urgently take the patient to the operating room. The surgical indications are at times controversial but include decreased range of motion of the eye as well as loss of vision/color discrimination. This patient only had markedly decreased range of motion of the eye. The patient was taken to the operating room; afrin pledgets were placed and the middle turbinate was medialized. At this time the edema and swelling of the ethmoid sinuses was evident. The traditional teaching is to remove the ethmoid air cells and open up the lamina papyrecea. For the past several years, the author has adopted a less is more approach - where the author opens up the ethmoid sinuses and exposes the lamina to allow the pus a route of egress. This video clearly epitomizes the less is more approach. The ethmoid cells have been opened up and there is a large route of egress for the pus which is under pressure. The video demonstrates that upon palpation of the right eye (the Stankiewicz maneuver), there is a massive amount of pus that drains out. The child recovered expeditiously. Endoscopic sinus surgery is an area where is there significant potential for errors and complications - especially inadvertent injury to the eye and brain. As such, the author believes that in some cases, a less is more approach ultimately benefits the patient. DOI: http://dx.doi.org/10.17797/13t22bikb2

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 DOI: http://dx.doi.org/10.17797/maqcmavan0

Supraglottoplasty for Laryngomalacia (Cold Steel)

1. Purpose of Surgery: To alleviate upper airway obstruction secondary to laryngomalacia after failed medical management (twice daily proton pump inhbitor, reflux precautions). Indications for surgery are the following: failure to thrive, dysphagia, aspiration, cyanosis, sleep apnea, pulmonary hypertension, core pulmonale, pectus excavatum. Approximately 10% of children with laryngomalacia will meet criteria for surgery. 2. Instruments: Parson's laryngoscope, Medtronic MicroFrance Bouchayer Laryngeal instruments (heart shaped forceps, fine cup forceps, Micro Scissors curved right &left, micro suction), oxymetazoline soaked pledgelet 3. Landmarks: vallecula, epiglottis, aryepiglottic fold, cuneiform cartilage, interarytenoid space 4. Procedure: a. Larynx sprayed with topical 2% lidocaine. and a direct laryngoscopy and bronchoscopy is performed to rule out a synchronous airway lesions. b. Parson's laryngoscope placed in the vallecula and in suspension with the patient spontaneously breathing. Inhalational anesthesia is given through sideport of laryngoscope. c. If the aryepiglottic fold is shortened then it is divided with a curved micro scissor at its attachment to the epiglottis. Division proceeds until the epiglottis is released and it springs anteriorly. (Special care should be taken to not divide the pharyngoepiglottic fold). d. If the cuneiforms cartilage is prolapsing into the airway then it is grasped with a small cup forcep or heart shaped forcep and removed with a curved scissor making sure not to remove mucosa/tissue in the interarytenoid region. e. Hemostasis is achieved with an oxymetazoline soaked pledge let. f. Steps c, d, and e are repeated on the contralateral side. g. Patient remains extubated and transferred to the intensive care unit. Decadron 0.5mg/kg every 8 hours for 24 hours. Twice daily proton pump inhibitor and reflux precautions for at least 30 days and then weaned off. h. Clinical swallow evaluation is performed 4 hours postoperatively and patient resumes age appropriate diet. i. Flexible fiberoptic laryngoscopy is performed one week postoperatively. 5. Conflict of interest: none 6. References: none DOI#: http://dx.doi.org/10.17797/cb0bwa6ggv

Revision Supraglottoplasty

1. Purpose of Surgery: To alleviate upper airway obstruction secondary to recurrent laryngomalacia after failed initial supraglottoplasty. Reasons for failing initial surgery can be a conservative initial supraglottoplasty or severe reflux with failure to comply with postoperative reflux protocol. Preoperative consultation is obtained with a pediatric gastroentrologist to perform a full gastrointestinal evaluation. 2. Instruments: Parsons laryngoscope, Medtronic MicroFrance Bouchayer Laryngeal instruments (heart shaped forceps, fine cup forceps, Micro Scissors curved right & left, micro suction), oxymetazoline soaked pledget 3. Landmarks: vallecula, epiglottis, aryepiglottic fold, cuneiform cartilage, interarytenoid space 4. Procedure: a. Larynx sprayed with topical 2% lidocaine. b. Parsons laryngoscope placed in the vallecula and in suspension and patient is intubated. c. Aryepiglottic fold is redivided with a curved micro scissor at its attachment to the epiglottis. Division proceeds until the epiglottis is released and it springs anteriorly. (Special care should be taken to not divide the pharyngoepiglottic fold). d. One side of the curved epiglottis is grasped with a small cup forcep or heart shaped forcep. The epiglottis is then trimmed with a curved scissor (mucosa and cartilage). e. Hemostasis is achieved with an oxymetazoline soaked pledget. f. The patient remains extubated and is transferred to the intensive care unit. The patient is given Decadron at a dosage of 0.5mg/kg every 8 hours for 24 hours following the procedure and twice daily proton pump inhibitor and reflux precautions for at least 30 days and then weaned off. g. Clinical swallow evaluation is performed 4 hours postoperatively and patient resumes age appropriate diet. h. Flexible fiberoptic laryngoscopy is performed one week postoperatively. 5. Conflict of interest: none. 6. References: none DOI: http://dx.doi.org/10.17797/ag049330ri

Pressure Equalization Tube Placement

Contributor: Gresham T. Richter, MD (Arkansas Children's Hospital) Pressure equalization tube placement is one of the most common procedures in the pediatric population. This video demonstrates the surgeon's view of the right ear through the operative microscope. Indications: recurrent otitis media with effusion, chronic otitis media with effusion (>3 months duration), speech/language delay secondary to otitis. Instruments: operative microscope, ear speculum, ear curette, myringotomy knife, suction tube, pressure equalization tube Procedure Steps: 1. Speculum inserted into external auditory canal 2. Cerumen removed with the curette (not shown in video) 3. Myringotomy performed on anterior-inferior quadrant of tympanic membrane 4. Fluid aspirated with suction tube 5. Pressure equalization tube (PET) inserted and secured 6. Antibiotic otic drops applied 7. Cotton dressing applied Recommended Resource: Lambert E, Roy S. Otitis media and ear tubes. Pediatric Clinics of North America. 2013;60(4):809-26. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23905821 The authors have no conflicts of interest or financial disclosures. DOI: http://dx.doi.org/10.17797/fzlqossgrh

Laparoscopic Nissen Fundoplication

A 51-year-old man seeks medical attention for intermittent chest pain. He describes the pain as “burning” and it has become increasingly frequent after meals over the last 4 to 6 months. In addition, he experiences regurgitation, and often wakes up at night with a feeling of choking. He has also noted hoarseness and cough. Proton pump inhibitors are very helpful for the heartburn and chest pain but do not improve the regurgitation. Long-term results have shown that a fundoplication provides control of reflux in about 90% of patients. To achieve these results the surgeon should focus on the technical elements of the operation, rather than on the eponyms. The technical elements of the operation are the following: (1) division of the short gastric vessels to achieve complete fundic mobilization; (2) extensive dissection of the distal esophagus in the posterior mediastinum to bring the gastroesophageal junction at least 3 cm below the diaphragm; (3) meticulous closure of the right and left pillar of the crus with non-absorbable sutures; (4) use of a bougie to decrease postoperative dysphagia; (5) a short fundoplication with three interrupted stitches placed at 1 cm of distance from each other (2-2.5 cm long). All these technical elements have been shown to positively impact long-term outcomes. Patients who are still symptomatic postoperatively must be thoroughly evaluated to identify the cause of failure, and treatment must be individualized. by Ciro Andolfi (The University of Chicago Medicine) Marco G. Patti (The University of Chicago Medicine) DOI: http://dx.doi.org/10.17797/287pfs38ls Editor Recruited By: Jeffrey Matthews, MD

Laparoscopic Paraesophageal/Hiatal Hernia Repair

Contributor: Ciro Andolfi (University of Chicago), Marco G. Patti (University of Chicago) We describe our preoperative work-up and the surgical technique of Laparoscopic paraesophageal/hiatal hernia repair. DOI: http://dx.doi.org/10.17797/56by9lqzf5 Editor Recruited By: Dr. Jeffrey Matthews

Tonsillectomy Using Electrocautery

Contributors: Conor Smith (Arkansas Children's Hospital) and Gresham Richter M.d. (Arkansas Children's Hospital) The removal of tonsils is most often indicated by tonsillar hypertrophy contributing to obstructive sleep apnea or chronic/recurring throat infections from pathogens such as streptococcal bacteria. Electrocautery is the most commonly used technique to safely and effectively excavate the tonsils. DOI: http://dx.doi.org/10.17797/cb233d20mk

Robotic Rectal Dissection; Total Mesorectal Excision (TME)

Robotic rectal dissection begins posteriorly in total mesorectal excision plane (TME) using 30° down-viewing scope. Posterior dissection in a TME plane provides a relatively bloodless plane of dissection and creates an anatomical reference point from which lateral and anterior dissection can proceed. With an assistant retracting the rectum anteriorly and cephalad, the robotic single fenestrated grasper retracts the posterior aspect of the mesorectum anteriorly and slightly caudally. When performed correctly the surgeon can visualize a “cotton candy”-like areolar tissue between the fascia propria of the rectum and presacral fascia. The hook cautery is used to divide the tissue in a U-shaped fashion. The dissection is taken to the level of Waldeyer’s fascia. Lateral Dissection and Division of Lateral Stalks The lateral dissection proceeds initially on the right side where the surgeon has a safer plane of dissection (away from left ureter). A monopolar hook moves from posterior to anterior at a deliberate pace while applying current. If the right and posterior dissection was performed correctly, the only structures that need to be divided on the left side are a layer of peritoneum and a small amount of remaining lateral stalks. The left lateral side is dissected by dividing the peritoneum over the left pararectal sulcus. The left ureter must be visualized during this step. It is important to control all vessels, even the ones that appear to be only mildly oozing. Failure to do so may result in the field becoming bloody and dark. In this video, a vessel, encounterd within the left stalk is coagulated using a bipolar grasper while retracting the mesorectum with the hook. After the vessel is sealed it is divided with hook cautery. Anterior Dissection As the dissection advances inferiorly, the right and left lateral peritoneal incisions that are created during lateral dissection at this point are connected in front of the rectum. At this stage in operation, with the switch to a 0° scope and change of the retraction of the rectum from anterior and cephalad to posterior and cephalad, the rectum is pulled straight out of the pelvis. Because the posterior dissection has now released the mesorectum, the rectum can be easily stretched placing under tension the anterior plane of dissection. Circumferential Dissection of the Rectum If the rectal cancer is distal within the rectum, the mobilization proceeds to the level of pelvic floor and occasionally performing some dissection within the levator muscle complex. As the surgeon advances towards the pelvic floor, the dissection alternates between the posterior, lateral and interior planes as the tissue tension changes based on dissection performed. One of the signs that the dissection is at the level of pelvic floor is observation of levator ani skeletal muscle fibers that contract upon contact with electrocautery and the tapering of the mesorectum. As it narrows at the level of pelvic floor, the rectum can be carefully grasped with a robotic grasper and retracted to obtain the necessary tension to provide dissection. Editor Recruited By: Jeffrey B. Matthews, MD DOI: http://dx.doi.org/10.17797/4bvv6oyrym

Fully Laparoscopic Total Gastrectomy with Double Staple Anastomosis

Contributor: Joseph Kim This video demonstrates a fully laparoscopic total gastrectomy using a double-staple technique that facilitates the safe and effective creation of an esophagojejunal anastomosis. Fully laparoscopic total gastrectomy provides distinct advantages over the open laparotomy technique. An elderly gentleman was found to be anemic on routine bloodwork exam. Subsequent upper endoscopy revealed gastric cancer of the cardia, necessitating complete gastric resection. This video demonstrates a fully laparoscopic total gastrectomy using a double staple technique that facilitates the safe and effective creation of an esophagojejunal anastomosis. DOI: http://dx.doi.org/10.17797/i3nfwwigio Editor Recruited By: Jeffrey B. Matthews, MD

Pediatric Ansa to Recurrent Laryngeal Nerve Reinnervation

The procedure shown in this video is a pediatric ansa to recurrent laryngeal nerve reinnervation. It is performed with a concurrent laryngeal electromyography and injection laryngoplasty. Editor Recruited By: Sanjay Parikh, MD, FACS DOI: http://dx.doi.org/10.17797/7jjbn56ca3

Spleen Preserving Laparoscopic Distal Pancreatectomy for a Solid Pseudopapillary Tumor

Contributors: Bestoun Ahmed Spleen preservation is advisable if feasible during distal pancreatectomy for benign pancreatic tumors. A 31 year old patient had a blunt abdominal injury. Computed Tomography (CT) scan showed an incidental tumor in the body of the pancreas. EUS-guided cytology revealed a solid pseudopapillary tumor with benign features.This video demonstrates the technical details during a minimally invasive excision of a rare tumor of the pancreas in a male patient. Very few cases have been reported in males. Editor Recruited By: Jeffrey B. Matthews, MD DOI: http://dx.doi.org/10.17797/cc7ot3ymd8

Laparoscopic Transgastric Pancreatic Necrosectomy and Cystgastrostomy

Contributors: Michael Nussbaum Pancreatic necrosectomy is a necessary operation for necrotizing pancreatitis. The traditional open approach has been associated with difficult access and significant negative outcomes including wound complications, pancreatic fistula and prolonged hospital stay. A 57-y-old female patient presented with mild abdominal pain and epigastric fullness.She had a history of multiple episodes of acute pancreatitis and pseudocyst formation. Abdominal computed tomography (CT )scan showed a large pseudocyst of 12x15 cm size compressing the posterior wall of the stomach. Following cystgastrostomy, a large amount of necrotic pancreatic tissue is found and so necrosectomty step was added to the operation.This video demonstrates the technical details during a minimally invasive necrosectomy of the pancreas with an expedited recovery. DOI: http://dx.doi.org/10.17797/1ms9xzjz24 Editor Recruited By: Jeffrey B. Matthews, MD

Routine Laparoscopic Ultrasound During Laparoscopic Cholecystectomy

Laparoscopic ultrasound (LUS) is a simple and reliable method for evaluating the common bile duct (CBD) during laparoscopic cholecystectomy. It is particularly useful for identifying the location of the CBD and common hepatic duct (CHD) during difficult operative circumstances when the anatomy is obscured. LUS can be performed prior to any potentially hazardous dissection and can easily be repeated as necessary to safely guide dissection. This brief video demonstrates the technique of LUS during routine LC. A flexible tip probe with a multi-frequency, side viewing, curvilinear transducer is used. Scanning is typically performed at a frequency of 10 MHz. During intraoperative applications, the ability to place the transducer in close contact with the tissue being examined allows use of a higher frequency transducer. Higher frequency ultrasound waves yield better resolution than the lower frequencies that are necessary for adequate depth of penetration during transabdominal imaging. Fluid is instilled over the hepatoduodenal ligament to improve acoustic coupling. The ultrasound probe, covered by a sterile sheath, is introduced through a 10 mm sub-xiphoid port. The probe is extended to the patients’ right side and then angled to 90 degrees. The bend is maneuvered under the lateral segment of the left liver so that the transducer can be positioned over the hepatoduodenal ligament with light contact. Scanning is started in a plane transverse to the hepatoduodenal structures. The normal anatomic landmarks are described as depicted in the sonographic image on the video. The junction of the cystic duct with the CBD is identified. The proper hepatic artery (HA) is to the right of the CBD on the screen. The portal vein (PV) is dorsal (“posterior”). The cross sectional image of the PV, HA and CBD together create a “Mickey Mouse” pattern with the cartoon characters’ circular head (PV) below and ears (CBD & HA) on top. The CBD is traced caudally to the duodenal ampulla which is well seen. This is accomplished by subtle rotation of the operators’ wrist. The internal diameter of the CBD is measured to be 4 mm (normal upper limit 6-7 mm). If present, stones are readily visualized as echogenic structures with posterior acoustic shadowing and sludge as echogenic material without shadowing. The CBD is traced cephalad and the transducer is rotated to yield a longitudinal view of the CBD and PV which appear as parallel tubular structures. In this plane, the right hepatic artery appears as a round structure and is most typically located dorsal to the CHD. Doppler can demonstrate the characteristic waveforms of the vascular structures, although it is not usually necessary for identification. The PV has a low velocity, continuous forward flow with minor undulations due to cardiac activity. Flow in the inferior vena cava is bi-directional due to the cardiac cycle and respirations. The HA demonstrates features of a low resistance type vessel with a bi-phasic spectral waveform that continues forward during diastole. The CBD has no Doppler signal other than the interference from respiratory excursion. The aorta and right renal artery are also seen at the inferior aspect of the sonographic images. When the examination has been completed, the flexible probe is straightened and withdrawn under direct vision. DOI: http://dx.doi.org/10.17797/njy9uc14u2 Editor Recruited By: Jeffrey B. Matthews, MD

