Criteria: >= 4 cm bowel dilation, TPN dependence
1. Measure the duodenal width to obtain ‘standard’ width for the child
2. Cut a pledget to use as a measuring stick (to above length)
3. Mark the antimesenteric border of the bowel and always keep this up
4. Start distally (r/o stricture at sb-colon anastomosis)
5. Spread a clamp through the mesentery from side to side (AM border up), have a red robinson cath pulled through to guide the stapler
6. Measure twice with the pledget and fire stapler
7. Leave the mesenteric defect open
8. Figure of 8 the cut crotch of the bowel with 4-0 or 5-0 Prolene
9. NPO for one week then UGI SBFT
10. Slow increase in fdgs – drip at night via GT and bolus during day

Powered by ScribeFire.

Here is a brief video clip of laparoscopic gastrostomy:

1. Take down all adhesions, mark the penis for the procedure.

2. Place a 5-0 Prolene suture through the glans as a traction suture.
3. Insert and 8 French feeding tube, decompressed the bladder, and leave the catheter in place.
4. Inject Xylocaine with epinephrine 1:1000 (standard mixture) into the glans wings area with a 30 gauge needle.
5. Deglove the penis, preserving a vascularized pedicle of tissue from the ventral aspect.

6. Raise the glans wings, working your way up from the shaft.
7. Check for chordee if necessary, with an artificial erection test.
8. Incise the urethral plate sharply, to allow it to hinge.

9. Reapproximate the neourethra in the ventral midline with a running 7 0 Vicryl suture as the first layer of closure.
10. Do not bring the closure too far out to the tip, as this may result in a later stricture.
11. Swing up the vascularized pedicle to cover the suture line as a second layer of closure (use 7-0 Maxon).
12. Lay in three sutures of 6-0 PDS to reapproximate the glans wings in the ventral midline. Be certain to leave the 8 French feeding tube in place. The sutures are secured after all are in place. This is the third layer of closure.

13. A fourth layer of closure is provided by reapproximating the more superficial layers of the glans with horizontal mattress sutures of 7-0 Maxon.
14. The feeding tube is removed and replaced with a 6 French soft Silastic stent.
15. A three-way Tegaderm pressure dressing is applied.
16. A caudal block is performed by anesthesia.
17. The dressing is removed the following day at home by parents. At the same time, the drip stent is trimmed back to approximately one inch in length.
18. The patient is discharged on Bactrim (if no allergy) on a qhs suppressive dose, along with narcotic pain medication (Tylenol codeine).
19. A clinic visit in one week is scheduled. At that time, the stent is removed, and bathing or swimming may recommence.
20. Most common complications include leak (fistula). The risk of this depends on the location of the native urethral opening. For most TIPS repairs, the risk is a few out of 100. A stricture can occur, the risk is approximately 2 – 5%. Cosmetic results are usually quite good.

1. Position the patient upright, either sitting or standing, and mark a line from the mid-clavicular point down to the areola-nipple complex (ANC) on both sides.

2. Measure the distance from the clavicle down to the top of the nipple and record it (normal in 16-17 year old males is approximately 17).
3. Mark a midline down from sternal notch to xiphoid.
4. Mark the anchor- type incision inferiorly for tissue to be removed.

5. Once the patient is asleep, prep the arms out extended on arm boards bilaterally.
6. Administer IV antibiotics (Ancef).
7. It is critically important to preserve the inferior blood supply to the ANC. The steps involved in doing this are as follows:
A. Stretch the surrounding skin around the nipple out with the aid of your assistant.
B. Place a sterile quarter over the native nipple and exert hard pressure.
C. Use the indentation line from the pressure to mark with a marking pen.
D. Drop two parallel lines down inferiorly to the lower border of the dissection (this is your vascularized pedicle).
E. This is the portion that will be de-epithelialized. In addition, you will de-epithelialize a small area around the outside of the border of the nipple marking you just made.
8. Inject Xylocaine with Epinephrine into the lateral and medial edges of the triangle you created on either side, as well as the apex of the triangle. Do not inject into the base of the area where the pedicle will be nor directly around the ANC.
9. De-epithelialize the inferior vertical band of skin and the circumferential area around the nipple.
10. Carry the deep incisions down around the breast tissue, remembering that this is not a cancer operation.
11. Perform the medial part of the dissection on either side of your preserved island pedicle. It is very important not to dissect in towards the pedicle too much as you will devascularize it.
12. Remove excess breast tissue, keeping it symmetrical on both sides.
13. Use a triangulation suture to close the triangular defect, bringing the mid or lower portions of the lateral sides down to the mid-portion of the bottom, taking care not to run the suture too deep into the pedicle tissue area.21. Use opposite side suturing techniques each time to secure the nipple complex of the surrounding tissues.
14. The areola, with its preserved vascular supply, is simply buried at this point.
15. Marks are made on either side down from the clavicle on the vertical access previously dropped. It is important to make sure that each nipple complex is positioned the same distance down from the clavicle.
16. The skin has been closed with interrupted nylon sutures vertically and with absorbable suture material inferiorly.
17. A closed-suction drain has been left in place prior to the skin closure.
18. Once all the aforementioned is completed, the sterile quarters are again used to mark the exit sites of the nipple, again making sure they are equal distance from the clavicles on either side.
19. Marks are made around the sterile quarters and then the skin is excised.
20. Underneath the opening, “fish” for the nipple. Bring the ANC up through the area and radially secure it.

