1. Check pre op LFT’s, CBC, plts, coags, T and S
2. What did the US show?
85% of biliary atresia have no GB seen. If CBD seen -> ? “Uncorrectable BA”.
3. What were the IDA and Biopsy results (if done). BA -> bile duct proliferation on biopsy
4. IV abts, NG, Foley, good IV access
5. Mark for chevron, but initially use only small incision over GB. “Bump” under the liver
6. Purse string top of GB if present with silk suture and do cholangiogram. “Uncorrectable BA” has good downstream flow into bowel but none up into liver. White bile means no proximal connection.
7. Take down the GB from distal to proximal; preserve the cystic artery if GB Kasai
8. Mobilize the liver. Divide the coronary ligaments and the falciform and put packing behind the liver to elevate it.
9. Identify the common hepatic artery and its branches to the left and right
10. Follow the arteries out to distal. Often there is a branch from the left hepatic to the GB bed, this can be divided.
11. Follow the falciform ligament down to the left portal vein.
12. The left portal vein is followed peripherally and several small branches toward the porta need to be suture ligated. A bridge of liver is divided with the cautery.
13. The right portal vein will have the right hepatic artery over it. This is followed out to?
14. The center of the portal triad is NOT where the microscopic ducts are. These are on the right and left as illustrated.
15. The porta is cored out with a hooked #12 blade running parallel to the vessels. The right and left extended dissection is critical.
16. A Roux-en-Y is mad by dividing the jejunum 10 cm distal to the ligament of Treitz, and is about 35 cm long.
17. In the rare case of a GB Kasai, the GB is spatulated and a 2.7 Broviac is used to drain it (exit the catheter via the suture line).
Tag Archives: Tutorials
Laparoscopic Pyeloplasty
Laparoscopic UPJ Repair:
The patient is positioned with a “bump” underneath the affected side and the table is rotated towards the camera. A 10 mm port is placed in the umbilicus and two stab incisions are used. These can be somewhat medial so that they are directed at the UPJ area.
A Foley catheter was placed prior to the procedure and this area was prepped in the field in case a cystoscopy is necessary to confirm the position of the double J at his left.
It often is necessary to go through the mesentery of the mesocolon, since if you take the colon down it is in the way during the procedure, and making a small opening to get out the UPJ is acceptable.
The instruments are a 10 mm port in the umbilicus and a 3 mm stab incision in smaller children. A 5 mm port can be placed in larger children.
The UPJ is dissected free. The gonads are usually preserved if possible. The scissors are used to open the pelvis side first, usually from the interior to caudal, leaving intact the caudal bridge. This is then grasped and pulled up, and the ureter itself is then incised down stream and split vertically, leaving again this bridge where the actual ureteropelvic junction is.
Prior to starting the anastomosis extracorporeally, a 5-0 PDS was tied to itself thoroughly and then passed on down and then used to run each side. Prior to completing anastomosis a double J is placed. This is usually a length of 10 plus the patient’s age in years, roughly the anastomosis was then completed. It is not necessary to excise a huge portion of the pelvis, but simply make it dependent and spatulate the ureteral opening. The specimen was then removed. Prior to completing anastomosis a double J was placed. This was done by advancing a guidewire through a small stab incision, placing the guidewire and then sliding the double J down over the guidewire and then using the pusher to push it on into place or alternatively a grasper.
Once the anastomosis is completed a plain film is shot on the table to see if the catheter is coiled up in the bladder where it should be distally. If there is any question a cystoscope can be advanced in to check this.
The Foley catheter is left in place overnight and removed in the morning. The patient’s diet is started in the morning and usually advanced. The actual operative time is usually about two to three hours and the patients usually go home in about 48 hours or so. In about six weeks the double J is removed.
Left Lobe Liver Resection
Left hepatic lobectomy – Technique
1. Smaller incision until resectability assessed, then extend bilateral subcostal incision
2. Take down any colonic or stomach attachments.
3. Plane is through gb bed to the vena cava
4. Diaphragmatic attachments are taken down, and phrenic vein divided
5. Hepatoduodenal ligament is skeletonized and a standard open cholecystectomy performed.
6. Demarcation between lobes is seen ? left hepatic artery temporarily occluded for this?
7. Left hepatic vein is mobilized and divided (stick ties)
8. Attention is turned back to the porta hepatis
9. Left hepatic artery is divided and stick tied.
10. Left portal vein is isolated and divided (stick ties).
11. Left hepatic duct then ligated
12. Central hepatic vein is then isolated and ligated
13. The capsule of the liver is scored with the cautery (should be well-demarcated).
14. Hepatic dissection is done with the electrocautery
15. Bridging vein and bile ducts are isolated and ligated with silk sutures.
16. Two drains (10 mm JP) are left in the area.
Hirschsprung’s Disease: Lap assisted transanal pullthrough Tutorial
The baby is positioned on the lower end of the bed, with the legs hanging over (barely), as shown in the Figure. A circumferential prep is performed, with the normal – sized cautery pad on the upper back. Stockinets are used on the legs, which are held by an assistant during the prep. A split sheet is used.