Laparoscopic Sigmoid Colectomy for Complicated Diverticulitis

Contributors: Justin A. Maykel MD The following video demonstrates a laparoscopic sigmoid colectomy for the treatment of complicated sigmoid diverticulitis. The patient was initially managed with intravenous antibiotics and allowed three months for the acute inflammatory process to resolve. Subsequently she was taken to operating room electively for an uncomplicated sigmoid colectomy with a primary anastomosis. DOI: http://dx.doi.org/10.17797/xq6fosqsh3 Editor Recruited By: Jeffrey B. Matthews, MD

Skeeter Microdrill and Contact Laser Choanal Atresia Repair in Very Low Weight Newborns

DOI: http://dx.doi.org/10.17797/zn1m3e9e41 Editor Recruited By: Sanjay Parikh, MD, FACS

Use of a Heineke-Mikulicz Like Stricturoplasty for Skin Level Anal Strictures in Children with Anorectal Malformations

Contributors: Taiwo Lawal Richard Wood Victoria Lane Alessandra Gasior Karen Diefenbach Marc Levitt Anal strictures in children who have had anorectoplasties for anorectal malformation, although largely preventable, can be of two types; at the skin level or more extensive in nature. Skin level strictures are preventable and usually treatable by anal dilations but require surgery when intractable. We recently introduced a modification of the Heineke-Mikulicz technique to treat this problem, able to be performed in an ambulatory setting and without a protective colostomy. The aim of this article is to describe the technique and outcome in a series of patients. DOI: http://dx.doi.org/10.17797/dvy3xhv1k0 Editor Recruited By: Robert C. Shamberger, MD

Laparoscopic Needle Assisted Technique for Repair of Inguinal Hernias in Children

Contributors: Chris Streck (MUSC) Aaron Lesher (MUSC) Robert Cina (MUSC) Step-by-step demonstration on how to perform the laparoscopic needles assisted repair (LNAR) of inguinal hernias in infants and young children. This fairly new technique for laparoscopic repair of inguinal hernias in infants and children is now well accepted among many pediatric surgeons. Because of the very small skin incisions, it is associated with minimal pain and has great cosmetic appeal. The operation is indicated in the treatment of inguinal hernias and communicating hydroceles in children less than 12 years of age. Preliminary results reported by the authors have suggested a similar recurrence rate as reported for the open technique. Interestingly, the recurrence rate is lower in small and premature infants compared to open surgery. The authors prefer the use of non-absorbable suture (like Prolene) in order to minimize the risk of recurrence. Our experience has demonstrated that the laparoscopic needle-assisted repair of inguinal hernia is safe with a 4% rate of minor complications. The most common complication is the development of a suture granuloma at the site of the suture placement for closure of the internal inguinal ring. It usually can be treated medically. In rare occasions, it might be necessary to remove the suture. Other less common reported complications include infection, residual hydrocele, hernia recurrence, and injury to the spermatic vessels or vas. DOI: http://dx.doi.org/10.17797/bdmv3e7y2c Editor Recruited By: Robert Shamberger, MD

Laparoscopic Hepatic Left Lateral Sectionectomy

Contributors: David A Geller Laparoscopic left lateral sectionectomy performed for a 14 cm hypervascular left lobe liver mass which is hypervascular during arterial phase and isodense to liver during venous phasem consistent with giant Focal Nodular Hyperplasia. DOI: http://dx.doi.org/10.17797/yjare8xwt2 Editor Recruited By: Jeffrey B. Matthews, MD

Endoscopic Tracheoesophageal Fistula Repair

Contributors: Noemie Rouillard-Bazinet, MD and Deepak Mehta, MD Endoscopic repair of tracheoesophageal fistula using electrocautery and fibrin glue. DOI: http://dx.doi.org/10.17797/uq9ifhudgd Editor Recruited By: Sanjay Parikh, MD, FACS

Right Hepatic Lobectomy with Intraparenchymal Vascular Control

Contributors: Amy D. Lu and Diego Di Sabato A right hepatic lobectomy with laparoscopic mobolization and division of the short hepatic veins and intraparenchymal division of the vasculature is depiected in this video. Editor Recruited By: Jeffrey Matthews, MD DOI: http://dx.doi.org/10.17797/i04zpfb2x3

Endoscopic Removal of Suprastomal Granuloma Using a Flexible KTP laser

Surgical removal of suprastomal granuloma is a procedure performed prior to the probable decannulation of a tracheostomy. There are several ways of achieving this objective, but in certain cases, a KTP laser on a flexible delivery system offers a precise and controlled method to successful debulking of the granuloma with minimal risks of haemorrhage into the airway. DOI: http://dx.doi.org/10.17797/pqzu0ns9y9 Editor Recruited By: Sanjay Parikh, MD, FACS

Stapled Ileoanal Reservoir for Restorative Ileal Pouch Anal Anastomosis

Contributors: Roger Hurst and Neil Hyman This video demonstrates the approach to stapled ileoanal reservoir (Ileal pouch anal anastomosis (IPAA)) construction initiated utilizing enterotomy at the future reservoir inlet. This approach has the advantage of permitting reservoir eversion during construction to ensure hemostasis and limiting the apical enterotomy to a stab puncture for the sharp anvil trochar. Dr. F. Michelassi and Dr. G.E. Block originally described this technique in 1993, and the authors have made minor adaptations (1) DOI: http://dx.doi.org/10.17797/4gf38v9mw2 Editor Recruited By: Jeffrey B. Matthews, MD

Laparoscopic Roux-En-Y Gastric Bypass with Circular Stapled Gastrojejunostomy

Contributors: Ranjan Sudan This video depicts a laparoscopic Roux-en-Y gastric bypass performed with a linear stapled jejunojejunostomy and a circular stapled gastrojejunostomy. DOI: http://dx.doi.org/10.17797/4mc50uaz8e Editor Recruited By: Jeffrey B. Matthews, MD

Heineke - Mikulicz Strictureplasty in Crohn's Disease

This video shows the performance of a Heineke - Mikulicz Strictureplasty in the treatment of stricturing Crohn's disease of the small bowel. DOI: http://dx.doi.org/10.17797/jj8ee1q3mr Editor Recruited By: Jeffrey B. Matthews, MD

Endoscopic Ampullectomy

Contributor: Darin L. Dufault This video illustrates two cases of ampullary adenoma treated with endoscopic papillectomy (a.k.a. endoscopic ampullectomy in many manuscripts). Along with local surgical ampullectomy and pancreaticoduodenectomy, endoscopic papillectomy is an established treatment option for benign lesions of the ampulla of Vater. For the majority of benign ampullary lesions, complete endoscopic resection of ampullary lesions is usually feasible. Limitations to endoscopic therapy include deep extension into the bile or pancreatic duct, > 50% lateral extension along the duodenal wall, and carcinomatous transformation. In general, endoscopic resection should be considered equivalent to local surgical ampullectomy in terms of its depth of dissection. In the first case, the patient was noted to have adenomatous appearing change of the ampulla on endoscopy. An electrocautery snare is used to remove the entire papilla. When technically feasible, cholangiopancreatography should precede tissue resection to evaluate for intraductal extension and identify the orifices for post-resection therapy. Since this was unsuccessful prior to resection, the pancreatic duct is then cannulated and a pancreatogram is obtained. A pancreatic duct stent is then placed after pancreatic sphincterotomy to minimize the risk of post-ampullectomy and ERCP pancreatitis, and to prevent stenosis of the pancreatic orifice long-term. Then, a cholangiogram is performed, confirming no intraductal extension and to facilitate a biliary sphincterotomy. The second case is a patient referred for further evaluation of cholestatic liver function tests and a dilated bile duct. Endoscopically, they were noted to have a protuberant papilla. Endoscopic ultrasound (EUS) showed a mass between the bile and pancreatic ducts and within the ampulla of Vater, along with a significantly dilated bile duct. The mass did not invade the duodenal wall, as showed by preservation of the muscularis propria. In cases where malignancy is not suspected and in smaller lesions, EUS may not be required. Prior to papillectomy, the pancreatic duct was cannulated and methylene blue injected into the duct to allow easier identification of the duct following papillectomy. The mass was also able to be seen on cholangiogram (green circle). It is preferred to remove the papilla en bloc, as shown in case one, although this is not always possible. There was a small amount of residual tissue at the core of the lesion that was further resected in piecemeal fashion using a hot snare with blended cut and coagulation current. Biliary and pancreatic stents were then placed to minimize the risk of post-ERCP pancreatitis, delayed post-ampullectomy bleeding, and orifice stenosis. These stents are typically removed after 1-2 months, at which time the resection site may be surveyed for residual adenomatous tissue. Last, a small amount of residual abnormal appearing tissue was ablated using APC. Editor Recruited By: Jeffrey Matthews, MD DOI: http://dx.doi.org/10.17797/ju7gthra0v

Technique of Pancreaticojejunostomy

Contributors: Emily Gross and Mark Callery This video demonstrates an end-to-side duct-to-mucosa pancreaticojejunostomy as part of a pancreaticoduodenectomy to resect a pancreatic head neoplasm. The patient is a 69 year-old female who experienced months of right upper quadrant abdominal pain and had labs consistent with biliary obstruction. Work-up with endoscopic retrograde cholangiopancreatography (ERCP) identified an ampullary mass that was biopsied and returned as ampullary carcinoma. DOI: http://dx.doi.org/10.17797/dyb8dqxxnr Editor Recruited By: Jeffrey B. Matthews, MD

Endoscopic Ear Surgery - Incus Interposition for Traumatic Ossicular Discontinuity

A five year old with conductive hearing loss due to traumatic ossicular discontinuity presents for surgical management. Ossicular discontinuity with a fibrous union of the incudostapedial joint is identified. Transcanal Endoscopic middle ear exploration with incus interposition is performed. DOI: http://dx.doi.org/10.17797/t0il7famg9 Editor Recruited By: Sanjay Parikh, MD, FACS

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

Laparoscopic-assisted Small Bowel Resection for Retained Endoscopic Capsule

Contributors: Anna Sabih and Edward Auyang This video depicts a laparoscopic-assisted approach for the retrieval of an endoscopic capsule retained within the small bowel. DOI: http://dx.doi.org/10.17797/prub9rczs1 Editor Recruited By: Jeffrey B. Matthews, MD

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

Laparoscopic Choledochoduodenostomy for the Management of Post Gastric Bypass Biliary Stricture

Contributors: Jessica Cioffi

Laparoscopic hepatoduodenostomy is an excellent option for post-gastric-bypass patients with benign biliary tract disease as an indication for biliary bypass. It involves minimal dissection, but does require complex intracorporial suturing.

DOI: http://dx.doi.org/10.17797/5aizaeub3p

Editor Recruited By: Jeffrey B. Matthews, MD

LAPAROSCOPIC TRANSCYSTIC COMMON BILE DUCT EXPLORATION IN AN INFANT

Contributors: Stephanie Chao, David Worhunsky, James Wall, and Sanjeev Dutta This video depicts a laparoscopic transcystic common bile duct exploration in a 2 month old infant who was found to have a 1 cm common bile duct stone. DOI: http://dx.doi.org/10.17797/wrw1syb8d5

Endoscopic Assisted Laparoscopic Transgastric Resection of GE Junction Gastrointestinal Stromal Tumor (GIST)

Contributors: Irving Waxman and John C. Alverdy Laparoscopic intragastric resection of a gastrointestinal stromal tumor 0.5cm distal to the gastroesophageal junction performed with oral endoscopic assistance. Related External Links: http://www.wjgnet.com/1948-5190/full/v7/i1/53.htm http://www.ncbi.nlm.nih.gov/pubmed/21224608 DOI: http://dx.doi.org/10.17797/5v0bdou315 Editor Recruited By: Jeffrey Matthews, MD

Laparoscopic Choledocotomy for Common Bile Duct Exploration

Contributor: Manish Parikh The patient is a 50 year-old man with a history of gallstone pancreatitis treated with endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct stent at an outside hospital. The patient subsequently had migration of the stent into the stomach and recurrent choledocholithiasis. This is a video demonstrating techniques used for laparoscopic common bile duct (CBD) exploration via choledochotomy with primary closure of the duct. The intraoperative cholangiogram revealed the “meniscus sign” consistent with a large stone at the ampulla. Attempts at transcystic CBD exploration failed due to a tortuous duct and inability to pass the fogarty balloon. A laparoscopic choledochotomy was then made for stone extraction. A longitudinal choledochotomy was performed sharply after exposing the anterior aspect of the common bile duct. Intraoperative choledochoscopy confirmed the stone at the ampulla. A 4Fr fogarty catheter was used to extract the stone. Repeat choledochoscopy confirmed clearance of the duct. The choledochotomy was closed with 4-0 PDS sutures in interrupted fashion. The patient’s stent was removed from the stomach via intra-operative Esophagogastroduodenoscopy (EGD) at the conclusion of the procedure. If the surgeon confirms that the common duct is cleared, the evidence supports primary closure of the duct. In scenarios where the duct is not completely cleared of stones or if there is doubt, closure over a 14-16Fr t-tube is performed. A 10 Fr. JP is routinely left in the right upper quadrant when a choledochotomy is performed. DOI: http://dx.doi.org/10.17797/hawlc80i6c Editor Recruited By: H. Leon Pachter, MD

Totally Laparoscopic Total Proctocolectomy for Ulcerative Colitis

Contributor: Linda Ferrari Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is today considered the gold standard and, in experienced hands, can now be performed safely for UC with a low postoperative complication rate and a long-term pouch failure rate reported less than 10%6-8. The introduction of minimally invasive techniques might further decrease postoperative morbidity and improve patients’ satisfaction, with reduced impact on body image and better cosmesis9-11. Unfortunately not every patient is a candidate for a restorative operation and, like in the case of our patient, a total proctocolectomy (TPC) with a permanent Brook ileostomy is performed with a laparoscopic approach. Laparoscopic TPC offers significant advantages over the open conventional procedure in terms of body image and cosmesis, important factors in the acceptance of surgery in this young patient population, while conflicting results have been reported in terms of postoperative recovery. Faster return of bowel function after laparoscopy and decreased use of narcotics have been reported by some authors, not always translating into shorter hospital stay. DOI: http://dx.doi.org/10.17797/ukm5thekea Editor Recruited By: Jeffrey B. Matthews, MD

Invaginated Pancreaticojejunostomy (Whipple Reconstruction)

Contributor: Charles J Yeo Overview:The invaginated pancreaticojejunostomy is a method of reconstructing the pancreatic remnant to the intestinal tract during the Whipple operation. DOI: http://dx.doi.org/10.17797/ouyyb9jyj1 Editor Recruited By: Jeffrey B. Matthews, MD

Hybrid Laparoscopic and Robotic Pancreaticoduodenectomy

Contributors: Sricharan Chalikonda and R. Matthew Walsh Two separate general approaches are described to perform minimally invasive pancreaticoduodenectomy (PD): pure laparoscopic and robotic. The technique shown is a hybrid utilizing laparoscopy for the resection and surgical robot for the reconstruction. We feel that this technique combines the advantages of both laparoscopic and robotic surgery.

