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.
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
This video highlights a pulmonary valve replacement in a patient with Tetralogy of Fallot.
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.
This video showcases a minimal incision, partial sternotomy exposure for complete ASD patch repair performed at Arkansas Children's Hospital.
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
This video highlights a pulmonary valve replacement in a patient with Tetralogy of Fallot.
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.
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.
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 firstname.lastname@example.org 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.
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 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.
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
Cranioplasty with barrel stave osteotomies to treat sagittal suture craniosynostosis.
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.
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
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
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
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
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
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
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
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
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
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
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
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 Malformationsvideo
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
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
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
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
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
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
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
Bilateral ear keloid excision with steroid injection. DOI# 10.17797/rfealpdd24
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
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
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
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
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
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
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.
Transanal full thickness rectal mobilization with an ischiorectal fat pad to repair an H-Type rectovaginal fistulavideo
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
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.
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 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)
This video is a step by step depiction of the diagnostic tools and the thoracoscopic mobilization and resection of a mature mediastinal teratoma.
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 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)
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
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.
Endoscopic Assisted Laparoscopic Transgastric Division of a Gastroesophageal Fistula in an Adolescentvideo
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.
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.
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.
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.
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.
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.
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)
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.
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
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.
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 email@example.com 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.
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.
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.
Authors Gilberto Eduardo Marrugo Pardo Titular professor, Department of Otorhinolaryngology, Universidad Nacional de Colombia, Bogotá, Colombia. Fundación hospital de la misericordia. firstname.lastname@example.org JuanSebastián Parra Charris Department of Otorhinolaryngology, Universidad Nacional de Colombia, Bogotá, Colombia email@example.com
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.
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.
This video demonstrates how to perform a tongue reduction using a Y-V advancement technique for pediatric macroglossia.
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- firstname.lastname@example.org 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.
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
Institution: University of Arkansas for Medical Sciences Authors: Thomas Heye - email@example.com Lawrence Greiten MD - firstname.lastname@example.org Christian Eisenring ACNP-BC -EisenringC@archildrens.org
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 brief patient history is provided, followed by preoperative imaging, intraoperative repair, and postoperative imaging.
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.
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.
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!
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 Injuryvideo
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
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 Pheochromocytomavideo
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
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
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
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 Childrenâ€™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
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.
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 ARCHvideo
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 FISTULAvideo
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.
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 thyroidâ€™s microscopic unit is the follicle - an irregularly shaped cell lined structure that surrounds collections of colloidal thyroglobin. Most of a follicleâ€™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
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.
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.
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
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 â€œwalkâ€ 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
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.
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.
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.
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 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
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
Contributors: Andre Hebra, MD
Contributors: Joe Iocono, MD
Contributors: Joe Iocono, MD
Contributors: Joe Iocono
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 (Cooperâ€™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.
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.
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.
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.
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.
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
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.
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
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
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.
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 Hirschsprungâ€™s disease who are suffering from recurrent enterocolitis, sclerotherapy for rectal prolapse, and seton placement in complicated Crohnâ€™s perirectal fistulas.
Contributors: Uteri:2 Vaginas
This is a computerized tomography scan of a severe pulmonary contusion. Author Tony Escobar
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 Staplervideo
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 resection of a focal lesion of congenital hyperinsulinism.
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
Video courtesy of: Christoper Corkins, MD Alfred Trappey, MD Ian Mitchell, MD
Author: Brent Weil
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 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.
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.
Contributors: Kamal Dev LAPAROSCOPIC ASSISTED GASTRIC PULL-UP FOR LONG-GAP ESOPHAGEAL ATRESIA - TECHNICAL ASPECTS Hans Joachim Kirschner, MD, Joerg Fuchs, MD. University Childrenâ€™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 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 Sibsonâ€™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 Sibsonâ€™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 Robert Kelly, MD1, Sherif Emil, MD, CM2. 1Childrenâ€™s Hospital of the Kingâ€™s Daughters; East Virginia Medical School, Norfolk, VA, USA, 2Montreal Childrenâ€™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
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
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.
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.
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
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.
Walaa Elfar, MD Upper endoscopy and esophageal FB removal chapters
Author: Karen Elizabeth Speck
Augmented Reality In A Hybrid Or For Pulmonary Nodule Localization And Thoracoscopic Resection - Feasibility Of A Novel Techniquevideo
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.
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.
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
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