Antibiotics are given, the umbilicus is dilated, and a 5 mm port placed. Initially, a stab incision is used in the right lower quadrant for a 3 mm Duck-billed grasper, as shown. It is important to slightly vertically extend the umbilical incision, in order to bring the colon up through it. The grasper brings the portion of the colon to biopsy up through the umbilicus (the port is temporarily removed), and 2 silk sutures are used to close the biopsy (obtained with tenotomy scissors). Alternatively, a Hegar dilator can be placed in the rectum and used to push the rectosigmoid up to the umbilicus.
Once the level is established, a second 3 mm stab incision is made above and medial to the first in the right lower abdomen, for use by the operating surgeon. Another stab incision is made in the left lower abdomen, for the assistant on the camera to also hold and retract the sigmoid colon upwards.
Dissection is kept on the bowel wall, and the retrorectal space cleared. The mesentery to the bowel being resected is divided. Trendelenberg is helpful to get the small bowel out of the way. The hook cautery may be helpful.
Once the intraabdominal dissection is complete, the Thompson retractor is placed so that the wrapped legs (Kerlix) can be used to elevate the legs over the head. After the laparoscopy instruments are withdrawn and the abdomen decompressed, the headlight is placed on the now seated operator, and the nasal speculum placed in the rectum. The colorado tip Bovie is used to score the rectum 1 cm above the dentate line, and 4-0 silk sutures on a TF needle are circumferentially placed for traction
A Lone Star retractor is placed (8 x 8, semi blunt tips) is placed, and the cautery tip is switched to the paddle. The submucosal dissection is begun. This is continued until the peritoneal cavity is entered.
Again keeping the dissection on the rectal wall, the rectum is mobilized until the level of ganglion cells (and 5 cm or so above, preferably) is reached. The bowel is transected, and the anastomosis done with 4-0 Vicryl breakaways.
Once the anastomosis is completed, the scope is placed back in for a final check (r/o bleeding, be certain the bowel is not twisted).
Laparoscopic repair of duodenal atresia
The left upper quadrant suture is usually unnecessary. The suture around the falciform ligament is sometimes helpful, but not essential. The right lowermost stab inscision should be fairly medial (near the camera port. Only the umbilical 5 mm port is a true port – the others are just stab incisions with short 3 mm instruments. It may be helpful to sew the 5 mm port to the skin.
A bump is placed transversely in the mid back to help expose the duodenum and keep the liver out of the way.
Actually, the first suture is a 9 cm long 3-0 silk in the left corner of the anastomosis. Its tag is kept long so that the assistant can grasp it and pull to the left upper quadrant for exposure. Another silk corner suture may be helpful.
The covered “Colorado” Bovie tip is used at a setting of 7.
The U-Clips are the small S-60 clips.
Laparoscopic Splenectomy
1. Positioning – Place the patient supine, but put a pad/bump underneath the left kidney. The table will be rotated significantly towards the patient’s right side, and mild Trendelenberg as well. The surgeon and assistant stand on the patient’s right, with the operating surgeon nearer the head.
2. Preoperative US or CT or both are useful: If the spleen is > 15 cm, lap splenectomy may not be possible. If the patient has spherocytosis, there may be gallstones.
3. Preoperative vaccinations should not be forgotten. Immunisation should be given at least 2 weeks before elective splenectomy, and includes: Pneumococcal 23 valent, Hib vaccine (if not already immunized, Meningococcal immunization, and Influenza vaccination. Many needed to be repeated every 5 – 10 yrs (or shorter intervals)
4. Preoperative labs: CBS, Lytes, Plts, PT, PTT, +/- LFT’s
5. IV preoperative antibiotics should be given
6. Trocars: positioning is as shown below (except the 5th port in the left flank is not used). In most children, a 12 mm port is used in the umbilicus, and the others are all 5 mm ports. The 12 mm port is exchanged for a 15 mm port and extension of the fascial incision when the spleen is ready to be removed.
7. The lower pole of the spleen is mobilized the the Harmonic scalpel (? 4 setting). Watch out for the kidney throughout, and be careful not to burn the colon with the hot Harmonic. The Harmonic can be used to divide the short gastric vessels.
8. Once the spleen is free, the 12 mm umbilical port is switched to a 15 mm port, and the fascia is extended slightly vertically. The large endo bag is inserted, and the ring forceps is used to morcelate the spleen.
9. The hospital stay is typically that of discharge the next morning.
10. Post operative antibiotic and vaccine management and careful instructions regarding recognition and management of post splenectomy sepsis syndrome are essential. Usually 250 mg po BID of PCN is used until adulthood (some use 16 yrs, some 21 yrs)