Open Transhiatal Esophagectomy

Contributors: Mitchell C. Posner Open transhiatal esophagectomy DOI: http://dx.doi.org/10.17797/6ob5owtokl Editor Recruited By: Jeffrey Matthews, MD

Keloid Excision

Bilateral ear keloid excision with steroid injection. DOI# 10.17797/rfealpdd24

Endoscopic Excision of Concha Bullosa

Contributors: Gresham Richter Here we present endoscopic excision of a concha bullosa (a pneumatized middle turbinate) that was causing obstruction in the left nasal cavity.  This particular patient failed medical management of his chronic sinusitis including antibiotic and steroid therapy. The concha bullosa was causing obstruction of the maxillary sinus ostium and deviation of the nasal septum. Resection of the concha bullosa was necessary in order to complete a functional endoscopic sinus surgery afterward and septoplasty (not shown). DOI # 10.17797/pyzfxehca8 Author Recruited by: Gresham Ritcher

Robotic Sigmoid Resection and Intracorporeal Anastomosis

This is a 60 yo woman with diverticulitis not responsive to medical management. Open, laparoscopic, and robotic operative options were discussed. We agreed on robotic sigmoid resection in the Enhanced Recovery Pathway. This video demonstrates an intracorporeal colorectal anastomosis between the descending colon and upper rectum. Sigmoid colectomies are typically characterized by by specimen extraction through an open incision after minimally invasive mobilization of the colon and mesentery, placement of an anvil into the descending colon through this open incision, and then laparoscopic or robotic colorectal anastomosis with a circular stapler after re-establishing pneumoperitoneum. This intracorporeal anastomosis does not require stretching colon and mesentery to an open extraction site with the possible need for extending the open incision. There is less visceral manipulation and potentially less ileus and quicker return to gastrointestinal activity. The extraction site can be anywhere the surgeon chooses and the extraction incision size is limited only by the sixe of the pathology. DOI # http://dx.doi.org/10.17797/p11gskfc90 Recruited By: Vincent Obias

Rib Cartilage Harvest for Laryngotracheal Reconstruction

Contributors: Deepak Mehta This video depicts how to harvest a rib cartilage graft for use in pediatric laryngotracheal reconstruction for airway stenosis. DOI# http://dx.doi.org/10.17797/oo77838cxt Authors Recruited By: Deepak Metha

Cranioplasty and Scar Revision

Contributors: Michael Golinko (MD) and Kumar Patel (PA) A six-year-old male with history of skull trauma acquired in an ATV accident underwent emergency craniotomy three years ago. He now presents with bone resorption, frontal bossing, scalloped bone, and a widened scar in the middle of his forehead from the previous surgery. DOI#:https://doi.org/10.17797/bysho32ez5

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

Laparoscopic Transanal Total Mesorectal Excision: Rectal Cancer

Contributors: Justin A. Maykel MD The following video demonstrates a laparoscopic transanal total mesorectal excision (taTME) for the treatment of a locally advanced mid-rectal tumor. Eight weeks following neoadjuvant chemotherapy and radiation she was brought to the operating room for radical resection. DOI#: https://doi.org/10.17797/wvn5h86w7l Referred by Jeffrey B. Matthews

Fronto-Orbital Advancement and Cranial Vault Remodeling for Metopic Craniosynostosis

Contributors:Michael Golinko, MD, MA, Eylem Ocal, MD and Kumar Patel, PA Premature metopic suture fusion is corrected using fronto-orbital advancement and cranial vault remodeling to open the fused suture and allow for adequate brain growth. DOI#: https://doi.org/10.17797/hg9xbuxoms

Excision of Thyroglossal Duct Cyst

Contributors: Juliana Bonilla-Velez and Gresham Richter This patient presented with an anterior neck mass that was mobile with tongue movement. This is consistent with a thyroglossal duct cyst.  The following video demonstrates the excision of a thyroglossal duct cyst using the Sistrunk procedure. DOI#: http://dx.doi.org/10.17797/oelc9n6wlc

Laparoscopic Ligation of a Type II Endoleak from the Inferior Mesenteric Artery

Contributors: Gregory Westin and Paresh Shah Endovascular stent grafting (EVAR) is now the preferred approach to repair of abdominal aortic aneurysms for many patients. One of the most common complications associated with EVAR is the development of an endoleak, or continued flow of blood into the aneurysm sac outside the graft. Type II endoleaks, those due to retrograde flow through a branch vessel such as the inferior mesenteric artery (IMA) or a lumbar artery, are the most common. Options for treatment include transarterial embolization, translumbar embolization, and laparoscopic ligation. Embolization techniques require reintervention in approximately 20%, with less than half free from aneurysm sac growth at five years, though current evidence is insufficient to determine a clear threshold for intervention or optimal technique.[1,2] DOI#: http://dx.doi.org/10.17797/wu4visdfw2

Laparoscopic Extracorporeal Repair of a Morgagni Diaphragmatic Hernia

Contributors: Anahita Jalilvand and Marco P. Fisichella This video describes a laparoscopic-extracorporeal repair with mesh of a Morgagni diaphragmatic hernia in an 81 year old female. We used Ventralight™ ST Mesh which is an uncoated lightweight monofilament polypropylene mesh on the anterior side with an absorbable hydrogel barrier based on Sepra® Technology on the posterior side for laparoscopic ventral hernia repair. The posterior side mesh does not cause adhesion with the abdominal organs. DOI: https://doi.org/10.17797/k8ktfjncgn A quick review of the literature of laparoscopic cases has shown that in a substantial amount of cases the hernia was reduced and the defect repaired with mesh placement without hernia sac resection . Therefore, non-resecting the sac is an acceptable option.

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.

Laparoscopic Right Hemicolectomy with Isoperistaltic Intracorporeal Anastomosis

Authors: David Schwartzberg, Noah Cohen, Jordan Schwartzberg, Paresh C. Shah Oncologic outcomes of laparoscopic and open colectomy have been demonstrated to be equivalent, with similar three-year disease-free survival and overall survival rates for any stage. Compared to patients who undergo open colectomy, patients who undergo laparoscopic colectomy benefit from a shorter median length of hospital stay and decreased post-operative use of pain medication. Intraoperative and post-operative complications are similar between open and laparoscopic colectomy. A Comparison of Laparoscopically Assisted and Open Colectomy for Colon Cancer. The Clinical Outcomes of Surgical Therapy Study Group. N Engl J Med 2004;350:2050-9 DOI: https://doi.org/10.17797/fdschc17au

Transanal full thickness rectal mobilization with an ischiorectal fat pad to repair an H-Type rectovaginal fistula

Transanal full thickness rectal mobilization with an ischiorectal fat pad to repair an H-Type rectovaginal fistula. Contributors: Alejandra Vilanova, Richard Wood, Victoria Lane, and Marc Levitt

Transoral Laser Excision of a Lingual Thyroglossal Duct Cyst

Contributors: Blaine D. Smith and Jaecel Shah The lingual thyroglossal duct cyst (LTGDC) is a rare variant of the most common congenital neck mass, the thyroglossal duct cyst. The presentation of this atypical cyst is often due to symptoms of upper airway obstruction, and can lead to infant death if left untreated.

Laparoscopic Heller Myotomy and Anterior Partial Fundoplication

Contributors: Marco G. Patti Laparoscopic Heller Myotomy and Anterior Partial Fundoplication DOI: http://dx.doi.org/10.17797/m5v0f8xzp3

Laparoscopic Heller Myotomy and Dor Fundoplication for Achalasia

Contributors: Marco P. Fisichella Laparoscopic Heller myotomy and Dor fundoplication for a patient with type 2 achalasia. DOI: http://dx.doi.org/10.17797/seyyttx9lk

Endoscopic assisted sagittal strip craniectomy with barrel stave osteotomies in sphinx position

Contributors: Rongsheng Cai and Roop Gill. Endoscopic assisted sagittal strip craniectomy with barrel stave osteotomies to treat sagittal suture craniosynostosis.

Myringotomy with Tympanostomy Tube Insertion

Myringotomy with tympanostomy tube insertion is among the most common pediatric operative procedures and is indicated to provide ventilation of the middle ear. Surgical incision in the tympanic membrane (myringotomy) is followed by tympanostomy tube insertion to prevent premature closure of the incision site. The goal of the procedure is to reduce the frequency, duration, and severity of subsequent otitis media episodes and to prevent recurrence of middle ear effusions. Soham Roy (University of Texas at Houston Medical School) Thomas Mitchell (University of Texas at Houston Medical School)

Laparoscopic loop duodenal switch

Contributors: Jeremy Slawin and George Fielding Revisional surgery after laparoscopic sleeve gastrectomy (LSG) is sometimes needed to manage complications of the procedure, in particular, weight loss failure. Several surgical options exist for revision including repeat sleeve gastrectomy (“re-sleeve”), placement of an adjustable gastric band around the sleeve, conversion to Roux-en-Y gastric bypass or conversion to biliopancreatic diversion-duodenal switch. The loop duodenal switch is a modification of the duodenal switch procedure whereby a malabsorptive component is added to improve weight loss but the procedure is simplified by having only one intestinal anastomosis. The patient presented is a 63-year-old male with a past medical history of coronary artery disease, diabetes mellitus type II, hyperlipidemia and morbid obesity. He had undergone LSG over a 36 French bougie at an outside institution two years prior. His past surgical history was also notable for previous laparoscopic ventral hernia repair and laparoscopic transabdominal inguinal hernia repair. The patient had lost weight after his LSG but had regained a significant amount, with worsening of his diabetes. His Body Mass Index (BMI) at revision is 37.7kg/m2.

Vagal Nerve Blocking Therapy for Weight Loss: Laparoscopic Technique for Placing Neuroregulator and Leads

Contributors: Shaina Eckhouse, Daniel Guerron, Keri Seymour, Ranjan Sudan , Jin Yoo, Chan Park , and Dana Portenier. The present video illustrates the technique utilized to place a vagal nerve stimulator for weight loss in a morbidly obese patient. As most surgical trainees do not routinely perform truncal vagotomy, laparoscopic or otherwise, the technical goal of this video is to depict the surgical technique needed to laparoscopically identify and work with the anterior and posterior vagus nerves. Vagal nerve blocking therapy is one of many procedures used for surgical weight loss. In the present case, the weight loss achieved was less than that seen with a gastric bypass or sleeve gastrectomy over a comparable time period.

Use of Mini-Laparoscopic Percutaneous Graspers During Laparoscopic Cholecystectomy

Contributors: Jin Yoo Percutaneous instrumentation is a new area of development within minimally invasive surgery. This video demonstrates the use of 2.3mm low profile percutaneous graspers during an elective laparoscopic cholecystectomy.

Thoracoscopic resection of a mature anterior mediastinal teratoma

This video is a step by step depiction of the diagnostic tools and the thoracoscopic mobilization and resection of a mature mediastinal teratoma.

Microlaryngoscopy in a Child with Normal Anatomy

Contributor: Thomas Mitchell A laryngoscope is used to allow magnified visualization of the anatomy of the larynx in a pediatric patient. Labelled stills are used to demonstrate specific anatomy and landmarks. This procedure is indicated to diagnose and/or treat pathology of the airway and vocal cords. However, no pathology is seen in this patient.

Adenoidectomy with Suction Electrocautery Technique

Adenoidectomy is among the most common surgical procedures performed in children. The two major indications are nasopharyngeal airway obstruction and recurrent or chronic infections of the nasopharynx. This surgery is often carried out with a combined tonsillectomy which is performed for similar indications. The technique used in this video is suction electrocautery, a recently developed technique that allows for more precision and minimal blood loss compared with more traditional techniques. Soham Roy (University of Texas Medical School at Houston) Thomas Mitchell (University of Texas Medical School at Houston)

Robotic Assisted Small Bowel Resection for Meckel's Diverticulum

We present a case of a 21-year-old male with a one-day history of right lower quadrant pain and CT scan findings suspicious for a perforated Meckel’s Diverticulum who underwent a robotic assisted small bowel resection with an intracorporeal anastomosis. Contributors: Milind D. Kachare, M.D. Nisha Dhir, M.D., FACS University Medical Center of Princeton at Plainsboro, Rutgers - Robert Wood Johnson Medical School

Endoscopic Management of a Type IV Branchial Cleft Anomaly

Trans-oral endoscopic approach to exposure of a type IV branchial cleft anomaly sinus tract in the left piriform recess and closure using cauterization and tisseel application. Co-author: Yi-Chun Carol Liu

Laparoscopic Common Bile Duct Exploration for Mirizzi Syndrome: Technical Tips

Mirizzi syndrome, the mechanical obstruction of the common hepatic duct secondary to extrinsic compression of stones impacted in the gallbladder neck or the cystic duct, is a rare complication of cholelithiasis (0.2% to 1.5% of patients). Up to 50% of patients are diagnosed intra-operatively.

We describe technical tips of laparoscopic treatement of Mirizzi Syndrome, including laparoscopic cholecystectomy, common bile duct exploration and stone extraction. Often it is best to fashion the ductotomy over the palpable stone. T tube cholangiogram is also invaluable.

In conclusion, laparoscopic treatment may be used for Mirizzi Syndrome.

Contributor:Dr. Manish Parikh

Modified Martius Flap for Rectovaginal Fistula

Contributors: Dr. Jimmy Lin, Dr. Juana Hutchinson-Colas, Dr. Nell Maloney-Patel

Rectovaginal fistulas can occur for a number of reasons, including obstetric trauma, iatrogenic, radiation damage and Crohn’s disease. Symptoms range from asymptomatic to uncontrollable passage of gas or feces from the vagina leading to poor quality of life for some patients. For those patients whom surgery is indicated, there are several different approaches depending on the fistula etiology and previous attempts at repair. These range from simple fistulectomy to transabdominal repair with tissue interposition to Martius flap interposition. Our patient in the video had previously underwent multiple various repairs which failed to provide adequate resolution of her fistula and therefore presented for a Modified Martius flap repair. The benefit of such a repair is to provide neovascularity at the site of repair with minimal cosmetic effect.

Superiorly Based Pharyngeal Flap for Velopharyngeal Dysfunction

Velopharyngeal dysfunction (VPD) refers to the improper control of airflow through the nasopharynx. The term VPD denotes the clinical finding of incomplete velopharyngeal closure. Other terms used to describe VPD include velopharyngeal insufficiency, inadequacy and incompetence. However, the use of VPD has gained popularity over these terms as they may be used to infer a specific etiology of impaired velopharyngeal closure.1 Control of airflow through the nasopharynx is dependent on the simultaneous elevation of the soft palate and constriction of the lateral and posterior pharyngeal walls. Disruptions of this mechanism caused by structural, muscular or neurologic pathology of the palate or pharyngeal walls can result in VPD. VPD can result in a hypernasal voice with compensatory misarticulations, nasal emissions and aberrant facial movements during speech.2 The assessment of velopharyngeal function is best preformed by a multispecialty team evaluation including speech-language pathologists, prosthodontists, otolaryngologists and plastic surgeons. The initial diagnosis of VPD is typically made with voice and resonance evaluation conducted by a speech-language pathologist. To better characterize the patient’s VPD, video nasopharyngeal endoscopy or speech videofluoroscopy can be used to visualize the velopharyngeal mechanism during speech. VPD may first be managed with speech-language therapy and removable prostheses. For those who are good surgical candidates and do not fully respond to speech-language therapy, surgical intervention may be pursued. Surgical management of VPD is most commonly accomplished by pharyngeal flap procedures or sphincter pharyngoplasty. In this video, a superiorly based pharyngeal flap with a uvular mucosal lining flap was preformed for VPD in a five-year-old patient with 22q11 Deletion Syndrome and aberrantly medial internal carotid arteries.

Robotic-assisted Low Anterior Resection with Proximal Colotomy

Contributors: Dr. Jimmy Lin and Dr. Craig Rezac Robotic surgery offers benefits to both patient and surgeon by allowing smaller incisions with faster recovery time, as well as better accuracy, flexibility and control. Many procedures which had previously been conducted with laparoscopy, or open surgery, are further improved upon with robotic surgery. This is a video of a robotic-assisted LAR in a male with a T4N2M0 rectal cancer with concern for invasion into the prostate and seminal vesicles. The patient also has a synchronous proximal tubulovillous adenoma which had been biopsied but not completely resected during a previous colonoscopy. He therefore also underwent an intra-operative colotomy and colon polyp resection. This video demonstrates the advantages of robotic-assisted surgery in conjunction with more traditional procedures in order to provide the best care possible for the patient.

Difficult Dissection during a Low Anterior Resection

It is well-accepted that recurrent or complicated diverticulitis is an indication for surgical resection. Minimally invasive techniques, like the daVinci robot, have been developed to enable better visualization of the pelvis with articulating instruments. However, many times, the minimally invasive approach is deferred for cases of severe disease and adhesions. This video demonstrates the dissection of a significantly diseased sigmoid colon during a robotic-assisted low anterior resection. As you can see, with surgeon experience and patience, even complicated cases can be done successfully using the robot. The patient is a 65-year-old male with a history of multiple episodes of diverticulitis. The most recent episode was complicated by a pericolonic abscess, which was treated non-operatively with drainage and antibiotics. He presents 2 months later for an elective resection.

Endoscopic Assisted Laparoscopic Transgastric Division of a Gastroesophageal Fistula in an Adolescent

This video describes division of a gastroesophageal fistula in a 16 year old female with a history of prior Nissen fundoplication and gastrostomy tube placement as an infant. She presented to our clinic with progressive dysphagia and epigastric pain over a 2 month period. Initial attempts were made to divide the stapler using only a 12mm transgastric port at the prior gastrostomy site for the stapling device and an endoscope for visualization. Ultimately division required placement of an additional 5mm transgastric port for a laparoscope. Using both endoscopic and laparscopic visualization, the fistula was able to be divided using a standard laparoscopic stapler. At the completion of the procedure, the 5mm gastrotomy was closed and a gastrostomy tube was placed at the 12mm trocar site, which was then removed 2 months later. The patient's dypshagia improved after the procedure and her gastrostomy tube site closed without event.

Combined drainage of subperiosteal orbital abscess complicating ethmoiditis

A 4 year-old boy presented to our tertiary center with acute left ethmoiditis and a subperiosteal orbital abscess. He presented with exophtalmia but had no visual impairment or limitation of ocular mobility. CT-scan found a 8 mm large subperiosteal orbital abscess with no further complications. Surgery was decided using a combined approach to drain the abscess and to obtain a bacterial sample: first external (incision in the inner canthus area) and then endonasal (functional endoscopic sinus surgery - FESS) to open the middle meatus and ethmoid. External approach: 10 mm incision in the inner canthus region, elevation of the lamina papyracea periosteum until the abscess was reached. Rubber drain was put in place for irrigation. Endonasal approach: after careful CT-scan examination, endonasal surgery was performed with a 30° rigid endoscope. The middle turbinate was medialised to expose the middle meatus, uncinectomy and antrostomy followed by anterior and posterior ethmoidectomy was performed. Antibiotics were given intravenously for 5 days and saline irrigation on the drain was performed during 2 days. Patient was discharged after 5 days.

