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.
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.
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.
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.