Tutorials

1. Approach is via left chest – skin incision is in the inframammary crease, and the chest is entered in the 3rd or 4th interspace.
   
2. The mediastinum is opened anteriorly, taking care to preserve the phrenic nerve.
   
3. The thymic lobe is retracted or resected to provide exposure.
   
4. The reflection of the pleura on the great vessels is identified. Several (3-4) sutures are placed between the pericardium (not the adventitia of the aorta) and the sternum. The sutures are laid in and left untied until all have been placed.
   
5. The procedure can be done with the bronchoscope and the camera in place and the pt ventilated through the scope. In this manner, the airway can be evaluated while the procedure is performed, and additional sutures can be placed as needed.
   

• with 'short' common channel (< 3cm)
  

  
  

• Dx Code: 751.2 CPT Code: 46740
  

  
  

• It is important that the child has undergone cystovaginoscopy to
  determine the length of the common channel.
  

  
  

• The patient is positioned prone, as for a Pena procedure
  

  
  
  

  
  

• An incision is made from the mid sacrum to the single perineal
  orifice and the sphincter is divided in the midline
  

  
  
  

  
  

  
  

• The rectum is encountered, and is opened in the midline. Silk
  traction sutures are placed along the cut edges of the rectal wall
  

  
  

• The rectal incision is extended through the entire posterior wall
  of the common urogenital sinus, and edge silk sutures are also
  placed
  

  
  
  

  
  

• The entire common UGS is opened to verify that the defect is low
  

  
  

• Separate the rectum from the vagina
  

  
  
  

  
  

• Total UGS mobilization can now be performed. Place many silk sutures
  through the vaginal edges and common channel edges
  

  
  
  

  
  

• Place a row of fine silk sutures transversely between the UGS end
  and 5 mm proximal to the clitoris (not shown)
  

  
  

• Transect the UGS between the last row of sutures and the clitoris
  

  
  

• A natural plane of dissection exists between the pubis and the UGS;
  there will be a suspensory ligament encountered (suspensory ligament
  of the urethra and bladder) - divide it and This will add 2 -3 cm
  of length
  

  
  

• Dissect the lateral and dorsal walls of the vagina to gain a little
  more length
  

  
  

• The old UGS common channel is divided in the midline to create 2
  lateral flaps which will become the labia minora (not shown)
  

  
  

• Sew the vaginal edges (Vicryl) to the skin to make an adequate
  introitus
  

  
  
  

  
  

• Stimulate the muscle to verify the location of the sphincter
  

  
  

• The perineal body is then reconstructed in the midline to make the
  anterior border of the sphincter
  

  
  

• The rectum is positioned within the sphincter
  

  
  

• The closure is completed
  

  
  
  

  
  

• The patient can be fed the same day
  

  
  

• The Foley is removed in the morning
  

  
  

• Discharge in 1-2 days
  

  
  

• Post op rectal and vaginal dilations per routine
  

  
  

• Stomal closure in 3 months if no complications
  

  
  

1. Make sure the patient's voiding dysfunction is well-controlled with behavioral and anticholinergic therapy.
   
2. The patient is placed in the carefully padded hanging stirrups. The camera (TV screen) is positioned around the patient's right shoulder area so that it can be viewed from between the patient's legs.
   
3. Do not open the Deflux until you are ready to inject, since the cost is 1,000 U.S. dollars per cubic centimeter (cc).
   
4. IV Gentamicin is given in the Operating Room pre-operatively.
   
5. A #12 French to #10 French scope is usually utilized with a 45 or 30 degree angulation.
   
6. The needle is flushed prior to placing it in the scope. This is done with saline solution. It is important not to inject any further saline after the Deflux has been inserted since saline may dissolve the Deflux.
   
7. 1.0 cc is generally used per orifice, but 2.0 cc can be used if necessary, particularly on larger children.
   