Laparoscopic single anastomosis gastric bypass

We present a laparoscopic single anastomosis gastric bypass with hand-sewn gastrojejunostomy for the treatment of obesity.

EFFECTIVE REMOVAL OF A PEDIATRIC EMBEDDED ESOPHAGEAL FOREIGN BODY

Authors: Amanda Munoz, MD; Ian Vannix, BA; Victoria Pepper, MD; Joanne Baerg, MD OVERVIEW: A three-year old girl had an unwitnessed ingestion of a radiolucent foreign body that became embedded in the esophagus with formation of a symptomatic stricture. The foreign body was not visible on initial chest radiograph or at flexible endoscopy. Pediatric surgery was consulted for removal.

Excision of Macrocystic Lymphatic Malformation

This patient is a 9-month-old with a macrocystic lymphatic malformation (LM) of the left neck. LMs, the second most common type of head and neck vascular malformation, are composed of dilated, abnormal lymphatic vessels thought to occur due to abnormal development of the lymphatic system. A complete resection was performed, and LM was confirmed by pathology. Soft tissue dissection was performed immediately adjacent to the mass to reflect tissue off the fluid-filled lesion. Neurovascular structures were preserved in this process.

Implantation of Tissue Expander in Poland Syndrome Patient

This patient is a seventeen-year-old female with Poland syndrome, resulting in a hypotrophic left pectoralis major muscle and rib anomalies. A tissue expander is implanted on the left side to increase the capacity of the left breast tissue in order to make room for a future, permanent implant.

Excision of Lymphatic Malformation of Tongue

The patient was then nasotracheally intubated, prepped and draped in sterile fashion and the tongue injected with 2 cc lidocaine with epi. Bovie was used to incise lesion in ellipse down to its base which was sent for pathology. A tongue stitch was used for traction. Hemostasis was also achieved with Bovie. The site was closed primarily with vicryl, deep and superficial. Bipolar was used to treat small surface lesions. All instrumentation was then removed and the patient was turned back over to anesthesia, awakened, and transferred to the recovery room extubated in stable condition.

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)

Laparoscopic Management of Hemoperitoneum Occurring As A Complication of Sleeve Gastrectomy

A laparoscopic approach was used to evaluate and manage hemoperitoneum that occurred in a 50 year-old woman who had undergone recent sleeve gastrectomy complicated by pulmonary embolism and hemoperitoneum. This case illustrates an important complication of laparoscopic sleeve gastrectomy, the usefulness of laparoscopy for managing complications of bariatric surgery, and the challenge of laparoscopy in an peritoneum filled with a significant quantity of blood. Authors: Donald Q Brubaker, BA - West Virginia University. Nova Szoka, MD - West Virginia University.

Sleeve gastrectomy to roux-en-y conversion

Laparoscopic conversion of sleeve gastrectomy to roux-en-y gastric bypass

Excision of a Preauricular Cyst

Background Preauricular cysts are a subset of asymptomatic, dome-shaped lesions referred to as epidermoid cysts. Cysts vary in size and have the ability to grow in diameter over time. These cysts can occur anywhere on the body and usually contain keratin. Upon examination of a suspected cyst, different characteristics can specify its type. Dermoid cysts are typically odorous lesions found around the eyes or on the base of the nose. If the cyst did not originate from sebaceous glands, it is not deemed a sebaceous cyst. Typically, surgical intervention is required to fully remove the cyst and prevent further infections or growth.  Introduction The video shows an 18-year-old female who presented with a preauricular cyst near her left ear. Upon history and physical examination, the mass was predicted to be a dermoid cyst rather than a sebaceous cyst. Surgical recommendations were given to perform an excisional biopsy of the cyst. The excision is displayed step-wise in the video. Methods A 2 cm incision was made just posterior to the lesion with a 15 blade scalpel. Dissection was carried with a sharp hemostat down the level of the parotid fascia. A 1 cm cystic structure was found adherent to the overlying dermis. An elliptical incision was then made over the mass and it was removed with the adherent overlying skin. The wound was then irrigated. Wound was closed in 3 layers. First, the deep layer was closed with 5-0 PDS in interrupted fashion, followed by 5-0 monocryl in running subcuticular fashion, followed by Dermabond Results The patient was returned to the care of anesthesia where she was awoken, extubated, and transported to PACU in stable condition. The patient tolerated the procedure well and was discharged the same day. The specimen was sent for pathological analysis. The pathology report showed that the mass was an epidermal inclusion cyst.

Laparoscopic Treatment for Hydatid Cyst of the Liver

Authors: Maja Odovic M.D, Dider Roulin M.D, Nermin Halkic PD MER Correspondence to: Maja Odovic M.D. Department of Visceral Surgery University Hospital of Lausanne (CHUV) E-mail: Maja.Odovic@chuv.ch Didier Roulin M.D Department of Visceral Surgery University Hospital of Lausanne (CHUV) E-mail: Dider.Roulin@chuv.ch Nermin Halkic PD MER Department of Visceral Surgery University Hospital of Lausanne (CHUV) E-mail: Nermin. Halkic@chuv.ch This is a video of surgical technique for laparoscopic pericystectomie. The video describes all the steps of the procedure and pays special attention to the pitfalls.

Robotic Loop Ileostomy Closure

71 yrs old male s/p robotic low anterior resection with primary coloproctostomy and diverting loop ileostomy for bulky, locally advanced rectal cancer. Robotic approach for loop ileostomy closure was planned due to obese body habitus. We utilized DaVinci Xi robotic platform. The set up consisted in 4-port placement, with ports # 2, 3 and 4 positioned starting in the left upper abdominal quadrant along MCL and port # 1 in suprapubic area. After docking and insertion of robotic instruments, the RLQ ileostomy was visualized. Appropriate orientation of efferent and afferent limbs was confirmed. Two enterotomies were created with electrocautery at the antimesenteric border of each limb, approximately 10 cm from the fascia. Head and anvil components of a robotic 60 mm stapler were then inserted in each enterotomy and the stapler fired in order to create a common channel between the lumens. After stay suture with 3-0 Vicryl was placed at the crotch of the anastomosis, common enterotomy defect was approximated with running 3-0 V-Lock suture in two layers. The matured portions of the loop ileostomy were then divided right below the fascia level with robotic 60 mm stapler after gentle dissection of the mesenteric border of each limb, while the mesentery was divided with robotic vessel sealer. The robotic system was then undocked and the ports removed. The remaining portion of the loop ileostomy was finally dissected from the abdominal wall at the mucocutaneous junction and the fascia defect approximated in the usual fashion (not included in the video).

Inferior Turbinate Trim

Basic Info: A 14-year-old male presented with chronic nasal obstruction and awake stertor. It was discovered that the patient had severe bilateral turbinate hypertrophy. A trial of Flonase and antihistamine was attempted with no improvement. It was recommended that the patient undergo a bilateral nasal turbinate reduction. This procedure is displayed step-wise in the video. Introduction: Chronic nasal obstruction can be caused by inferior turbinate hypertrophy. This video portrays a surgical treatment for turbinate hypertrophy, a turbinate trim with a microdebrider blade. Methods: An Afrin pledget was inserted into each nostril and lidocaine was injected into each inferior turbinate. Each turbinate was medially fractured using a freer. The microdebrider blade was used to trim the inferior 1/3 of each turbinate. A freer was used to out-fracture each inferior turbinate. Afrin pledgets were inserted into each nostril for hemostasis. Results: The inferior one-third of each inferior turbinate was removed via a microdebrider. Patient was sent to recovery in good condition, and Afrin pledgets were removed in recovery once hemostasis was achieved. No adverse reactions were reported by the surgeon or patient. Conclusion: Chronic nasal obstruction can be significantly improved by an inferior turbinate trim and out-fracture. Author: Merit Turner, BS, BS Surgeon: Gresham T. Richter, MD Institutions: Department of Otolaryngology-Head and Neck Surgery, Arkansas Children’s Hospital, Little Rock, AR University of Arkansas for Medical Sciences, Little Rock, AR

Microlaryngoscopy, Bronchoscopy + Supraglottoplasty in COVID-19 Era

This video demonstrates microlaryngoscopy, bronchoscopy (MLB) + supraglottoplasty in a three-month old male with laryngomalacia, with a special focus on appropriate personal protection equipment (PPE) and safe surgical considerations in the setting of a COVID-19 status unknown patient.

Lateral Rectus Plication

Introduction Muscle plication is a type of strabismus surgery that aims to tighten an extraocular muscle by partially folding the muscle under or over itself without disinsertion. The patient is a 14-year-old with alternating esotropia, who previously had a medial rectus recession. Therefore, she underwent plication of the lateral rectus muscle for this procedure. Methods A conjunctival incision is made in the fornix. Tenon's capsule is dissected to expose the lateral rectus muscle. The lateral rectus muscle is isolated using a Stevens tenotomy hook followed by a Jameson muscle hook. A Stevens tenotomy hook is used to sweep around the muscle to confirm the location of the muscle pole. A caliper is used to mark the predetermined amount of plication, starting at the muscle insertion and marking further posteriorly on the muscle. The muscle is then secured at the location marked by the caliper with a double-armed 6-0 VicrylTM suture with a central bite and double-locking bites at each pole of the muscle. Plication is achieved by bringing the muscle anteriorly and attaching it to the sclera adjacent to the muscle insertion with half-scleral depth bites in crossed-swords fashion. The muscle is tied down to its new location and 6-0 plain gut sutures are used to close the conjunctival incision. Results 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 alternating esotropia had improved. Conclusion Lateral rectus plication is a safe procedure that can effectively treat esotropia. By: Michelle Huynh College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA mhuynh@uams.edu Surgeons: Brita Rook, MD Arkansas Children’s Hospital – Department of Ophthalmology, Little Rock, Arkansas, USA BSRook@uams.edu Joseph Fong, MD Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA JFong@uams.edu Video was performed at Arkansas Children’s Hospital, Little Rock, AR, USA.

Treatment of Chronic Atelectatic Middle Ear with Endoscopic Placement of Cartilage Shield T-tube

Chronic tympanic membrane (TM) atelectasis is a difficult condition with many management challenges and currently has no acceptable gold standard treatment. TM atelectasis is the loss of the normal elasticity of the TM as a result of chronic negative pressure in the middle ear and can be associated with retraction pockets. The under-ventilation of the middle ear and TM retraction can cause ossicular erosion, hearing loss, or cholesteatoma formation. Atelectasis can be halted or reversed with placement of pressure equalization tube (PET). Cartilage tympanoplasty with or without PET has been reported as the preferred material likely due to its higher mechanical stability under negative pressure changes within the middle ear, in addition to its resistance to resorption. This video demonstrates the feasibility of a minimally invasive endoscopic approach of cartilage shield T-tube tympanoplasty as a treatment of chronic TM atelectasis.

Closure of H-type tracheoesophageal fistula

We present the case of a 20 months old boy with developmental delay and chromosomal abnormality, who presented with a history of chronic aspiration. He was found to have a laryngeal cleft, which was injected with Prolaryn, then formally repaired, twice. Despite an initial a negative swallow study, the patient had persistent aspiration. A repeat direct laryngoscopy and bronchoscopy finally revealed the presence of an H-type tracheoesophageal fistula (TEF). We describe here the steps of the surgical repair of an H-type tracheoesophageal fistula.

How to perform a Tracheostomy on an infant

Authors Gilberto Eduardo Marrugo Pardo Titular professor, Department of Otorhinolaryngology, Universidad Nacional de Colombia, Bogotá, Colombia. Fundación hospital de la misericordia. gemarrugop@unal.edu.co JuanSebastián Parra Charris Department of Otorhinolaryngology, Universidad Nacional de Colombia, Bogotá, Colombia jusparrach@unal.edu.co    

Pediatric Tracheostomy with Maturation Sutures

Procedure: This video demonstrates the operative method of pediatric tracheostomy with maturation sutures of the tracheocutaneous fistula tract. Introduction: Pediatric tracheostomy provides an alternate airway. Indications: This procedure is done to alleviate upper airway obstruction, facilitate prolonged mechanical ventilation, or pulmonary toilet. Contraindications: There are no absolute contraindications to this procedure, however, like any procedure, it has recognized possible risks. Conclusion: Pediatric tracheostomy with maturation sutures provides an alternate airway to bypass obstruction, facilitate long term ventilation, or pulmonary toilet.

RESECTION OF THE POSTERIOR GASTRIC WALL: ANOTHER STRATEGY AGAINST GIST WITH ENDOLUMINAL GROWTH

Gastrointestinal stromal tumors (GIST) occur most frequently at the gastric level. Surgical resection is the mainstay of treatment and can usually be performed using laparoscopic approaches (1). The resection strategy must be adjusted to each case, the selection of location, size and growth pattern of the tumor (2). We present the case of a 78-year-old female patient who, after going to the Emergency Department due to symptoms of upper gastrointestinal bleeding, showed a 5 cm heterogeneous tumor depending on the muscular layer itself in a posterior gastric wall, endoluminal growth, and without objectifying others injuries in the study of extension. A wide posterior resection of the gastric posterior wall and primary closure with a barbed suture was performed laparoscopically. The postoperative evolution was satisfactory. The histopathological study shows low-risk GIST (5 mitosis / 50 CGA) with free margins; during follow-up, no recurrence was observed. Simple laparoscopic resection of gastric GIST tumors seems to be a useful strategy in terms of oncological safety, reducing excessive resection of tumor-free tissue and increasing gastric remnant.

TENT TECHNIQUE OF LAPAROSCOPIC RETROPERITONEAL LYMPHADENECTOMY- TRANSPERITONEAL APPROACH

Authors: First author: Dr. Thammineedi Subramanyeshwar Rao, M.S, MCh, FMAS Corresponding author: Dr. R Rajagopalan Iyer, DNB,FSOG,MNAMS,FMAS Third author: Dr. Srijan Shukla, M.S,FMAS Affiliation of all authors: Basavatarakam Indo-American Cancer Institute and Research Centre, Road no. 10, Banjara Hills, Hyderabad, Telangana, India; PIN: 500034 Corresponding author’s mailing address: Department of Surgical Oncology, 4th floor, Block 1, Basavatarakam Indo American Cancer Hospital, Road no. 10, Banjara Hills, Hyderabad, Telangana, India; PIN: 500034 Corresponding author's email address: rajagopalan99@hotmail.com Disclosure/ Conflict of interest: The authors whose names are listed above certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers ’bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. NO FUNDING SOURCES .

Totally Robotic Sigmoidectomy with Trans-anal Specimen Extraction and Intra- corporeal, Single Stapler, End-to-End Anastomosis

As technique and technology have evolved in the modern age, surgical emphasis has shifted steadily towards minimally invasive alternatives. In colon surgery, laparoscopy has been shown to improve multiple outcome metrics, including reductions in post-operative morbidity, pain, and hospital length of stay, while maintaining surgical success rates. Unfortunately, despite the minimally invasive approach, elective laparoscopic sigmoidectomy typically requires an abdominal wall extraction site, leaving a large incision in addition to the laparoscopic port sites. It also utilizes three different types of intestinal staplers, leading to an anastomosis that may have multiple intersecting staple lines, thereby potentially influencing the anastomotic integrity, as well as increasing procedural costs substantially. We present a case of a totally robotic sigmoidectomy utilizing a single stapler technique and natural orifice specimen extraction in a patient with multiple, severe, recurrent episodes of sigmoid diverticulitis over a 2-year period.

Chalazion Incision and Curettage

Intro A chalazion is a lipogranulomatous inflammation of a meibomian gland in the eyelid that presents as a painless eyelid nodule or swelling. This pediatric patient presented with a chalazion that caused symptoms of eye irritation. The lesion had persisted for many months without improvement in response to warm compresses and eyelid scrubs with baby shampoo. Therefore, she underwent chalazion incision and curettage under sedation. Methods This video highlights the steps of chalazion incision and curettage. With a chalazion clamp tightened over the lesion, the eyelid is everted and an incision is made into the tarsus. A curette is used to scrape the walls of the cyst to remove the chalazion contents. At the conclusion of the procedure, the clamp is removed and pressure is applied to the area of the lesion for hemostasis. Conclusion Incision and curettage is a safe, relatively quick, and effective procedure for the management of persistent chalazia. Authors Michelle L. Huynh, BA College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA Muhammad Shamim, MD Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA Christian Ponder, MD Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA A. Paula Grigorian, MD Arkansas Children’s Hospital – Department of Ophthalmology, Little Rock, Arkansas, USA The procedure was performed at Arkansas Children’s Hospital, Little Rock, AR, USA. Music by bensound.com.

Tongue Reduction (Partial Glossectomy) for Pediatric Macroglossia

This video demonstrates how to perform a tongue reduction using a Y-V advancement technique for pediatric macroglossia.

