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.
Acquired tracheomalacia in the form of suprastomal collapse may occur as a complication of long-term tracheotomy dependence. Prolapse of the weakened suprastomal segment of trachea during inspiration may prevent safe decannulation. Management of such an issue may require a secondary surgical procedure such as anterior tracheoplasty.2 In 2001, Forte et al described the use of thyroid ala cartilage as a reliable cartilage source for anterior augmentation laryngotracheal reconstruction in neonates. This technique may yield a favorable result given similar thickness of the cartilages and use of a single incision operation for airway reconstruction.1 Here, we present a modification of the procedure described by Forte for anterior cervical tracheoplasty for the indication of suprastomal collapse preventing decannulation. The procedure begins with nasotracheal intubation and excision of tracheostomy tract and stoma. Strap muscles are then divided to expose the laryngotracheal cartilages. Cartilages are divided at the midline anteriorly, and the diseased segment of anterior trachea is discarded. The defect is measured, and if the size match is favorable, the superior thyroid alar cartilage is harvested. The resulting cartilage graft is slightly larger than the tracheal defect and is placed so that the perichondrium is facing into the airway lumen. Interrupted sutures of 4-0 vicryl are used to inset the graft in a submucosal fashion. Once the graft is secured with sutures, a Valsalva maneuver is performed after the cuff of the endotracheal tube is taken down to assure no leak. Strap muscles are reapproximated, a Penrose drain is placed, and the skin is closed. The child is kept intubated and sedated for 3 days before subsequent extubation in the intensive care unit. A bronchoscopy is performed at the 6-week postoperative interval to assure successful healing and to remove any persistent granulation tissue if present.
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.
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)
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