8. A urine culture is obtained as soon as the scope is advanced in.
   
9. The needle is advanced in with the bevel upwards, and it is advanced inside the floor of the urethral orifice. There is a black mark on the needle indicating how far in it should be advanced. The bevel can be rotated in order to control where the injection is going, particularly if it seems to be extravasating laterally or medially. Once the injection is completed, the needle is left in place for about a minute and then withdrawn.
   
10. Once the needle is withdrawn, the scope is advanced into the orifice and the flush used with the cystoscope to see if you can balloon out the orifice. If so, perhaps more Deflux injection is necessary.
    
11. Do Not Run Fluid Through the Cystoscope While Injecting
    
12. Two-week follow-up is not generally necessary unless the patient is symptomatic. A phone call is perhaps worthwhile.
    
13. No follow-up ultrasounds are usually obtained unless patient is symptomatic.
    
14. A VCUG is obtained in three to four months and then again at one year.
    
15. On dictation of the Operative Report, remember to have the nurses check the urine culture results.
    
16. The bladder is decompressed when the procedure is completed.
    
17. Viscous Lidocaine is injected into the urethra when finished with the procedure.
    

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• The left upper quadrant suture is usually unnecessary. The suture around the falciform ligament is sometimes helpful, but not essential. The right lowermost stab incision 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.
  
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• A bump is placed transversely in the mid back to help expose the duodenum and keep the liver out of the way.
  
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• 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.
  
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• The covered “Colorado” Bovie tip is used at a setting of 7.
  
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• The U-Clips are the small S-60 clips.
  
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• Position in the usual thoracotomy position, usually right side up unless abnormal location of aortic arch (RAA).
  
• Place ports as shown, but sometimes the ports are highest ANTERIOR to the scapular edge (stab incision), middle is 5 mm port for the clip and ligasure (3 bars setting), and the lowest is a 5 mm port for the camera.
  
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• The port (5 mm) under the border of the scapula should be positioned high - otherwise you will be sewing backwards. The lateral middle port is a stab incision for 3 mm instruments. The lower camera port is 5 mm, and the scope is 70 degree.
  
• 3-5 mm Hg of insufflation pressure is used. Left mainstem intubation is preferable if possible when using conventional mechanical ventilation, but an oscillator is much better.
  
• Divide the azygous vein with the Ligasure(Tm).
  
• Mobilize the esophagus in the usual fashion.
  
• The fistula is clipped with a 5 mm clip - usually singly, but if 2 clips can be placed well, go ahead.
  
• We use 4-0 silk or surgilon on a skiied needle, usually 8-10 cm long for the anastomosis. The needle may be a break-away.
  
• When the anastomosis is half completed, anesthesia advances a trans-nasal silastic tube through the repair, and it is well secured.
  
• The anastomosis is completed, and a 7 mm round Blake(Tm) drain is left through the lower port.
  
• Feedings can be started in 2-3 days via the trans-anastomotic tube.
  
• A contrast study is obtained in 7 days to check the anastomosis.
  
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• Patients are positioned at the end of the operating table; larger children (greater than six years) may require stirrups.
  
• If a gastrostomy is to be used, IV antibiotics are administered.
  
• Prepping and draping is unusual in that small strips of iodoform 3M dressing are cut and used to secure the edge of the drapes. The drape sheet is placed in the usual position. The ends of the laparoscopic plastic portion of the drape are cut off on the cephalad side.
  
• The liver retractor is attached to the right side at the shoulder level
  
• A 5 mm port is placed in the umbilicus
  
• Other than the camera site at the umbilicus, four stab incisions are used. These are located halfway between the rib margin and the umbilicus angling up towards the right shoulder. Two ports are used symmetrically positioned on either side of the midline about a finger breadth below the rib edge or sternum. A fourth symmetrical opening is made running from the umbilicus up towards the patient’s left shoulder, again halfway between the umbilicus and the edge of the rib. If a gastrostomy is to be used, some modification of the left upper quadrant port is made, i.e., it is larger and may need to be positioned slightly more inferiorly. Sometimes an actual port is then placed through this area as well.
  