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

Nasopharyngeal Papillomatosis- A combined Transnasal Transoral Coblation Assisted Approach

Title: Nasopharyngeal Papillomatosis- A combined trans nasal transoral coblation assisted approach Authors - 1. Dr Deepa Shivnani- corresponding author MBBS, DNB Otolaryngology , MNAMS, Fellowship in Pediatric Otolaryngology Children’s Airway & Swallowing Center Manipal Hospital, Bangalore , India email- deepa.shivnani14@gmail.com 2. Dr E V Raman MBBS, DLO , MS Otorhinolaryngology Children’s Airway & Swallowing Center Manipal Hospital, Bangalore Here I am presenting a case of 16 yrs old boy, who had nasal block and occasional cough. Nasal endoscopy revealed an exophytic papillomatous growth in the nasopharynx. MRI showed lesion arising from the nasopharyngeal surface of the soft palate. The lesion was free from the posterior pharyngeal wall. The patient was taken up for the procedure under general anaesthesia. The transoral approach was followed first. The tissue was taken for histopathological examination followed by a traction suture placed over uvula for better visualisation. Once exposed, coblation device was used transorally with 45 degree hopkins rod transorally. The tissue was ablated with coblation and coagulation settings of 9:5 respectively. The base was ablated too, to prevent further recurrence. Tonsillar pillar retractor was then used for better visualisation and exposure. The coblation was then continued. The tissue was removed transorally as much as possible then trans nasal approach was performed. Then, the same coblation device with the same setting was used but the nasal endoscope was changed to O degree Pediatric scope due to space constraints. The lesion was pushed upward with the help of yankaurs suction tip for better exposure and the remaining tissue was removed with the help of same coblation device. The lesion was excised completely and successfully with minimal blood loss. The operative area was confirmed with the 70Degree hopkins rod for complete removal of the lesion. Post operative recovery was uneventful. Combined transoral trans nasal coblation assisted approach is potential to be safer, easier and less invasive than uvulo palato pharyngoplasty in Pediatric age group specially, in the areas which are difficult to access like nasopharyngeal surface of the soft palate what we showed in this video.

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

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.

A Safe Stepwise Approach to the Critical View of Safety During Laparoscopic Cholecystectomy

Contributors: Eric Zimmerman and Pierre F Saldinger After the introduction of laparoscopic cholecystectomy bile duct injury rates have increased (3 per 1,000 cholecystectomies). Bile duct injuries after cholecystectomies are unfortunate events that can lead to significant morbidity, high cost and impair in quality of life. The purpose of this video is to demonstrate a safe stepwise approach to the critical view of safety described by Strasberg during laparoscopic cholecystectomy. DOI: http://dx.doi.org/10.17797/ce9i07jf03 Editor Recruited By: Jeffrey B. Matthews, MD

Single Incision Laparoscopic Surgical (SILS) Placement of an Adjustable Gastric Band

Contributors: Melissa Beitner and George Fielding This video shows a single incision laparoscopic surgical placement of an adjustable gastric band. DOI: https://doi.org/10.17797/jdzx4zu6s8

Aortic Valve Replacement via the Ross Procedure

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

Donghang Huang’s procedure for thyroidectomy

Donghang Huang’s procedure, also termed as direct-access single-port endoscopy assisted mini-incision thyroidectomy, is a hybrid surgery conducted in the following 3 major steps: 1.A mini-incision of approximately 2.5-3 cm long on the central neck is made. A working space under the platysmal muscle or strap muscles for single-port endoscopic surgery is constructed with carbon dioxide insufflation (performed under direct vision). 2.Mobilization of the superior and inferior pole of the thyroid lobe, and exposure of the recurrent laryngeal nerve (performed under single-port endoscopy). 3.Extraction and resection of the thyroid lobe. (performed under direct vision). Donghang Huang's procedure can provide shorter incision and better cosmetic results while maintaining adequate exposure.

Robotic-assisted pyeloplasty for ureteropelvic junction obstruction

Introduction We present a case of ureteropelvic junction obstruction secondary to aberrant crossing gonadal vessels in a symptomatic 11-year-old female with horseshoe kidney, treated with a robotic-assisted pyeloplasty. Diagnostic Evaluation The patient presented with intermittent right-sided flank pain and vomiting. Renal ultrasound showed right-sided hydronephrosis and an abnormal-shaped kidney. MAG-3 renal scan demonstrated decreased function of the right kidney and no drainage. A MR Urogram showed a horseshoe type kidney with malrotation and an anterior dilated renal pelvis. Surgical Technique The patient underwent a robotic-assisted dismembered pyeloplasty. Intraoperatively, the right kidney was confirmed to be malrotated with a large, anteriorly directed renal pelvis. A packet of aberrant crossing gonadal vessels was identified and dissected from the right ureter and surrounding tissue. The ureter was sharply divided at the level of the ureteropelvic junction and transposed above the crossing vessels. A tension free mucosal to mucosal water-tight anastomosis was performed starting at the apex of the incision. A double-J stent was introduced into the ureter. The remainder of the anastomosis was completed with interrupted sutures. There were no intraoperative or postoperative complications. Conclusions Robotic-assisted dismembered pyeloplasty is a safe and effective method for UPJO correction in symptomatic patients with complex renal anatomy.

How to Correctly Place the Pelvic Binder - A Life-Saving Technique

This video demonstrates how to place the pelvic binder quickly and correctly, which may be life-saving in cases of pelvic ring fractures with associated potential massive bleeding. Proper pelvic binder placement technique requires attention to some details, including the 5Ps (pulses, penis, pockets, pain and pulses), horizontal force application in opposing vectors and ensuring the pelvic binder is locked.

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. Thank you for watching!

Rectovaginal Fistula Repair with a Vascularized Gracilis Muscle Interposition Flap

The surgical management of rectovaginal fistulas remains difficult, as they tend to be recurrent and vary widely in location and complexity. We present a case of a 63-year-old woman with a low-lying rectovaginal fistula who initially underwent chemoradiation and a Low Anterior Resection for a low-lying rectal cancer. Her course was uneventful until two years post-operatively, at which time her anastomotic staple line became stenotic with associated bleeding. This was initially addressed by Gastroenterology who executed a dilation and achieved hemostasis with Argon Plasma Coagulation. This remedied the stenosis, however, it was complicated by the formation of a rectovaginal fistula. Due to the low-lying location and its presence in an irradiated field, a transvaginal approach with an interposed gracilis flap was elected for repair.

Robotic-Assisted Transanal Polyp Resection

Contributors: Benjamin Biteman and Vincent Obias Robotic Transanal minimally invasive surgical removal of 1.8cm villous adenoma with high grade dysplasia at 22cm. DOI#:https://doi.org/10.17797/kzimoid3xj Editor Recruited By: Vincent Obias

Robotic Sigmoid resection for Colovesicular Fistula and use of Firefly

Contributors: Ben Biteman, MD 61 year old male with diverticulitis and colovesicular fistula. Patient underwent robotic sigmoid colectomy with takedown of fistula. Firefly used to help identify if fistula still present. Editor Recruited By: Vincent Obias, MD, MS DOI# http://dx.doi.org/10.17797/9qxwhlr1q5

Robotic Assisted Redo Rectopexy and Low Anterior Resection

Contributors: Craig Rezac, MD Low anterior resection and rectopexy is the optimal treatment for well functioning patients with rectal prolapse. Reoperations for rectal prolapse may be challenging due to significant adhesions. Use of the robot for low anterior resection and rectopexy is safe, feasible and may be more useful than laparoscopy especially in challenging cases. DOI:http://dx.doi.org/10.17797/vkp7axh60l

Low Anterior Resection for Diverticulitis

Contributors: Craig Rezac, MD Treatment for recurrent or complicated diverticulitis is surgical resection. Minimally invasive techniques are associated with decreased length of stay and decreased post operative pain. However, laparoscopic low anterior resection is challenging especially in the narrow pelvis. Robotic surgery may overcome these obstacles and allow more surgery for divertiuclitis to be performed minimally invasively. These surgeons always do a LAR for diverticulitis because they transect on the proximal rectum. They take down the lateral stalks in order to mobilize the rectum and get the eea stapler through the rectum easier. Bilateral ureteral stents are routinely placed to better identify the ureters. This is especially important in cases of chronic/active diverticulitis or diverticulitis that has been complicated by abscess or fistula. This is the preference of the surgeon. DOI# http://dx.doi.org/10.17797/y1f1omu3mt

Completely Robotic Total Proctocolectomy and Ileal Pouch Anal Anastomosis

Contributors: Nell Maloney Patel, MD and Craig Rezac, MD There is little role for the use of minimally invasive techniques in the emergent setting for ulcerative colitis. However, for elective procedures, studies have shown that laparoscopic restorative proctocolectomy with IPAA is equivalent to open IPAA with regards to safety and feasibility, and that laparoscopic IPAA is associated with shorter recovery times, earlier return to bowel function, less post operative pain and a better cosmetic result. However laparoscopic approaches are difficult especially in the narrow pelvis. These challenges maybe overcome with the daVinci robotic system. DOI:http://dx.doi.org/10.17797/r1oi8fx5c2 Editor Recruited by: Neil Tanna

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

Novel use of a balloon for bronchial bead foreign body removal

Contributors: Josephine Czechowicz and Sanjay Parikh Removal of a bronchial foreign body with a smooth surface can be challenging with standard optical forceps. The fogarty arterial embolectomy catheter is a suitable alternative, particularly in the setting of a bead or other hollow object. DOI: http://dx.doi.org/10.17797/7gq2gil0v3 Editor Recruited by: Sanjay Parikh

Sequential Balloon Dilation and Triamcinolone Injection in Premature Infant to Treat Glottic and Subglottic Injury

Contributors: Sanjay Parikh Sequential Balloon Dilation and Triamcinolone Injection in Premature Infant to Treat Glottic and Subglottic Injury. This video with narration shows a marked improvement in neonatal airway edema and successful extubation after three interventions of triamcinolone injection and balloon dilation. DOI# http://dx.doi.org/10.17797/w2iwnogofq Author Recruited by: Sanjay Parikh, MD. FACS

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.

Laparoscopic Completion Right Adrenalectomy after Open Left Adrenalectomy and Partial Right Adrenalectomy for Pheochromocytoma

Contributors: Charles M Leys This video will depict the salient steps in performing a laparoscopic completion right adrenalectomy in a teenager who has previously undergone an open left adrenalectomy and partial right adrenalectomy five years earlier for pheochromocytoma. DOI: http://dx.doi.org/10.17797/ftk20lm0ez

Laparoscopy for Contralateral Patent Processus Vaginalis

This video depicts several findings on the contralateral inguinal region when performing a diagnostic laparosocpy at the time of open repair of a unilateral inguinal hernia. DOI: http://dx.doi.org/10.17797/w6xnoqy0un

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

Laparoscopic Coledocoscopy

A 47-year-old male, with a history of multiple cholelithiasis and multiple choledochal lithiasis, who presented with multiple episodes of cholangitis for which endoscopic treatment (ERCP + stenting) was performed. After 4 unsuccessful attempts to resolve the bile duct by endoscopic approach, it was decided to perform minimally invasive laparoscopic surgery. In this video we can observe the Choledochotomy, followed by extraction of stones and biliary mud. Subsequently, a choledochoscopy is performed with the laparoscopic camera (10 mm) with infusion of sterile Physiological Solution since the patient had a very dilated bile duct. Choledochorrhaphy is then performed.

LAPAROSCOPIC HEPATIC S5-6 SEGMENTECTOMY FOR BLEEDING HCC

A 75-year-old male with history of chronic HCV- related hepatitis, in regular follow-up and sustained viral response (SVR), presented at our Emergency Department for sudden epigastric pain. Urgency CT scan and subsequent abdominal MRI revealed a 2,5cm monofocal HCC in S5 with surrounding hepatic hematoma (7cm of extension) and hemoperitoneum layer. The procedure consisted in laparoscopic exploration, lysis of tenacious adhesions between hepatic hematoma and the right colic flexure, intraoperative ultrasound to assess tumor extension, preparation of Pringle Maneuver and parenchyma transection with ultrasound dissector combined with colecistectomy.

Faisal Aziz, MD

Penn State University

• Assistant Professor of Surgery and Interim Chief of Vascular Surgery

Dr. Faisal Aziz completed his General Surgery Residency at New York Medical College in Valhalla, New York and his Vascular Surgery Fellowship at Jobst Vascular Center in Toledo, Ohio. He currently works as an Assistant Professor of Surgery and Interim Chief of Vascular Surgery at Penn State University. Dr. Aziz has authored numerous book chapters and peer-reviewed publications, and was awarded the Servier Traveling Fellowship Award by American Venous Forum. Dr. Aziz also serves as the Section Editor for Venous Disorders, VESAP-4 and Examination Consultant for the American Board of Surgery.

Shadi Abu-Halimah, MD

West Virginia University, Charleston Division

• Assistant Professor of Surgery

Shadi J. Abu-Halimah, M.D. FACS is a Vascular/Endovascular Surgeon. He is Double Boarded in Vascular and General surgery. He was born in Riyadh, Saudi Arabia and currently resides in Charleston, WV. Dr. Abu-Halimah received his doctorate degree in 2000 from the University of Jordan in Amman, Jordan with Honors. He is licensed to practice in the state of West Virginia.

Currently, Dr. Abu-Halimah serves as Assistant Professor of Surgery at the Robert C. Byrd Health Science Center, West Virginia University (WVU), Charleston Division, as well as Clinical Assistant Professor of Surgery at WVU SOM in Lewisburg, WV.

Since 2000, Dr. Abu-Halimah has completed extensive post-doctoral training, as follows: (2000-2001) General Surgery Internship at the Ministry of Health Hospitals in Amman, Jordan; (2001 – 2003) General Surgery Residency at Ministry of Health Hospitals in Amman, Jordan; (2003 – 2004) General Surgery Prelim at WVU in Charleston, WV; (2004 – 2009) General Surgery Residency at WVU in Charleston, WV; and (2009 – 2011) Vascular Surgery Fellowship at University of North Carolina in Chapel Hill, NC.

Dr. Abu-Halimah currently belongs to several professional societies, including the Eastern Vascular Society, the Southern Association for Vascular Surgery, the Society for Vascular Surgery, and the American College of Surgeons. Moreover, from 2011 to present day, Dr. Abu-Halimah has served on numerous medical committees ranging from national, departmental, and institutional levels across the country.

Dr. Abu-Halimah’s previous teaching responsibilities include undergraduate medical education and supervision of medical trainees in a weekly outpatient clinic; at the graduate level, he was Attending Physician for the University V2 Vascular Surgery Service and delivered presentations at various conferences in areas of general surgery and vascular education.

He is a consultant for various medical/device companies involved in developing and teaching new technologies across the country. This involves case reviews, monitoring, and proctoring physicians at the national, local, and institutional levels.

Dr. Abu-Halimah has participated extensively in numerous lectures around the world where he was invited to deliver presentations on various topics of general and vascular surgery. He has been widely published in peer-reviewed articles, and research and clinical trials where he served as primary investigator and sub-investigator, as well as numerous book chapters around the world.

Jack Elder, MD, FACS

Massachusetts General Hospital

• Chief of Pediatric Urology

Jack S. Elder, M.D., FACS, is Chief of Pediatric Urology, Mass General. Dr. Elder received an M.D. with distinction from the University of Oklahoma College of Medicine, and was Vice President of Alpha Omega Alpha. He completed general surgery training at Yale-New Haven Hospital and a residency in urology, including chief resident, at The Johns Hopkins Hospital. Dr. Elder completed a pediatric urology fellowship at Johns Hopkins and at Children’s Hospital of Philadelphia. He was Director of Pediatric Urology at Rainbow Babies and Children’s Hospital for 21 years, and tenured Carter Kissell Professor of Urology at Case Western University School of Medicine. Subsequently, Dr. Elder was appointed Chief of Urology and Chief of Pediatric Urology, Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI.

Dr. Elder was the Pediatric Urology Section Editor of The Journal of Urology from 1998-2007. Currently, he is on the editorial board of European Urology, Pediatric Surgery International, BJU International, Annals of Urology, and International Scholarly Research Notices. Dr. Elder served as President of the Society for Pediatric Urology and the American Academy of Pediatric Urologists. He was the Chairman of the first American Urological Association Pediatric Vesicoureteral Reflux Guidelines Committee, and was the facilitator of the second AUA Reflux Guidelines Committee, which published updated recommendations in 2010. He also is the Section Head, Pediatric Urology, AUA Online Robotic Surgery Handbook and is an annual reviewer for the European Association of Urology Paediatric Urology Guidelines. Dr. Elder has been Visiting Professor or Visiting Surgeon at 54 U.S. and international medical centers. Dr. Elder has > 160 peer-reviewed publications, edited or authored 6 books, 150 book chapters, and writes the pediatric urology section of the Nelson Textbook of Pediatrics. He is listed in Boston Magazine 2016 Top Docs.

