Laparoscopic repair of Morgagni hernia in infant.
A brief patient history is provided, followed by preoperative imaging, intraoperative repair, and postoperative imaging.
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.
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.
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.
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.
Robotic-assisted dismembered pyeloplasty is a safe and effective method for UPJO correction in symptomatic patients with complex renal anatomy.
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.
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.
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.
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.
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.
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