• The first portion of the procedure consists of the assistant holding the left lower quadrant grasper and pulling on the spleen side of the short gastrics. The operating surgeon uses both of the superior graspers to hold with the left hand and then divide with electrocautery up the greater curvature including the phrenoesophageal membrane.
  
• At this point, an entry site is made underneath the esophagus in order to get across posteriorly. It is important not to place this too low, underneath the left gastric artery.
  
• After the twelve o’clock position is reached around the phrenoesophageal ligament, the approach is then from the right side of the crura, again grasping as described above and dividing with the cautery.
  
• During this process, it may be necessary to have the assistant reach with the left lower quadrant grasper up around from the right side of the stomach across and underneath it posteriorally through the window to elevate the stomach. It is important throughout this process that the NG tube is decompressing the stomach.
  
• Once the dissection is completed and an adequate length of esophagus is mobilized, the posterior crural sutures are placed. It is sometimes helpful at this point to advance the bougie down and then withdraw it slightly. The size of the bougie is determined by chart on the wall in the operating room. The posterior crural sutures are placed. Two additional sutures are placed at approximately nine or ten o’clock and three o’clock or two o’clock to secure esophagus to the crura. The second of these is a difficult suture to place and must be done in two bites.
  
• The bougie is advanced in and a wrap begun. Sutures are placed through stomach, esophagus and stomach. The wrap is not usually tacked to the diaphragm. The wrap is measured with a cut string. It should be approximately 2 cm at least in length in an infant. The are 3 sutures – top 2 incorporate the esophagus also, but the lower one doesn’t have to. The clip device can be used to secure sutures – pull only the needle end of the suture back up thru the port thru which it was introduced, and cut off the needle, thread both suture ends thru the wire loop, slide the metal ‘needle’ back, then hold the suture and push the securing device down.
  
• Once the wrap is completed, the bougie is removed.
  
• Marcaine is injected through all the port sites under direct visualization.
  
• The umbilical site is closed with the Vicryl suture as is the larger left upper quadrant site.
  
• Feedings are started six hours after the surgery, no NG tube is used. The advancement formula is similar to that used for pyloric stenosis (at least in infants). Most patients go home the next day. A pureed diet is given for 2 weeks.
  
• Here is a video
  

• Watch this brief clip
  

• Take down all adhesions, mark the penis for the procedure.
  
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• Place a 5-0 Prolene suture through the glans as a traction suture.
  
• Insert and 8 French feeding tube, decompressed the bladder, and leave the catheter in place.
  
• Inject Xylocaine with epinephrine 1:1000 (standard mixture) into the glans wings area with a 30 gauge needle.
  
• Deglove the penis, preserving a vascularized pedicle of tissue from the ventral aspect.
  
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• Raise the glans wings, working your way up from the shaft.
  
• Check for chordee if necessary, with an artificial erection test.
  
• Incise the urethral plate sharply, to allow it to hinge.
  
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• Re-approximate the neourethra in the ventral midline with a running 7 0 Vicryl suture as the first layer of closure.
  
• Do not bring the closure too far out to the tip, as this may result in a later stricture.
  
• Swing up the vascularized pedicle to cover the suture line as a second layer of closure (use 7-0 Maxon).
  
• 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.
  
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• A fourth layer of closure is provided by reapproximating the more superficial layers of the glans with horizontal mattress sutures of 7-0 Maxon.
  
• The feeding tube is removed and replaced with a 6 French soft Silastic stent.
  
• A three-way Tegaderm pressure dressing is applied.
  
• A caudal block is performed by anesthesia.
  
• 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.
  
• The patient is discharged on Bactrim (if no allergy) on a qhs suppressive dose, along with narcotic pain medication (Tylenol codeine).
  
• A clinic visit in one week is scheduled. At that time, the stent is removed, and bathing or swimming may recommence.
  
• 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 to 5%. Cosmetic results are usually quite good.
  
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• 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.
  
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• 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.
  
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• 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.
  
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• 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.
  