22. Steri-strips and pressure dressings are applied.
23. The patient is admitted overnight and the drains removed in the morning.
24. The sutures are removed in two weeks in the clinic as an outpatient.
25. Pressure dressing is applied and left at least overnight, if not for 48 hours.

1. Marks are made for the procedure. It is important to mark the scrotal skin, prior to its being distorted by the prep and drape.
2. A transverse inguinal incision is used, dissection is carried down to Scarpa’s fascia.
3. Scarpa’s fascia is incised carefully, since rarely a long looping vas will be situated on top of the external oblique aponeurosis.
4. The external oblique aponeurosis is split in the direction of its fibers, and the ilioinguinal nerve is identified and preserved.
5. The hernia sac and cord structures were mobilized from distal to proximal, any traction suture placed through the testicle itself. A reasonable amount of traction must be kept on the testicle to facilitate the next part of the dissection.
6. While preserving downward traction, the hernia sac is skeletonized away from the cord structures. If this proves impossible, or the sac is entered repeatedly, then a sharp iris scissors is used to dissect the sac off of the cord. The sac commonly envelops the cord.
7. Circumferential retroperitoneal mobilization of the vas and vessels is carried out. Lateral attachments may be carefully divided. It is essential to apply upward traction on the hernia sac and perpendicular downward traction on the testicular traction suture. The hernia sac is doubly stick ligated.
8. If necessary, the cord structures can be passed medial to the inferior epigastric vessels. It is not necessary to define these vessels, simply use a right angle clamp to create a space underneath them. This allows for a more “straight shot” for the vessels down to the scrotum.
9. The inguinal canal is dilated over the examining finger, and the previously made scrotal incision sharply incised over the digit.
10. The dartos pouch is created, usually by blunt dissection. Bleeding and small vessels may need to be cauterized.
11. A mosquito clamp is inserted from the scrotum upwards, by pressing the tip of the clamp underneath the fingernail and advancing both as a unit.
12. The traction suture is grasped by the clamp, and the testicle gently pulled downward into the dartos pouch taking care not to twist it.
13. Soft tissue surrounding the inlet of the testicle into the dartos pouch is within either plicated around the testicle to contract it, or alternatively, peritesticular absorbable suture material is used to secure the testicle in the pouch. At testicle under tension will retract regardless of how it is sutured.

14. The dartos pouch skin is closed with a running horizontal mattress chromic suture.
15. The upper incision is closed in layers with absorbable suture.
16. Marcaine is injected into the incision for postoperative analgesia.
17. Two week follow up and six months follow-up are scheduled. Straddle toys and activities which might cause trauma to the area are avoided for at least two weeks.

1. A transverse inguinal incision is made

2. Dissection is carried down to the Scarpa’s fascia, which is sharply incised

3. The external oblique aponeurosis is identified, and dissection continued laterally and inferiorly to identify the area where it “curves over”

4. The dissection is continued downward along the inguinal ligament until the site where it “flares out” is identified – this is the external inguinal ring

5. The external inguinal ring is instrumented, and a longitudinal incision made along the direction of the fibers of the external oblique aponeurosis. Care is taken to avoid injury to the ilioinguinal nerve.

6. The handle of the knife is used to sweep clean the internal surface of the external oblique aponeurosis.

7. Gentle downward pressure is exerted by retractors on both sides-this causes bulging of the hernia sac upwards, making it easier to identify.

8. The cremasteric fibers are divided bluntly from side to side

9. The hernia sac is grasped, remaining cremasteric fibers are swept off of it, and a small amount of distal dissection is carried out to obtain more cord mobility.

10. The cord structures are carefully separated from the hernia sac. This can be accomplished by grasping the sac between the thumb and forefinger, identifying the yellowish fatty tissue, and applying perpendicular gentle traction to distract the vital structures away from the sac.

11. The distal sac is widely opened. However, complete excision is not necessary. The hydrocele fluid is evacuated.

12. Application of a vessel loop around the cord structures may facilitate the dissection. The proximal sac is followed up to the internal inguinal ring while traction is applied via the vessel loop to the cord structures. Countertraction is applied to the hernia sac.