Craig Rezac, MD

Rutgers Robert Wood Johnson Medical School

• Associate Professor of Surgery
• Section Chief, Colon and Rectal Surgery

Craig Rezac, M.D., is a Double Board Certified Surgeon with clinical interest in Colon and Rectal Surgery. American-born, Dr. Rezac received his doctorate degree from Pisa Medical School in Pisa, Italy in 1995, and his undergraduate degree from Adelphi University in Long Island, NY in 1981. Dr. Rezac is licensed to practice in New Jersey and the Republic of Italy.

Currently, Dr. Rezac serves as Associate Professor of Surgery, Section Chief Colon and Rectal Surgery at Rutgers Robert Wood Johnson Medical School (RWJMS) in New Brunswick, NJ. He also serves as Staff Physician, General Surgery at Somerset Medical Center in Somerville, NJ.

After receiving his medical degree, Dr. Rezac completed a Surgical Externship at La Spezia Hospital in La Spezia, Italy. He then completed a General Surgery Internship at the Monmouth Hospital in Long Branch, NJ. This was followed by a General Surgery Residency at UMDNJ-Robert Wood Johnson Medical School in New Brunswick, NJ, and a Colorectal Surgery Fellowship at UMDNJ-Robert Wood Johnson Medical School in Edison, NJ. Lastly, Dr. Rezac completed a Laparoscopic Fellowship at Hackensack University Hospital in Hackensack, NJ.

Dr. Rezac holds numerous medical certifications as follows: Cyberknife, Davinci Laparoscopic Robotic Surgery, Davinci Advanced Laparoscopic Robotic Surgery for Colon and Rectal Surgery, American Heart Association (BLS/CPR), Trans Anal Endoscopic Microsurgery (TEM), and Stapled Trans Anal Rectal Resection (STARR). Dr. Rezac has the distinct honour of being the first doctor in New Jersey to be certified in both TEM and STARR.

Dr. Rezac is a member of several professional associations, including: American College of Surgeons (Fellowship), American Society of Colon and Rectal Surgeons, Society of Laparoendoscopic Surgeons, American College of Surgeons, New Jersey Chapter, and the New Jersey Chapter of American Society of Colon and Rectal Surgeons (past-President).

Dr. Rezac has received a number of honors and awards for outstanding performance both academically and professionally. He currently serves on several major committees, in addition to school and hospital committees, while continuing to meet various teaching and clinical responsibilities.

Dr. Rezac has received substantial grant support for medical studies and has been widely published in national and international medical journals, books, monographs, chapters, and articles. Dr. Rezac has generously shared his time and talents to deliver over 30 scientific and clinical presentations around the world.

Anand R. Kumar, MD, FACS, FAAP

Johns Hopkins University School of Medicine

• Associate Professor, Departments of Plastic Surgery and Pediatrics

Anand R. Kumar, MD, FACS, FAAP is an Associate Professor in the Departments of Plastic Surgery and Pediatrics at the Johns Hopkins University School of Medicine. A pediatric plastic/craniofacial surgeon and basic science researcher, he conducts investigation into the cellular biology of muscle derived progenitor cells as a source of pathologic heterotopic ossification and for novel regenerative medicine applications. His clinical practice focuses on craniofacial surgery including craniosynostosis, correction of hypertelorism(wide eyes), pediatric and adolescent facial skeletal deformities (Pierre Robin Sequence) with airway obstruction using traditional orthognathic (jaw) surgery and distraction osteogenesis.

Dr. Kumar established the center for facial skeletal surgery and the center for pediatric craniofacial surgery at the University of Pittsburgh Medical Center and now at Johns Hopkins respectively with an emphasis on multidisciplinary care for dentofacial anomalies. He has led efforts to improve outcomes in pediatric sleep apnea using skeletal surgery and distraction osteogenesis for multilevel airway obstruction. In addition, he has participated in multi-institutional trials for improvement of clinical outcomes in neonatal tongue base collapse (Pierre-Robin Sequence).

Dr. Kumar as authored over 30 original scientific publications in peer-reviewed journals and contributed to multiple plastic and orthopedic surgery textbooks over the last 10 years. He serves as a reviewer for many plastic surgery and basic science journals and has been invited as a speaker or panelist to many institutions and at organizational meetings across the United States. He currently serves as Vice President of Communications on the board of the American Society of Maxillofacial Surgeons (ASMS). In addition, he serves on multiple committees in the American Society of Plastic Surgeons and the ASMS.

As an honor student in the biological sciences at the University of California, Irvine, Dr. Kumar received his medical degree from the Albert Einstein College of Medicine. He completed his general surgery residency at the Mayo Clinic Rochester and later completed a second residency in plastic and reconstructive surgery at the University of California, Los Angeles (UCLA). He subsequently completed a pediatric plastic/craniofacial surgery fellowship after his residency at UCLA. In 2004, prior to his academic appointment, Dr. Kumar volunteered for military service and joined the United States Navy until 2010. In Bethesda, MD, he served as director and staff pediatric plastic surgeon of the Military Craniofacial Unit at Walter Reed National Military Medical Center. He served as division chief in plastic and reconstructive surgery at the National Naval Medical Center in Bethesda and on board the United States Naval Support Hospital Ship Comfort. In 2010, Dr. Kumar was recruited to the University of Pittsburgh as the director of facial skeletal surgery until 2013 when he was recruited to Johns Hopkins.

Michael Golinko, MD

University of Arkansas for Medical Sciences

• Medical Director of Craniofacial Program, Arkansas Children’s Hospital
• Assistant Professor of Plastic Surgery, UAMS

Dr. Michael Golinko, M.D., is a Board Certified General Surgeon with clinical interests in Craniofacial, Cleft & Paediatric Plastic Surgery. Dr. Golinko is also Board Eligible with the American Board of Plastic Surgery, and is licensed in the states of Arkansas, and Georgia. Currently, Dr. Golinko serves as one of the Medical Directors of Arkansas Children’s Hospital Craniofacial Program, and is Assistant Professor of Plastic Surgery at the University of Arkansas Medical Sciences.

Dr. Golinko received his M.D. degree from University of South Florida (USF) in 2004, preceded by a M.A. in Medical Anthropology from Universiteit van Amsterdam (UVA) in 2002, and a B.Sc. in Physics from Massachusetts Institute of Technology (MIT) in 1998.

Dr. Golinko’s professional training includes General Surgery residencies at State University of New York (SUNY) and New York University (NYU), as well as a residency in Plastic & Reconstructive Surgery at Emory University School of Medicine, and he most recently served as a Fellow in Craniofacial Surgery/Pediatric Plastic Surgery at New York University (NYU).

From 1998 to 2008, Dr. Golinko held medical research positions at MIT, Massachusetts General Hospital, and completed Post-Doctoral Research Fellowships in the Department of Surgery, Division of Wound Healing at both Columbia University and New York University.

Dr. Golinko has contributed extensively to numerous peer-reviewed publications, book chapters, and abstracts. Moreover, Dr. Golinko has travelled the world to deliver numerous presentations, co-chair lectures and conferences, and media appearances.

Dr. Golinko has been awarded and recognized for the following: Operation Smile Regan Fellowship Recipient (2012), National Institute of Health (NIH) Loan Repayment Program Recipient (2007 – 2009), and Columbia University College of Physicians & Surgeons, Department of Surgery, Startup Grant (2006).

In the spirit of a true leader, Dr. Golinko served as past-President and Mission Leader of Project World Health, Managing Trustee of the Barry Golinko Trust of the Jewish Communal Fund, past-Surgery Department Representative of the Committee on Interns and Residents (CIR) and currently was selected to participate in the Arkansas Children’s Hospital Physician Leadership Development course.

Dr. Golinko currently belongs to several professional societies as follows: American Cleft Palate-Craniofacial Association, American Association of Wound Care, American College of Surgeons, and the Southeastern Society Of Reconstructive Plastic Surgeons.
In 2016, Dr. Golinko served on the American Society of Maxillofacial Surgeons/Plastic Surgery Foundation Combined Pilot Research Grant Committee. In addition to his professional work, Dr. Golinko has generously donated his time and many talents to numerous volunteer and humanitarian efforts all over the world.

Dov Goldenberg, MD

University of Sao Paulo Medical School

• Coordinator of Pediatric Plastic Surgery
• Supervisor (Residency Program in Plastic Surgery at the Division of Plastic Surgery), Hospital das Clinicas – University of Sao Paulo Medical School
• Attending Cranio-facial Surgeon – Division of Head and Neck Surgery and Otorhiolaryngology, Hospital A.C. Camargo
• Senior Surgeon and head of Cranio-maxillo-facial Surgery Team, Hospital Albert Einstein
• Chief of Pediatric Plastic Surgery Group, Hospital Municipal Infantil Menino Jesus

Residing in São Paulo, Brazil, Dr. Goldenberg graduated from the University of São Paulo Medical School. He then continued his studies with Postdoctoral Training and completed the Residency Program in General Surgery, followed by the Residency Program in Plastic Surgery at the Hospital of the Faculty of Medicine, University of São Paulo, Brazil.

Soon thereafter, Dr. Goldenberg earned his PhD in Plastic Surgery at the University of São Paulo Medical School, where he also gained his title as Full Professor of the Department of Surgery.

Dr. Goldenberg is the Editor-In-Chief for the Brazilian Journal of Plastic, International Associate Editor of Plastic and Reconstructive Surgery Journal (PRS), and past President of the Brazilian Association of Craniomaxillofacial Surgery.

His areas of interest in plastic surgery include Pediatric Plastic Surgery, Cranio-facial Surgery and Vascular Anomalies.

Steven Scot Rothenberg, MD

Columbia University College of Physicians and Surgeons

• Chief of Pediatric Surgery, Rocky Mountain Hospital for Children
• Clinical Professor of Surgery, Columbia University College of Physicians and Surgeons

Dr. Rothenberg is the Chief of Pediatric Surgery at the Rocky Mountain Hospital for Children at PSL in Denver, Co. He is also a Clinical Professor of Surgery at Columbia University College of Physicians and Surgeons. He is a world leader in the field of endoscopic surgery in infants and children and has pioneered many of the procedures using minimally invasive techniques.

Dr. Rothenberg completed medical school and general surgery residency at the University of Colorado in Denver. He then spent a year in England doing a fellowship in General Thoracic Surgery prior to returning to the states where he completed a two year Pediatric Surgery fellowship at Texas Children’s Hospital in Houston. He returned to Colorado in 1992 where he has been in practice for over the last 20 years.

Dr. Rothenberg was one of the founding members of the International Pediatric Surgical Group (IPEG) and is a past-president. He was also the Chair of the Pediatric Committee and on the Board of Directors for SAGES (The Society of American Gastro-intestinal Endoscopic Surgeons). He has authored over 180 publications on minimally invasive surgery in children and has given over 300 lectures on the subject nationally and internationally. In 2015 He received “The Pioneer in Surgical Endoscopy Award” from SAGES. He is also on the editorial board for the Journal of Laparoendoscopic Surgery and Advanced Surgical Technique, The Journal of Pediatric Surgery, and Pediatric Surgery International.

Dr. Rothenberg has been married to his wife Susan for over 30 years and has three children Jessica, Catherine, and Zachary. He is an avid outdoorsman and spends most of his free time in the mountains of Colorado skiing, hiking, biking, and fishing.

George W. Holcomb, III, MD, MBA

Children’s Mercy Hospital

• Surgeon-in-Chief
• Director of the Center for Minimally Invasive Surgery

Dr. George W. Holcomb, III was born in Osaka, Japan on December 11, 1953. He was raised in Nashville, Tennessee and attended elementary and high school in Nashville. He attended the University of Virginia for college and then Vanderbilt Medical School. His general surgery training was at Vanderbilt University Medical School and his pediatric surgery training was at the Children’s Hospital of Philadelphia. He began his pediatric surgery practice in 1988 as an Assistant and subsequently Associate Professor of Surgery in the Department of Pediatric Surgery at Vanderbilt University School of Medicine. In 1999, he was recruited to replace Dr. Keith Aschraft as Surgeon-in-Chief at Children’s Mercy Hospital in Kansas City, Missouri. In addition to being the Surgeon-in-Chief, he is also the Director of the Center for Minimally Invasive Surgery.

Dr. Holcomb is best known for his interest in minimally invasive surgery in infants and children and his emphasis on evidence-based medicine. He is the author of over 240 peer-reviewed publications and 50 book chapters, and has been the editor of 5 textbooks.

Stefan Scholz, MD

Assistant Professor of Surgery, University of Pittsburgh

Director of Minimal Invasive Surgery, Children’s Hospital Pittsburgh

Stefan Scholz, M.D., is a Double Board Certified Surgeon born in Marburg, Germany and currently resides in Pittsburgh, PA. Dr. Scholz received his M.D. degree in 1997 from Philipps-Universitat Marburg school of Medicine in Marburg, Germany. In 2000, Dr. Scholz received his Dr. Med. Degree in Comparative Endocrinology at the Thomas Jefferson University in Philadelphia, PA.

Dr. Scholz currently serves as Assistant Professor of Surgery at University of Pittsburgh as well as Director of Minimal Invasive Surgery at Children’s Hospital Pittsburgh. Previous positions held include Clinical Fellow of Surgery at Harvard Medical School (2004-2008), and Clinical Instructor of Surgery at Johns Hopkins University (2008-2010). Dr. Scholz is currently licensed to practice medicine in Germany, Maryland, and Pennsylvania.

Dr. Scholz has completed extensive post-graduate work from 2000-2011 in the fields of pediatric surgery, endoscopic and laparoscopic surgery, and general surgery at various institutions in Germany, Tennessee, Georgia, Massachusetts, Maryland, and UK.

Dr. Scholz has received numerous certifications as follows: The American Board of Surgery – General Surgery (2009) and Pediatric Surgery (2011); Fundamentals of Laparoscopic Surgery (2007); Ultrasound Instructor, American College of Surgeons (2007); Basic Life Support (2006); Advanced Cardiac Life Support (2006); Advanced Trauma Life Support (2011/2015); Pediatric Advanced Life Support (2011); and daVinci Surgical System Console Surgeon (2011).

Since 2008, Dr. Scholz held various hospital administrative positions, committee appointments, and committee leadership roles at the following institutions: Johns Hopkins Hospital, Johns Hopkins University (2008-2010), Diana, Princess of Wales Children’s Hospital, University of Birmingham (2010-2011), Magee Women’s Hospital (2011), and Children’s Hospital of Pittsburgh of UPMC (2011-2016).

Since 1999, Dr. Scholz has been a member of several professional and scientific societies. Special honors include a Teaching Award – Best Resident at Beth Israel Deaconess Medical Center (2008), and SAGES Service Award Medal (2016).

Dr. Scholz has been extensively published around the world in various articles, reviews, invited papers, abstracts, monographs, books, and book chapters. Professional activities include formal teaching of resident students, grand rounds presentations, and peer teaching. Dr. Scholz has served on numerous national and international committees, panels, and boards.

H. Leon Pachter, MD

George David Stewart Professor of Surgery, Chair of the Department of Surgery at NYU Langone Medical Center

Known for his passion, energy, and skill, Dr. Pachter has perfected a number of life-saving techniques over the years, including a multidisciplinary approach to treating tumors of the adrenal gland. By introducing advances in minimally invasive surgical techniques, Dr. Pachter has played a key role in making NYU Langone’s surgical service one of the finest in the country. Dr. Pachter is also a world-renowned educator, whose mentees have become national leaders at other prestigious medical centers.

Dr. Pachter’s roots to NYU Langone stretch back to his days as a student and chief resident in the early 1970s. After completing his MD, residency, and American Cancer Society Fellowship at NYU School of Medicine, Dr. Pachter has had an unbroken record of outstanding contributions—as director of the Trauma Service at Bellevue Hospitals Center from 1978 to 1998; as executive director from 1999 to 2006; as director of Bellevue’s Surgical Intensive Care Unit from 1978 to 1997; as chairman of the Medical Board of Tisch Hospital; as vice chairman for Faculty Affairs; as division chief of General Surgery; and as author, clinical scientist, master laparoscopic surgeon, and world-class mentor. Additionally, Dr. Pachter was instrumental in garnering significant support from the city council to build the Ranson laboratory at Bellevue Hospital, a site of important cancer research investigations.

The author of more than 100 peer-reviewed publications and numerous book chapters, Dr. Pachter serves on the Editorial Board for the American Journal of Surgery, Annals of Surgery and The Journal of Trauma and Critical Care. He also served on the American Board of Surgery as a consultant for the written boards for 8 years and is currently serving on the membership committee of the American Surgical Association. The American College of Surgeons has also designated him a mentor for young female academic surgeons in the U.S. This year Dr. Pachter was chosen by the Society of Black Academic Surgeons for its 2015 fellowship award for his efforts to diversify his department and his seminal contributions to surgery.