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• 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
  
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• A Lone Star retractor (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.
  
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• 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.
  
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• 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).
  
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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.
    
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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).
    

1. 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.
   
2. 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.
   
3. 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.
   
4. 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.
   
5. 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.
   
6. 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.
   
7. 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.
   
8. 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.
   

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.
    

1. Prep with arms abducted on arm boards to 90 degrees.
   
2. Preop IV antibiotics, contd for 24 hrs post op; double glove
   
3. Mark while awake in SDS the site of the interspace the bar will go thru on the right and left, at the site one interspace ABOVE the deepest part of the deformity
   
4. Widely drape and use iodoform drape to secure the towels
   
5. Measure for the bar in inches – from mid axillary line to mid axillary line – use the orange/brown Lorenz models for the bar
   
6. Make an oblique (mostly transverse) incision in R and L mid axillary lines, with pocket for the stabilizers
   
7. Bend the bar to the correct position – Too short is better than too long
   
8. Make a subxiphoid vertical midline incision – remove the xiphoid, and BLUNTLY dissect the retrosternal plane – a small Richardson retractor or appendix retractor helps lift up the sternum.
   
9. Use the curved long clamp to go over the muscle and fascia from lateral to pop thru against your finger beside the sternum. The passer is then substituted to bring the tape from lateral to the midline. Shove the passer all the way in – it dilates the space. The same process is carried out on the other side and the taped pulled from the midline to the lateral incision. 2 umbilical tapes are used.
   
10. Tie one of the tapes to the bar, and pull it through over the guiding finger (asst can lift up the sternum with the Richardson).
    
11. Flip the bar over and adjust as needed.
    
12. Each stabilizer is secured with two #5 Tevdeks (each hole) and another of the same sutures is passed around the bar.
    
13. Use antibiotic irrigation, and suck out mediastinum and inflate lungs to 30 cm before closing xiphoid incision
    
14. CXR in RR – may not need to treat PTX if small
    
15. Bend one end of bar at removal
    

• 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.
  
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• 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).
  
• Mark a midline down from sternal notch to xiphoid.
  
• Mark the anchor- type incision inferiorly for tissue to be removed.
  
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• Once the patient is asleep, prep the arms out extended on arm boards bilaterally.
  
• Administer IV antibiotics (Ancef).
  
• 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.
  
• 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.
  
• De-epithelialize the inferior vertical band of skin and the circumferential area around the nipple.
  
• Carry the deep incisions down around the breast tissue, remembering that this is not a cancer operation.
  
• 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.
  
• Remove excess breast tissue, keeping it symmetrical on both sides.
  
• 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.
  
• The areola, with its preserved vascular supply, is simply buried at this point.
  
• 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.
  
• The skin has been closed with interrupted nylon sutures vertically and with absorbable suture material inferiorly.
  
• A closed-suction drain has been left in place prior to the skin closure.
  
• 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.
  
• Marks are made around the sterile quarters and then the skin is excised.
  
• Underneath the opening, “fish” for the nipple. Bring the ANC up through the area and radially secure it.
  
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• Steri-strips and pressure dressings are applied.
  
• The patient is admitted overnight and the drains removed in the morning.
  
• The sutures are removed in two weeks in the clinic as an outpatient.
  
• Pressure dressing is applied and left at least overnight, if not for 48 hours.
  

• Marks are made for the procedure. It is important to mark the scrotal skin, prior to its being distorted by the prep and drape.
  
• A transverse inguinal incision is used, dissection is carried down to Scarpa’s fascia.
  
• Scarpa’s fascia is incised carefully, since rarely a long looping vas will be situated on top of the external oblique aponeurosis.
  
• The external oblique aponeurosis is split in the direction of its fibers, and the ilioinguinal nerve is identified and preserved.
  
• 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.
  
• 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.
  
• 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.
  
• 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.
  
• The inguinal canal is dilated over the examining finger, and the previously made scrotal incision sharply incised over the digit.
  
• The dartos pouch is created, usually by blunt dissection. Bleeding and small vessels may need to be cauterized.
  
