Anteriorly-based Tongue Flap for Large Palatal Fistula

This video presents a case of a large hard palate fistula, which was repaired with an anterior tongue flap. The details of the procedure are described and demonstrated in detail, including both stages of the reconstruction, which were timed 3-4 weeks apart.

Robotic Assisted Type 1 Laryngeal Cleft Repair

Contributors: Umamaheshwar Duvvuri (University of Pittsburgh Medical Center)

A DaVinci Robot is used to dock in with a 30 degree up telescope.The oral cavity is exposed using a FK retractor or a modified McIvor mouth gag( one with a flat blade). Robotic 5 mm Maryland forceps and 5 mm monopolar diathermy forceps is used. After getting a good exposure of the laryngeal cleft the diathermy at a setting of 4-5 watts is used to make the incision.and using the maryland forceps the laryngeal and esophageal flaps are created.A 5.0 PDS suture with a P2 tapered needle is used.The apex of the esophageal flap is first closed with suturing it.After this the apex of the laryngeal surface is closed.For a laryngeal cleft repair 2-4 sutures are required to obtain a closure. The sutures on the laryngeal surface are buried.The patient is kept intubated for a day or two to avoid excess movement of larynx. Pre and post operative treatment of reflux is important for healing.


Total Calvarial Reconstruction for Increased Intracranial Pressure and Chiari Malformation

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

Kelsey Cobourn, BS – Children’s National Medical Center Division of Neurosurgery and Georgetown University

Owen Ayers – Children’s National Medical Center Division of Neurosurgery and Princeton University

Deki Tsering, MS – Children’s National Medical Center Division of Neurosurgery

Gary Rogers, MD, JD, MBA, MPH – Children’s National Medical Center Division of Plastic and Reconstructive Surgery and George Washington University School of Medicine

Robert Keating, MD – Children’s National Medical Center Division of Neurosurgery and George Washington University School of Medicine (corresponding author)

Robotic-assisted Base of Tongue Resection for Adult Sleep Apnea

A 52-year-old female presented for an evaluation for sleep apnea surgery.  She complained of choking sensation at night.  She had an AHI of 6.7 events per hour, a oxygen saturation nadir of 71%, and BMI of 30.6.  She and a prior history of adenotonsillectomy as a child.  Flexible examination in the office revealed grade 4 lingual tonsil hypertrophy.  She was deemed a candidate for lingual tonsillectomy and was taken to the operating for robotic lingual tonsillectomy.  The technique for adult lingual tonsillectomy is shown in step-by-step fashion with tips for good results both operatively and functionally learned from robotic surgery for cancer of the unknown primary origin.

Contributors: Jessica Moskovitz, MD, Leila J. Mady, MD, PhD, MPH, Umamaheswar Duvvuri, MD, PhD

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