Vincent Obias, MD, MS

Chief, Division of Colon and Rectal Surgery, George Washington University, Department of Surgery, Washington, DC

Dr. Obias is an Associate Professor of Surgery at George Washington University and Chief of the Division of Colon and Rectal Surgery.  Dr. Obias received his Bachelor’s Degree in Biology from James Madison University, his Masters degree in Physiology at the Medical College of Virginia, and his Doctorate in Medicine at the Medical College of Virginia.  He performed his internship and general surgery residency at Eastern Virginia Medical School in Norfolk, VA. Dr. Obias next undertook a fellowship in colon and rectal surgery at the Cleveland Clinic in Ohio. He further specialized in Advanced Laparoscopic colon and rectal surgery by undergoing a fellowship at University Hospitals Case Medical Center the following year. He is board certified in both general surgery and colon and rectal surgery.  Dr. Obias’s specialties include robotic and minimally invasive colon and rectal surgery. His interest include robotic single incision surgery, robotic transanal surgery, and clinical outcomes of robotic colorectal surgery.

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.

Samir Pandya, MD

New York Medical College

• Assistant Professor
• Department of Surgery and Pediatrics

Dr. Samir Pandya was awarded his Bachelor’s of Science with honors in Biomedical Engineering at the University of Miami. He subsequently pursued medicine to be on the front lines of patient care and medical device development. He completed his medical training at the Medical College of Virginia and then General Surgery residency at the Westchester Medical Center Campus of New York Medical College in Valhalla, NY. He went on to train in Pediatric General and Thoracic Surgery at Children’s Healthcare of Atlanta at Emory University in Atlanta. Upon completion of his fellowship training in 2011 he joined joined the faculty at New York Medical College as Assistant Professor in the Department of Surgery and Pediatrics.

He has a very strong interest in minimally invasive pediatric surgery with expertise in mini-laparoscopy and single-incision procedures. He is currently the Surgical Director for Newborn Surgery, Pediatric and Neonatal Extracorporeal Life Support programs at the Maria Fareri Children’s Hospital. He has a strong interest in thoracic diseases as related at to pediatric patients such as chest wall anomalies, congenital lung lesions as well as surgical oncology.

Academically he enjoys working with medical students, residents and fellows. He has received numerous teaching awards during his career. He currently also serves as the Associate Program Director of the General Surgery Residency at New York Medical College. Dr. Pandya is an active member on numerous committees in the American Pediatric Surgery Association as well as the International Pediatric Endosurgery Group. Outside of pediatric surgery, Dr. Pandya enjoys running, skiing, diving, digital photography and target shooting.

Joseph W. Turek, MD, PhD

University of Iowa

• Chief of Pediatric Cardiac Surgery
• Co-Director, University of Iowa Stead Family Congenital Cardiac Center
• Director of Extracorporeal Membrane Oxygenation Services
• Program Director of the Thoracic Surgery Fellowship and Thoracic Integrated Six-Year Residency Programs

Joseph William Turek, MD, PhD graduated from Northwestern University with a BA in Biochemistry in 1994 and received his MD/PhD (Pharmacology) from the University of Illinois – Chicago in 2002.  He completed his general surgery education at Duke University in 2007, where he also completed a cardiothoracic residency in 2010.  During this time he served as a visiting congenital fellow at Texas Children’s Hospital.  He completed a congenital cardiac fellowship at the Children’s Hospital of Philadelphia in 2011.  Dr. Turek was the third John H. Gibbon Jr. Research Scholarship Recipient awarded by the American Association for Thoracic Surgery (2014-2016).  Dr. Turek is Chief of Pediatric Cardiac Surgery and Co-Director, University of Iowa Stead Family Congenital Cardiac Center.  He is also the Director of Extracorporeal Membrane Oxygenation Services and serves as the Program Director of the Thoracic Surgery Fellowship and Thoracic Integrated Six-Year Residency Programs at the University of Iowa Hospitals and Clinics.  His specialties include congenital heart surgery, pediatric heart transplantation and assist devices.  Dr. Turek is quite active nationally, holding board positions and serving on varies committees.  Dr. Turek can be reached at his office number (319) 384-8365 or by e-mail at joseph-turek@uiowa.edu with any questions.

Jose M Marchena DMD, MD, FACS

• Associate Professor of Oral and Maxillofacial Surgery - University of Texas Health Science Center
• Chief of Oral and Maxillofacial Surgery - Ben Taub Hospital

Dr. Jose Marchena obtained his dental degree magna cum laude from Harvard School of Dental Medicine and his medical degree from Harvard Medical School. He completed internships in oral and maxillofacial surgery and general surgery at Massachusetts General Hospital in Boston and his residency training at Louisiana State University Medical Center in New Orleans. Dr. Marchena is an associate professor of oral and maxillofacial surgery at the University of Texas Health Science Center in Houston. He also serves as chief of oral and maxillofacial surgery at Ben Taub Hospital in Houston and as vice president of Smile Bangladesh, a nonprofit organization dedicated to providing cleft lip and palate repair operations in rural Bangladesh.

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.

L.D. Britt, MD, MPH, D.Sc (Hon), FACS, FCCM

Eastern Virginia Medical School

• Henry Ford Professor 
• Edward J. Brickhouse Chairman
• Department of Surgery

L.D. Britt, MD, MPH, D.Sc (Hon), FACS, FCCM, FRCSEng (Hon), FRCSEd (Hon), FWACS (Hon), FRCSI (Hon), FCS(SA) (Hon), FRCS(Glasg) (Hon) is a proud native of Suffolk, Virginia, has strong southern roots and is the product of the public school system. He attended the University of Virginia and was named to the Dean’s List each of the eight semesters. He received his Baccalaureate of Arts with Distinction.

Dr. L. D. Britt, a graduate of Harvard Medical School and Harvard School of Public Health, is the Brickhouse Professor and Chairman of the Department of Surgery at Eastern Virginia Medical School. He is the author of more than 220 peer-reviewed publications, more than 50 book chapters and non-peer-reviewed articles, and three books, including a recent edition of the highly touted Acute Care Surgery (Lippincott, Williams & Wilkens, Medford, NJ).

He serves on numerous editorial boards, including the Annals of Surgery, Archives of Surgery, World Journal of Surgery, Journal of the American College of Surgeons, the American Journal of Surgery (Associate Editor), the Journal of Trauma, Shock, Journal of Surgical Education, the American Surgeon, and others. In addition, he is a reviewer for the New England Journal of Medicine.

Dr. Britt, a member of Alpha Omega Alpha, is the recipient of the nation’s highest teaching award in medicine the Robert J. Glaser Distinguished Teaching Award, which is given by the AAMC in conjunction with AOA. He was honored by the Association of Surgical Education with its lifetime achievement award the Distinguished Educator Award given annually to one person considered by his peers to be a true master.

More than 180 institutions throughout the world have invited him to be their distinguished visiting professor. Dr. Britt is the past President of the Society of Surgical Chairs and the past Chairman of the ACGME Residency Review Committee for Surgery. Also, he is past Secretary of the Southern Surgical Association, the past Recorder/Program Chair for the American Association for the Surgery of Trauma, and past President of the Southeastern Surgical Congress, the Halsted Society, and the Southern Surgical Association. Dr. Britt is the past Chairman of the Board of Regents of the American College of Surgeons. He is also past President of the American College of Surgeons, the American Association for the Surgery of Trauma, and the American Surgical Association.

At the inaugural presidential ceremony held in Washington, D.C., during the 96th annual Clinical Congress of the American College of Surgeons, Dr. Britt was awarded the U.S. Surgeon Generals medallion for his outstanding achievements in medicine. The Honorable Regina Benjamin, MD, the 18th U.S. Surgeon General, presented this award at a formal ceremony. Dr. Britt was also appointed to the Robert Wood Johnson Clinical Scholar Program National Advisory Committee. The National Library of Medicine of the National Institutes of Medicine (in collaboration with the Reginald F. Lewis Museum of Maryland African American History and Culture) featured Dr. Britt for his contributions to academic surgery. President George W. Bush recognized Dr. Britts leadership role in medicine and nominated him to the Board of Regents of the Uniformed Services University (confirmed by the United States Senate).

At the end of his tenure, Dr. Britt was awarded the coveted Distinguished Service Medal. The National Board of Medical Examiners (NBME) also awarded him the Edithe J. Levit Distinguished Service Award.

An active participant in the community, Dr. Britt has received numerous awards for public service. Dr. Britt is the recipient of the 2010 Colgate Darden Citizen of the Year Award and the 2011 Dr. Martin Luther King, Jr. Community Award. Atlanta Post recently highlighted him as one of the top 21 black doctors in America. Ebony magazine recently listed him as one of the most influential African Americans in the nation.

At the 2012 annual meeting of the American Surgical Association, Dr. Britt became the 132nd President of the organization. He was conferred an Honorary Doctorate by the President of Tuskegee University. Dr. Britt was also elected to the position of Commissioner of the Joint Commission (formerly JACHO). In 2012, he was conferred an Honorary Fellowship in the French Academy of Surgery, and the Colleges of Medicine of South Africa.

Having recently been awarded an Honorary Fellowship in the Royal College of Surgeons of Glasgow, Dr. Britt now has the distinction of receiving the highest honor given by each of the four Royal Colleges in the United Kingdom England, Edinburg, Ireland, and Glasgow.

Dr. Britt, author of the term Acute Care Surgery and one of the principal architects of this emerging specialty, was the 2013 recipient of the prestigious Roswell Park Medal. He was honored for his major contributions to American surgery. At the 2015 annual meeting of the Society of Critical Care Medicine, Dr. Britt was bestowed the coveted title of Master of Critical Care Medicine (MCCM) by the American College of Critical Care Medicine. Recently, Virginia Governor Terry McAuliffe appointed Dr. Britt to the Board of Visitors of the University of Virginia.

Sudhen B. Desai, MD, FSIR

Baylor College of Medicine

• Department of Interventional Radiology  

Dr. Desai earned his Doctorate of Medicine with Distinction in Research and Alpha Omega Alpha honors from Albany Medical College, after completing the six-year BS/MD program in conjunction with Rensselaer Polytechnic Institute. During his latter years of medical school, he was selected as a scholar of the Clinical Research Training Program at the National Cancer Institute of the National Institutes of Health, a clinical fellowship geared towards the development of translational researchers. He then went on to residency at Stanford University (General Surgery) and UCSF (Diagnostic Radiology), followed by fellowship in Vascular and Interventional Radiology at Northwestern University. He was a private practice adult Interventional and Diagnostic Radiologist for ten years.  In July 2016, he returned to fellowship for an advanced training year with a focus on Pediatric Interventional Radiology, at Children’s Hospital of Boston. Subsequently, he joined Baylor College of Medicine (Houston, TX), on the staff at Texas Children’s Hospital.  He currently provides interventional care to adult and pediatric patients.

In his time outside of the clinic, he serves as a consultant to multiple established and start-up medical companies (TVA Medical, Exit BD/Bard 2018), Scientific Advisor to Santé Ventures (Austin, TX) and Chief Editor for Interventional Radiology CSurgeries.com.  Previously he was an invited advisor to the Rice University Jones School of Business (Technology Entrepreneurship). He was a member of the Advisory Council for the Masters in Clinical Translation Management at the St. Thomas (Houston, TX) University Cameron School of Business as well.  He has been appointed to multiple committees for the Society of Interventional Radiology and has lectured at multiple SIR annual meetings. He is the Chief Editor for IR Quarterly, a distribution of the SIR.

As Past-President/Founder of the Houston chapter of the Society of Physician Entrepreneurs, and a Member of the SoPE International Board of Directors, Dr. Desai works to engage physicians interested in innovation and idea development, as well as to provide mechanisms and insights to assist early-stage companies in tackling the many challenges to successful exits.

Umamaheswar Duvvuri, MD, PhD

University of Pittsburgh Medical Center

• Director of Robotic Surgery, Division of Head and Neck Surgery
• Director of the Center for Advanced Robotics Training (CART)
• University of Pittsburgh School of Medicine

Umamaheswar Duvvuri, MD, PhD, is a graduate of the University of Pennsylvania obtaining his Medical Degree in 2000 and his PhD in Biophysics in 2002. He completed an internship in General Surgery in 2003 and residency training in Otolaryngology in 2007 at the University of Pittsburgh Medical Center. He completed fellowship training in Head and Neck Surgery in 2008 at the University of Texas MD Anderson Cancer Center.

He joined the University of Pittsburgh in August 2008 as an Assistant Professor in the Department of Otolaryngology, Head and Neck Surgery Division and is also a staff physician in the VA Pittsburgh Healthcare System.

He serves as the Director of Robotic Surgery, Division of Head and Neck Surgery, at the University Of Pittsburgh School Of Medicine and is the current Director of the Center for Advanced Robotics Training (CART) at the University of Pittsburgh Medical Center. He directs the Cart Training Courses which provide technical and circumstantial resources to initiate and optimize robotic surgery programs.

He has authored numerous research publications and book chapters and is an invited guest lecturer/speaker on the subject of robotic surgery both nationally and internationally.

A Fulbright scholar, his research interests include minimally invasive endoscopic and robotic surgery of the head and neck, tumors of the thyroid and parathyroid glands and molecular oncology of head and neck cancer.

He directs a federally funded laboratory that studies the biology of head and neck cancer. He holds funding from the National Institute of Health, Department of Veterans Affairs and the “V” foundation.

Nitin Garg, MD

Wake Forest University School of Medicine

• Assistant Professor, Vascular & Endovascular Surgery

Dr. Nitin Garg is an Assistant Professor in Vascular & Endovascular Surgery at Wake Forest University School of Medicine in Winston Salem, North Carolina. He graduated from the prestigious All India Institute of Medical Sciences (AIIMS) in New Delhi and pursued a Master’s in Public Health at Johns Hopkins Bloomberg School of Public Health in Baltimore. Dr. Garg completed General Surgery internship and residency at Creighton University in Omaha and Vascular Surgery Fellowship at the Mayo Clinic in Rochester.

Dr. Garg has a strong interest in clinical education and firmly believes that the adequate training of the next generation of surgeons is the responsibility of the surgeons in practice. He also believes that education of patients is critical for their buy in into their own health. Dr. Garg’s clinical interests include complex arterial and venous reconstructions, using both open and endovascular (or hybrid) techniques.

Deanne King, M.D., Ph.D.

• Assistant Professor, University of Arkansas for Medical Sciences
• Director of Clinical Research, Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences

King has a Bachelor of Science in biochemistry from the Texas A&M University in College Station. She has an M.D./Ph.D. in molecular and cellular biology and pathobiology from the Medical University of South Carolina in Charleston. She completed an internship in general surgery and a surgery residency in otolaryngology-head and neck surgery, both at UAMS.

King said she enjoys helping researchers make connections.

“Research can sometimes be an isolating pursuit, but collaboration and idea-sharing is so important to the overall process,” King said. “I’m also looking forward to helping our students and residents. Otolaryngology-head and neck surgery is a highly competitive field. Having published research to your name early in your career is not only a valuable experience, but, increasingly, a necessity for medical students to successfully match into an otolaryngology residency.”

Faculty in the Department of Otolaryngology-Head and Neck Surgery are fellowship-trained in their specialty and cover all the sub-specialties in the field (otology, endocrine, head and neck, rhinology, laryngology, pediatric and vascular anomalies). The faculty consistently receive high scores on patient satisfaction, and six faculty are listed in “Best Doctors in America.” They practice at UAMS Medical Center, Arkansas Children’s Hospital and the Central Arkansas Veterans Health Care System.

Basics of Blunt Force Trauma: ZMC Fractures

This webinar will address the definition of zygomaticomaxillary complex (ZMC) fractures, will review pertinent literature, mechanisms of injury, classification, surgical approaches and complications. The presenter will make use of clinical photos and will allow an opportunity to answer questions.

Jose M Marchena DMD, MD, FACS

Associate Professor of Oral and Maxillofacial Surgery / Chief of Oral and Maxillofacial Surgery

University of Texas Health Science Center / Ben Taub Hospital

Dr. Jose Marchena obtained his dental degree magna cum laude from Harvard School of Dental Medicine and his medical degree from Harvard Medical School. He completed internships in oral and maxillofacial surgery and general surgery at Massachusetts General Hospital in Boston and his residency training at Louisiana State University Medical Center in New Orleans. Dr. Marchena is an associate professor of oral and maxillofacial surgery at the University of Texas Health Science Center in Houston. He also serves as chief of oral and maxillofacial surgery at Ben Taub Hospital in Houston and as vice president of Smile Bangladesh, a nonprofit organization dedicated to providing cleft lip and palate repair operations in rural Bangladesh.

