Video-assisted thoracoscopic ligation of a patent ductus arteriosus in a very low-birth-weight infant using a novel retractor.

Patent ductus arteriosus (PDA) ligation is a potentially lifesaving procedure that is frequently performed in very low-birth-weight (VLBW) infants. Video-assisted thoracoscopic surgery (VATS) PDA ligation has many advantages; however, this approach has not been widely used in these extremely small patients. We present a technique using a novel retractor that allows safe VATS PDA ligation in the VLBW neonate. A 740-g male infant with necrotizing enterocolitis underwent general anesthesia. After placement in the right lateral decubitus position, he underwent a left VATS PDA ligation using a new 3-mm fan retractor for lung retraction and exposure. A thoracostomy tube was not used. He recovered uneventfully and is well at 6-month follow-up. The technique is minimally invasive and provides superior visualization of the PDA and surrounding anatomical landmarks. Using this novel retractor, VATS PDA ligation is practical in even the smallest infants. This retractor may facilitate the performance of more advanced thoracoscopic procedures in VLBW infants.

Single site laparoscopic gastrostomy with a 4-mm bronchoscopic optical grasper.

Percutaneous endoscopic gastrostomy (PEG) is a common technique for gastrostomy placement. However, certain children may not be candidates for PEG, such as those with craniofacial or foregut anomalies and prior surgery. Laparoscopic gastrostomy has also gained popularity, but this requires 2 or 3 trocar sites. The use of a larger single operating laparoscope or multiple-port laparoscopic techniques may not be practical in small children and infants. We describe a simple technique for gastrostomy tube placement in infants using a 4-mm operative bronchoscope. A 1.4-kg infant with a cleft palate and hypotonia underwent general anesthesia. A 5-mm laparoscopic port was placed in the left upper quadrant at the site of the intended gastrostomy. Following pneumoperitoneum, a 4-mm bronchoscopic optical grasper was inserted into the abdomen via the single port. The stomach was grasped and pulled out through the port site. The extracorporeal portion of stomach was matured as a gastrostomy. A low-profile gastrostomy button was placed. Proper position of the gastrostomy device was verified intraoperatively using dye. At 2 months follow-up, the child and gastrostomy are without complication. This technique is minimally invasive and provides direct visualization through one 5-mm abdominal port without the requirement of endoscopy and blind percutaneous entrance into the abdominal cavity. This single-site laparoscopic gastrostomy may be a practical alternative for infants who may not be candidates for PEG or larger single-port operating systems.

Classical positioning decreases subclavian vein cross-sectional area in children.

BACKGROUND: Recommendations for subclavian vein catheter placement in children are extrapolated from adult experience. The purpose of this study was to determine the ideal body position to optimize the size of the subclavian vein in children for percutaneous catheter placement. METHODS: Children underwent ultrasound imaging of the subclavian vein in four supine body positions: head in a neutral position with the chin midline (NL) and no shoulder roll (SR); head turned 90 degrees away (TA) and no SR; head NL with an SR; and head TA with an SR. The cross-sectional area (CSA) of the subclavian vein was calculated and statistical significance was determined using the Student's t test and the Wilcoxon signed rank test. RESULTS: Nine children participated in the study, with a mean age of 5.3 years. The CSA of the subclavian vein was 0.39 +/- 0.24 cm2 with the head NL and no SR, compared with 0.31 +/- 0.20 cm2 with the head TA or 0.32 +/- 0.23 cm2 with the head TA and SR. This represented a significant reduction in the CSA of the subclavian vein by 22% and 18%, respectively (p < 0.05). CONCLUSION: In children, the recommended maneuvers of turning the head or turning the head and placing a posterior shoulder roll significantly reduce the cross-sectional area of the subclavian vein. Maintaining the head in a normal position with the chin midline without a shoulder roll optimizes subclavian vein size. Positioning children in this manner may serve to reduce the morbidity associated with percutaneous subclavian vein cannulation.

Principles for the surgical management of patients with Proteus syndrome and patients with overgrowth not meeting Proteus criteria.

BACKGROUND: Proteus syndrome is a rare, sporadic disorder consisting of disproportionate overgrowth of multiple tissues, vascular malformations, and connective tissue or epidermal nevi. Patients with Proteus syndrome present with diverse and variable phenotypes because of the syndrome's mosaic pattern of distribution. METHODS: Eighty patients with Proteus syndrome, satisfying published diagnostic criteria, and 51 patients with overgrowth not meeting Proteus criteria were identified from the literature. Three additional patients, one patient with Proteus syndrome and 2 patients with overgrowth, were treated at the author's institutions and are discussed in detail. All nonorthopedic and noncutaneous surgical interventions were reviewed. RESULTS: Fourteen genitourinary, 9 gastrointestinal, and 5 otolaryngologic operations were performed on patients with Proteus syndrome. Six genitourinary, 5 gastrointestinal, and 2 otolaryngologic operations were performed on patients with overgrowth not meeting Proteus criteria. Eight patients with Proteus syndrome and 4 patients with overgrowth experienced thoracic manifestations, generally diffuse cystic pulmonary lesions, but only 1 of 12 underwent surgical treatment. CONCLUSIONS: Patients with visceral manifestations of either Proteus syndrome or overgrowth not meeting Proteus criteria should be treated in a similar manner. Lesions involving the ovaries and testes, because of the high incidence of neoplasm, should be managed aggressively. Gastrointestinal and renal lesions may be managed conservatively with frequent follow-up to minimize abdominal explorations. All patients undergoing surgery should have a thorough preoperative assessment of their airway and pulmonary reserve because of the relatively high frequency of tonsillar hypertrophy and pulmonary cystic involvement.