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.