• 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.
  
• The traction suture is grasped by the clamp, and the testicle gently pulled downward into the dartos pouch taking care not to twist it.
  
• 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.
  
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• The dartos pouch skin is closed with a running horizontal mattress chromic suture.
  
• The upper incision is closed in layers with absorbable suture.
  
• Marcaine is injected into the incision for postoperative analgesia.
  
• 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.
  

• Watch this brief clip
  
• Have anesthesia place a 10 French red Robinson tube to decompress the stomach. This will be left in during the case to periodically decompress the stomach and, at the end, to insufflate air.
  
• Set the laparoscopic pressures to about 12 to 10.
  
• Set the flow to a setting of 2. If this is set too high, it can interfere with ventilation.
  
• The child is positioned sideways on the table. The head of the table, i.e. the patient’s right side is elevated and the table rotated toward the surgeon so that the patient’s feet are down and head is up.
  
• Frog leg the patient.
  
• The first incision is about a 3 mm incision through the umbilicus. Usually there is a fascial defect and an open technique can be used to place the small one step without the Veress needle. Both sides are firmly grasped and the 5 mm port – introduced or advanced in.
  
• 0° or 45° 4 mm scopes are used.
  
• A small incision is made laterally as if a line were drawn underneath the rib on the left side down to and past the pylorus. This is made just underneath the rib margin on the right side. The # 11 blade is advanced in nearly as far as it will go, appearing perhaps a little bit on the shallow side.
  
• The small grasper is advanced through the stab incision under direct vision and used to grasp the duodenum at the duodenal pyloric junction.
  
• A left upper quadrant incision is made on the line previously described through which the knife is advanced.
  
• The knife is advanced out to the second setting which is 2 mm which should be far less than the depth down to the mucosa.
  
• An incision is made from the white line well upon to the antrum.
  
• The knife is retracted back and the same instrument used to bluntly spread apart the muscle fibers and obtain mucosal outpouching.
  
• The spreader is advanced through the port that the knife was present in the left upper quadrant after it is removed.
  
• The spreader is used to spread the muscle fibers and obtain good mucosal outpouching.
  
• The spreader is advanced back in with a 2 cm thread. This is then grasped with the other grasper and laid over the incision to verify the length of it. This should be between 1.5 and 2 cm long.
  
• The spreader and grasper are used to grasp both sides and rock the pylorus back and forth to make sure that it is indeed split into two separate halves.
  
• Marcaine is injected at the entry sites under direct visualization.
  
• The stomach is then insufflated as previously described with a 10 French red Robinson catheter to make sure there is no bubbling or leakage.
  
• The two small stab incisions only need a steri-strip across the skin. The umbilical defect is closed with a figure of 8 suture of 4.0 or 3.0 Vicryl. A small gut suture is placed is in the skin at the umbilicus.
  

• 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.
  
• 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.
  
• 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)
  
• Preoperative labs: CBS, Lytes, Plts, PT, PTT, +/- LFT’s
  
• IV preoperative antibiotics should be given
  
• 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.
  
• 
  
• 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.
  
• 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.
  
• The hospital stay is typically that of discharge the next morning.
  
• 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)
  

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

1. The child is positioned supine
   
2. Endoscopy is done first - cystoscopy to look at vagina and cervix, then bladder
   
3. Sometimes the external sphincter can be seen
   
4. A dilator can be inserted with a finger used to measure the length
   of the confluence
   
5. A Fogarty catheter is placed through the urogenital sinus into the vagina
   
6. The cystoscope is used to verify the position of the Fogarty in the vagina
   
7. A Foley catheter is placed into the bladder
   
8. The entire lower body with the still sterile catheters is prepped
   
9. Stockinets are used on the legs
   
10. A traction suture is placed through the glans clitoris
    
11. Xylocaine with epinephrine is injected along the incision line
    
12. A sub-coronal glanular incision is made in the clitoris
    (example case is congenital adrenal hyperplasia with low confluence)
    