Alfredo R. Arribas DDS, MS, FACS

Assistant Professor in Department of Oral and Maxillofacial Surgery

University of Texas Health Sciences Center at Houston

Received his Bachelor of Science (BS) and Doctor in Dental Surgery (DDS) Degrees from Universidad Peruana Cayetano Heredia in Lima, Peru, in 1996, certificates in Advanced Education in General Dentistry (AEGD) at University of Maryland School of Dentistry, in 1998, two - year General Practice Residency (GPR) Program at LSU Health Sciences Center in 2000 and Oral, Maxillofacial Surgery internship at LSU Health Sciences Center in 2001, and Oral and Maxillofacial Surgery Residency at LSU Health Sciences Center, New Orleans in 2012, where he was trained in full scope Oral & Maxillofacial Surgery. Obtained a Master of Science (MS) degree in Health Care Management from University of New Orleans in 2004. Fields of interests includes: maxillofacial trauma, facial reconstructive surgery, dental implants, dentoalveolar surgery and orthognathic surgery.

Basics of Blunt Force Trauma: NOE Fractures

This webinar will address the definition of naso-orbito-ethmoidal (NOE) fractures, relevant anatomy, prevalence and etiology, diagnosis, classification, goals and timing of surgery, surgical sequence and complications. The presenter will make use of clinical photos and will allow an opportunity to answer questions.

Jose M Marchena DMD, MD, FACS

Associate Professor of Oral and Maxillofacial Surgery / Chief of Oral and Maxillofacial Surgery

University of Texas Health Science Center / Ben Taub Hospital

Dr. Jose Marchena obtained his dental degree magna cum laude from Harvard School of Dental Medicine and his medical degree from Harvard Medical School. He completed internships in oral and maxillofacial surgery and general surgery at Massachusetts General Hospital in Boston and his residency training at Louisiana State University Medical Center in New Orleans. Dr. Marchena is an associate professor of oral and maxillofacial surgery at the University of Texas Health Science Center in Houston. He also serves as chief of oral and maxillofacial surgery at Ben Taub Hospital in Houston and as vice president of Smile Bangladesh, a nonprofit organization dedicated to providing cleft lip and palate repair operations in rural Bangladesh.

Alfredo R. Arribas DDS, MS, FACS

Assistant Professor in Department of Oral and Maxillofacial Surgery

University of Texas Health Sciences Center at Houston

Received his Bachelor of Science (BS) and Doctor in Dental Surgery (DDS) Degrees from Universidad Peruana Cayetano Heredia in Lima, Peru, in 1996, certificates in Advanced Education in General Dentistry (AEGD) at University of Maryland School of Dentistry, in 1998, two - year General Practice Residency (GPR) Program at LSU Health Sciences Center in 2000 and Oral, Maxillofacial Surgery internship at LSU Health Sciences Center in 2001, and Oral and Maxillofacial Surgery Residency at LSU Health Sciences Center, New Orleans in 2012, where he was trained in full scope Oral & Maxillofacial Surgery. Obtained a Master of Science (MS) degree in Health Care Management from University of New Orleans in 2004. Fields of interests includes: maxillofacial trauma, facial reconstructive surgery, dental implants, dentoalveolar surgery and orthognathic surgery.

Surgical Pitfalls, Early Career Advancement and Leadership

In this last Cardiothoracic DocTalk session of the Pathway to Independence for Junior Surgeons we will discuss early career mistakes and how to avoid them. Viewers of this webinar will learn tips and tricks learned from senior partners and knowing when to call for help.

Lawrence Greiten, MD

Assistant Professor in Division of Congenital Cardiac Surgery
Arkansas Children's Hospital (ACH) and the University of Arkansas for Medical Sciences (UAMS)

Lawrence Greiten, M.D., is an Assistant Professor in the Division of Congenital Cardiac Surgery at Arkansas Children’s Hospital (ACH) and the University of Arkansas for Medical Sciences (UAMS). Dr. Greiten received his undergraduate degree from Kansas Wesleyan University and his medical degree from the University Of Arizona College Of Medicine. He completed both his General Surgery training and Cardiovascular and General Thoracic Surgery fellowship at the Mayo School of Graduate Medical Education, where he also earned a Masters in Biomedical Sciences, Clinical and Translational Science. He did an advanced Fellowship in Congenital Cardiac Surgery at Children’s Hospital Los Angeles, Keck Medical School at the University of Southern California.

Surgical Exposure, Minimal Incision Surgical Option for ASD Repair

In this second Cardiothoracic DocTalk session of the Pathway to Independence for Junior Surgeons we plan to discuss the approach to a Minimal Incision ASD. Our panel will discuss the merits of offering this approach along with the potential pitfalls. Viewers of this webinar will gain insight into optimizing surgical exposure and understanding when it is safe to proceed with less invasive techniques.

Lawrence Greiten, MD

Assistant Professor in Division of Congenital Cardiac Surgery
Arkansas Children's Hospital (ACH) and the University of Arkansas for Medical Sciences (UAMS)

Lawrence Greiten, M.D., is an Assistant Professor in the Division of Congenital Cardiac Surgery at Arkansas Children’s Hospital (ACH) and the University of Arkansas for Medical Sciences (UAMS). Dr. Greiten received his undergraduate degree from Kansas Wesleyan University and his medical degree from the University Of Arizona College Of Medicine. He completed both his General Surgery training and Cardiovascular and General Thoracic Surgery fellowship at the Mayo School of Graduate Medical Education, where he also earned a Masters in Biomedical Sciences, Clinical and Translational Science. He did an advanced Fellowship in Congenital Cardiac Surgery at Children’s Hospital Los Angeles, Keck Medical School at the University of Southern California.

Pre-Operative Planning, Intraoperative Considerations and Troubleshooting

In this first Cardiothoracic DocTalk session of the Pathway to Independence for Junior Surgeons we will discuss Redo Sternotomy and Pulmonary Valve Replacement in a patient who had prior TOF repair. We plan to highlight the pre-operative strategy which will include necessary imaging and testing along with how to manage an intra-operative complication of air embolism. Viewers of this webinar will gain valuable insight into a stepwise approach to managing a very complex surgical scenario.

Lawrence Greiten, MD

Assistant Professor in Division of Congenital Cardiac Surgery
Arkansas Children's Hospital (ACH) and the University of Arkansas for Medical Sciences (UAMS)

Lawrence Greiten, M.D., is an Assistant Professor in the Division of Congenital Cardiac Surgery at Arkansas Children’s Hospital (ACH) and the University of Arkansas for Medical Sciences (UAMS). Dr. Greiten received his undergraduate degree from Kansas Wesleyan University and his medical degree from the University Of Arizona College Of Medicine. He completed both his General Surgery training and Cardiovascular and General Thoracic Surgery fellowship at the Mayo School of Graduate Medical Education, where he also earned a Masters in Biomedical Sciences, Clinical and Translational Science. He did an advanced Fellowship in Congenital Cardiac Surgery at Children’s Hospital Los Angeles, Keck Medical School at the University of Southern California.

Transoral Approach to Mandibular Fractures: Tips and Tricks

This webinar will address factors relative to case selection and various tips and tricks that will help simplify trans-oral approaches to mandibular fractures. The presenter will make use of clinical photos and video and will allow an opportunity to answer questions.

Dr. Jose Marchena obtained his dental degree magna cum laude from Harvard School of Dental Medicine and his medical degree from Harvard Medical School. He completed internships in oral and maxillofacial surgery and general surgery at Massachusetts General Hospital in Boston and his residency training at Louisiana State University Medical Center in New Orleans. Dr. Marchena is an associate professor of oral and maxillofacial surgery at the University of Texas Health Science Center in Houston. He also serves as chief of oral and maxillofacial surgery at Ben Taub Hospital in Houston and as vice president of Smile Bangladesh, a nonprofit organization dedicated to providing cleft lip and palate repair operations in rural Bangladesh.

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.

Csurgeries Through The Eyes Of A Future Surgeon

Congratulations to our GoPro Contest winner, Akshay Krishan!  As a medical student, he shares his personal experience with CSurgeries and the value it provides to fellow students who may be interested in pursuing a career in surgery.   

Tell me little bit about yourself.

I am currently a 2nd year medical student at UAMS. I received my undergraduate degree from the University of North Carolina at Chapel Hill, but decided to come back home for my medical training.

I was initially introduced to CSurgeries through a “Summer in Surgery” Program I completed through UAMS last summer—a one month program that was started by the General Surgery Department at the hospital. The goal of the program is to introduce students to General Surgery, recruit them to the field and introduce them to what General Surgery has to offer.  Through that program, I met Dr. Golinko. He gave me the opportunity to film one of the procedures (Fronto-Orbital Advancement and Cranial Vault Remodeling for Metopic Craniosynostosis) and publish to the site.

Were you always interested in surgery? Was surgery what you had in mind when you were accepted to medical school?

Yes. I’ve always been interested in surgery. Going into medical school, I was interested in orthopedic surgery. But completing the Summer in Surgery Program has broadened my view of the surgical field, so I am definitely interested in other areas as well. I’m excited to start my third year and get on the surgery rotation to see what else the field has to offer.

How has CSurgeries contributed to your education at UAMS?

CSurgeries has been beneficial. After I filmed the surgery with Dr. Golinko, he gave me free rein to do my own research, edit the video as I pleased, and add in the necessary content. In doing so, I got to do quite a bit of research on various medical topics that I had no experience with previously. I learned so much by doing this first-hand research and also developed a deeper appreciation for various medical concepts that I had learned in class.

How were you able to determine the surgical steps to focus on when putting together your video for peer-reviewed publication?

The procedure itself was between 7-8 hours. I didn’t film it in entirety, but I did film a good amount to make sure I got all the footage I would need later on.  Before I began distilling my footage down to the main components, I talked with Dr. Golinko and created an outline of the key points to focus my video on. From there, I did plenty of research and made sure to include/explain every key step in the craniosynostosis procedure.    

How long did it take to find that information and put it all together?

As a whole, the project did not take very long. Doing the research was pretty easy, so most of my time was spent going through all the footage and editing the clips to fit into the 5 minute limit.

How did you film the procedure?

For the majority of the surgery, I used one of Dr. Golinko’s cameras. For the last portion, I used my iPhone (Dr. Golinko’s camera had run out of memory).

What would you like to see CSurgeries do in the future? How can we help medical students who are interested in surgery?

I was introduced to CSurgeries through the Summer in Surgery Program. If medical students knew more about CSurgeries and knew that they could actively contribute to the site and get some publications for their own resumes, that would be extremely beneficial.

For those who are interested in the surgical field (or those who never really considered surgery as an option), giving them the opportunity to watch the videos on the site would be really beneficial. It can get more people involved in surgery and is also a great educational tool. Every medical student is going to have to go into their third year and do some kind of surgical rotation, so just watching some of the more common surgical procedures on the site would give students a basic understanding of the things they are going to see. Students would also gain a better appreciation of things the surgeon must do throughout each surgery.

Do medical students get any education in regards to video education in class and/or lecture?

I myself have not received any formal education on video education or projects. I wasn’t aware that video publications are a type of publication that is commonly used until I was introduced to CSurgeries.  

As far as video and teaching is concerned, our in-class lectures are recorded, so we can go back and re-watch things if we need to. Outside of that, a lot of the video educational tools we use are primarily geared towards Step 1 preparation.  

What advice would you give medical students who are thinking about surgical residency?

Surgical residency and the quality of life of surgeons have a reputation of being very difficult, time intensive and exhausting. While that’s all true, the positives of surgery need to be detailed to the students.  It’s honestly a very rewarding field to get into. Just by shadowing various surgeons and participating in the Summer in Surgery Program, I gained an appreciation of how these kinds of procedures really changed patients’ lives. Introducing medical students to the field and showing them the positives of surgery would be immensely beneficial both for them and the surgical field as a whole.

The People Behind CSurgeries: Dr. Gerald Healy, CSurgeries Chief Surgical Officer

Meet Dr. Gerald Healy –
accomplished otolaryngologist and dedicated family man.
Learn more about his recipe for success and
how all surgeons can benefit from what he calls a
“House of Surgery”.

Q: What can you tell me about your role as Chief Surgical Officer, of CSurgeries? What are your main areas of focus?

A: First and foremost this really is a unique opportunity! There isn’t any other publication vehicle where all of the “House of Surgery” (as I like to call the surgical groups that are represented on CSurgeries) can present a compendium of information acceptable to all surgeons of all disciplines. As a specialty surgeon, I feel strongly that the surgical disciplines do not interact enough with each other. We have developed a silo mentality in medicine where we’re so focused on our own discipline, we fail to learn from the others. With CSurgeries, we have the ability to learn from surgeons in other disciplines. Even during my tenure as president of the American College of Surgeons, I worked to promote this “House of Surgery” concept ─a place where everyone lives and works together for the common goals of patient safety and quality care.

My primary role as Chief Surgical Officer, is to recruit the very best people we can find in the various surgical disciplines to be the Section Editors. We’ve welcomed some very well-known, accomplished surgeons (such as Dr. Britt who is our General Surgery editor and Dr. Shamberger who is our Pediatric Surgical Section Editor). The idea is to reach out to surgical leaders like these who can then go out and recruit the best videos. Our Section Editors are extremely well respected, recognizable names in their field. So much so that when they pick up the phone, you listen to what they have to say. People recognize that these individuals would only be affiliated with a valid journal that has something worthwhile to offer.

Q: What does CSurgeries have to offer learners of every type (trainees, patients, families, experienced surgeons) compared to other channels of surgical education?

A: CSurgeries is dedicated to serving all of those groups, and we will have to pay special attention to the development of a video library/process that addresses every viewer group. For example, the video presented to a lay person about a laparoscopic cholecystectomy might be completely different from the video we show an advanced surgeon who wants to simply see, “How does Dr. X take out gall bladder? I’d like to see the little tricks he uses when he’s in there”. Paying close attention to the viewing audience is critically important as we move forward- ensuring the production of educationally appropriate videos geared towards each viewer group or learner group.

Similarly, if we’re addressing a medical student audience, it would be acceptable to show them the same video of the gall bladder removal that we might also show a senior surgical professor. However, the audio portion (author explanation/narration) might be very different. Simply stated, the senior professor doesn’t need me telling him, “Put the scope here and look 30 degrees there”. He or she already knows that. What they want to know is, “What kind of a clamp does Dr. X use?” or “What kind of a clip, does he put on the gall bladder when he’s finished?” I expect those nuances would be differentiated through the video narration itself.

Q: Dr. Healy, your list of accomplishments are endless…You are an author, lecturer, scholar, and honorary society member (just to name a few). Where do find this motivation, what fuels you?

A: Like many people in many walks of life, I had a role model that I wanted to emulate. The short version is that when I was a small kid, I have this memory of my pediatrician who would come out in the middle of the night, in the snow, in the rain, and in the ice to see me because I was sick. Those visions stayed with me for my early life and drove me with a passion. I wanted to be like this guy. His name was Eli Friedman – an incredibly unique human being who actually has a lectureship at Boston Medical Center named in his honor because so many of his students over the years were so adoring of him. He’s what drove me.

I always knew I wanted to become a physician, but the question was whether or not I could achieve it. Could I get there? And once I got there, what was I going to do with it? The driving force behind my career really unfolded in three phases:

1. The first third of my career, I was a learner. I tried to absorb everything I could from everyone I met because I wanted to be the best surgeon I could be-helping patients with the very best of my ability.
2. The second part of my career, I made a concerted effort to try and share my experiences with others. I spent a lot of time giving talks, writing papers, presenting my material at various meetings and listening to the critiques.
3. The final third of my career, I decided to help as many as I could by becoming involved in medical organizations focused on driving the agenda so that we were always focused on what’s best for the patient and their quality of care.

*I’m also a passionate guy, who loves his family, always makes time for my wife and daughters and am driven to do the very best I can in all things.

Q: What advice would you give a medical student thinking about becoming a surgeon?

A: First and foremost, DO NOT look at medicine as a job. It’s a profession. Too many students today are looking at lifestyle choices. Being a surgeon is not an easy lifestyle. So, if you’re about working 8 am to 4pm and having all your nights and weekends off, don’t become a surgeon. But if you’re passionate about helping others, easing suffering, and changing things for the better, there is no part of our profession that’s more rewarding than surgery.

I often address medical students in and around Boston, and I let them know they are being given a unique privilege- the privilege of holding the life of another human being in their hands. It is an immense responsibility that you cannot take lightly. Once that person puts their trust in you and says, “Doctor, I need your help…” they need your help until the problem is solved. It’s not a job. It’s a profession and a calling.

1. How has medical teaching and surgical learning evolved over the years? Where do you see it going years from now?

Well, when I went to medical school, everything was pictures, book and journal reading and so forth. Now the electronic world has taken over. Visual learning, e-learning and interactive learning is the new norm. When it comes to surgery, people want to talk less and see more. That’ simply the world we live in. Today, simulation and the use of simulators is also extremely important.

I believe we are going to be heavily into robotic surgery. That’s a very important issue to think about because surgeons can easily make the mistake of becoming technicians and not doctors. By that I mean, operating, but having no relationship with the patient. Robots will replace you in the future if you enter surgery solely focused on being a technician and not an empathizing doctor. Let’s not forget about the importance of positive doctor-patient relationships…the very human side of surgery.

Have a question you would like to ask Dr. Healy? Feel free to post a comment or send him an email at Gerald.Healy@csurgeries.com