Collection of videos of pediatric surgical procedures.

Below is a collection of videos of pediatric surgical procedures. Most are from WebSurg (requires registration-free). I will update the list as I find more. Enjoy!

VATS Left lower lobectomy on an 11 month old infant for a congenital lung lesion. From WebSurg with Dr Rothenberg

VATS left upper lobectomy on a 3 year old for a congenital lung lesion.  From WebSurg with Dr Barcelo.

Lap Nissen fundoplication in 18 month old. From WebSurg with Dr Rothenberg

PSARP for recto-urethral fistula. From WebSurg with Dr Peña.

Meltzer III slip knot. Laparoscopic extracorporeal slip knot.

Lap Heller myotomy for achalasia from WebSurg with Dr MacKinlay

Lap Kasai portoenterostomy with Dr Dutta; Lucile Packard Children's Hostpial, Stanford

Lap choledocal cyst excision with Dr Hollands; LSU Health Sciences Center


Lap Duodenal atresia (and malrotation) repair with Dr Rothenberg.

VATS thoracic sympathectomy 

Left lap adrenalectomy WebSurg

Sketchnotes: VV ECMO

Sketchnotes: Differential diagnosis of mediastinal masses

Lung metastectomy in osteosarcoma: thoracotomy or VATS?

Osteosarcoma, which presents with metastatic lung disease in 15-20% of cases, is one of the few malignancies (along with non-rhabdo soft tissue sarcoma and hepatoblastoma) where resection of metastatic disease to the lung can improve survival.

Although lung metastectomy has been shown to be beneficial in this group, the optimal modality of resection, whether by open thoracotomy or VATS, is not clear. The argument for the use of an open thoracotomy in the management of lung mets has to do with the ability to palpate lesions, whereas VATS relies on imaging for detection of lung nodules. Studies have shown that a CT scan that detects a nodule(s) in the lung can miss additional palpable ones in 50% of patients, approximately half of which contain viable malignant tissue. So, in essence, VATS would likely miss additional malignant nodules, and thus leave behind otherwise palpable malignant lesions, in 25% of patients.

So it seems obvious that an open thoracotomy is the way to go, except that we don’t really know if a VATS followed by close monitoring to detect the 25% of patients with missed nodules that can be salvaged by a second VATS (and thus spare a number of kids a thoracotomy) changes the outcome in terms of long term survival when compared to primary resection of all the palpable nodules with an open thoracotomy.

Reference:
1. St Jude Oncology Review Course
2. Kayton ML et al. Computed tomographic scan of the chest underestimates
the number of metastatic lesions in osteosarcoma (2006);41:200

Why should kids with short gut syndrome be on proton pump inhibitors?

During rounds today, I noticed that someone had changed an order for a proton pump inhibitor to an H2 blocker on one of our patients with short gut syndrome. The reason was some form of shortage, so they decided it was OK to switch.

So it was time for that discussion again.

Patients with intestinal failure secondary to substantial small bowel loss need proton pump inhibitors because they are in a state of hypergastrinemia, as gastrin is primarily metabolized in the small bowel.

Elevated gastrin levels cause an increase in the volume and acidity of gastric secretions, which results in an acidic environment in the small bowel. The increase in volume worsens the fluid and electrolyte balance which is already tenuous in patients with short gut. Additionally, the acidic environment in the small bowel exacerbates malabsorption by causing bile acids to precipitate (sabotage micelle formation) and by inactivating pancreatic enzymes.

He's back on his proton pump inhibitors.

Reference:
Kocoshis SA. Medical management of pediatric intestinal failure. Seminars in Pediatric Surgery (2010);19:20

Is a bowel prep necessary before colostomy reversal?

Another paper that supports omitting bowel preps before pediatric bowel operations came out in this month’s issue of JPS. In this study, the authors conducted a retrospective, multi-institution study and compared the outcome of 272 children who underwent colostomy reversal with and without (187 vs. 85) a polyethylene glycol bowel prep.

The authors noted a significantly higher rate of wound infection (14.4% vs. 5.8%), as well as a longer hospital stay (5.6% vs. 4.4%) in the group who underwent a bowel prep. Additionally, they noted that the risk for other complications such as abdominal abscess formation (~1%) and ansastomotic leak (~1%) was the same whether a bowel prep was used or not.

Reasons given for the potential deleterious effects of the bowel prep included the characteristics of liquid stool (bowel prep) that make it more difficult to contain, the fact that the bacterial load in prep’d stool is not necessarily lower than unprepped stool (papers sited), and the potential harmful effect of the bowel prep on the integrity of the bowel mucosa.

As with all retrospective studies, the authors acknowledged the limitations of their results, but stressed that, except for intra-pelvic rectal surgery, a bowel prep is likely unnecessary for colonic surgery in children.

Reference:
Serrurier K et al. A multicenter evaluation of the role of mechanical bowel preparation in pediatric colostomy takedown. JPS (2012);47:190-193

Vascular lesions: time to abandon the nomenclature of edibles!

After a long conversation discussing the management plan for a “giant cavernous hemangioma” of the liver, and although I had just recently brushed up on the subject of vascular lesions, I had to go back and look it up again. I was pretty sure the term “cavernous hemangioma” was as antiquated as “strawberry hemangioma” or “port wine stain”; the generalized agreement around me on the diagnosis made me doubts myself. Back to the books.

Sure enough, as of 25 years ago, the International Society on the Study of Vascular Lesions adopted the Mulliken system of classification, which divides vascular lesions into tumors (mainly infantile hemangiomas) and malformations (capillary, venous, lymphatic malformations etc…). This division is based on clinical and histologic characteristics; vascular tumors display endothelial proliferation and usually regress with time, while vascular malformations have a quiescent epithelium, result from dysmorphogensis of vessels, and tend to enlarge with time.

No more should the term lymphangioma, which by vertue of the –oma suffix suggests a tumor, be used to describe a lesion that is a malformation (lymphatic malformation). Nor should the term cavernous hemangioma be used to describe what could either be a deep visceral hemangioma or a venous malformation (two distinct entities, treated in very different ways).

A study by Hassanein et al reviewed articles on vascular lesions and noted a 70% incidence of incorrect nomenclature and a subsequent 20% incidence of incorrect treatment based on erroneous classification. They commented that this is probably an underestimation of the incidence of incorrect diagnosis and treatment in clinical practice, given that experts had probably edited many of these articles for accuracy.

Another reason we should continue to read, read, and read some more.

Reference:
Hassanein et al. Evaluation of terminology for vascular anomalies in current literature. Plastic and Reconstructive Surgery (2011);127(1):347