13. A plane between dartos and Buck's fascia is developed to deglove
    the clitoris
    
14. The skin is incised ventrally to the meatus in the midline
    
15. Circumferential incision around the UGS meatus is made, and
    traction sutures placed through the distal sinus
    
16. An inverted U incision is made in the perineum, just below the
    labial incision, and bilateral superior U-shaped incisions for the
    labia (see Figure)
    
17. Perineal inverted U is opened to the ischial tuberosity on each
    side - use a middle stay suture for the flap
    
18. The UGS is mobilized from the phallus for a short distance
    
19. Laterally a free plane is always present on either side of the
    sinus as it goes towards and underneath the pubis
    
20. The UGS can now be easily mobilized well proximal to the corporal bifurcation
    
21. Near the pubis, the lateral avascular attachments to the UGS are
    divided.
    
22. The plane between the urethra and the pubis is developed, avoiding
    any muscle
    
23. After the attachments of the bulbospongiosus muscle are divided, the
    plane between the vagina and rectum opens, allowing blunt finger dissection
    
24. You may be able to feel the fogarty or see it now
    
25. Sutures are placed at the vaginal confluence for traction, and the
    posterior vaginal wall is exposed, and split open in the midline to
    expose the Fogarty catheter
    
26. Traction sutures are placed every one-half cm on each side of the
    posterior vaginal incision, which is carried proximally until the
    normal vagina is reached
    
27. The Fogarty can be removed
    
28. The UGS sinus is opened in the midline distally to proximally, and
    can be opened completely
    
29. The urethral opening will now reach the skin, as will the vaginal opening
    
30. The posterior flap is sewn to the posterior vagina with Vicryl
    sutures (lay them in before tying)
    
31. The clitoris is freed from surrounding attachments to its
    bifurcation, and a tourniquet placed at the base
    
32. Lateral longitudinal incisions are made thru Buck's fascia and
    the tunica albuginea on either side, and a plane made between the
    tunica albuginea and the erectile tissue. The erectile tissue is
    ligated at its base and at the glans, and excised.
    
33. The glans is left with its neurovascular bundle and dorsal tunica
    albuginea preserved
    
34. The phallus skin is split down the midline, stopping short to leave enough for a
    clitoral hood
    
35. The phallic skin is secured to the glans, and then afterwards, the
    glans is secure to the coronal stump with PDS.
    
36. The UGS sinus skin is preserved and secured to the clitoris;
    laterally it will be attached to the future labia minora
    
37. The labia minora skin flaps are secured to the UGS after the lateral perineal
    flap are sutured in place
    
38. The labia majora skin is mobilized and secured to the minora
    
39. The Foley is left in place
    
40. A 20 - 22 FR should pass into the vagina easily, and a penrose is
    left in the vagina
    

    
    

ICD code CPT Code

1. Most foregut duplication cysts do not communicate with native structures
   
2. Many are incidentally discovered on CT scans or other studies
   

   
   
   

   
   

3. They may be thin-walled and filled with mucus
   
4. Because of the potential for enlargement, infection, and malignancy
   they are usually excised
   
5. Most can be resected thoracoscopically
   
6. The patient is positioned in thoracotomy position, with the
   affected side up. Single lung ventilation is preferred.
   

   
   
   

   
   

7. Port placement is as shown; it is preferable to position the ports
   posterior to the posterior axillary line, since working over the
   lung is undesirable.
   

   
   
   

   
   

8. The camera is initially placed in the middle anterior 5 mm port (5
   mm 45 degree scope), but a 2nd 5 mm port is used superiorly, since
   it may be necessary to move the camera. The other 1 or 2 sites are
   stab incisions with 3 mm instruments in small children, 5 mm in
   larger.
   
9. The cyst is dissected free and removed; it will easily come thru
   the ports when decompressed
   

   
   
   

   
   

10. A Blake drain can be left if needed.
    
11. A CXR is obtained and if no abnormalities found, the patient can
    be discharged the following am.