# Mediastinum, Great Vessels and Diaphragm — GCMD Library living collection

Updated: n/a · 11 episodes · 63 cited statements

## Episodes
### Patent ductus and vascular rings
- [PDA ligation by Dr. Steven Rothenberg](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714) — video · 6:24 · [machine version](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714.md)
- [IPEG 2020 TOP ABSTRACT: Thoracoscopic Division of a Double Aortic Arch Vascular Ring Anomaly](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262) — video · 2:44 · [machine version](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262.md)
- [Thoracoscopic Stapled Division of a Double Aortic Arch](https://library.globalcastmd.com/watch/thoracoscopic-stapled-division-of-a-double-aortic-arch-11964) — video · [machine version](https://library.globalcastmd.com/watch/thoracoscopic-stapled-division-of-a-double-aortic-arch-11964.md)
- [Vascular ring handout](https://library.globalcastmd.com/watch/vascular-ring-handout-11980) — article · [machine version](https://library.globalcastmd.com/watch/vascular-ring-handout-11980.md)

### Mediastinal masses and thymus
- [Thoracoscopic Thymectomy](https://library.globalcastmd.com/watch/thoracoscopic-thymectomy-399) — video · [machine version](https://library.globalcastmd.com/watch/thoracoscopic-thymectomy-399.md)
- [mediastinal masses 2014](https://library.globalcastmd.com/watch/mediastinal-masses-2014-11989) — article · [machine version](https://library.globalcastmd.com/watch/mediastinal-masses-2014-11989.md)

### Thoracic duct and diaphragm
- [Thoracoscopic Ligation of the Thoracic Duct](https://library.globalcastmd.com/watch/thoracoscopic-ligation-of-the-thoracic-duct-11973) — video · [machine version](https://library.globalcastmd.com/watch/thoracoscopic-ligation-of-the-thoracic-duct-11973.md)
- [thoracoscopic thoracic duct ligation presentation. MIS w video. 1.15](https://library.globalcastmd.com/watch/thoracoscopic-thoracic-duct-ligation-presentation-mis-w-video-1-15-11998) — article · [machine version](https://library.globalcastmd.com/watch/thoracoscopic-thoracic-duct-ligation-presentation-mis-w-video-1-15-11998.md)
- [Thoracoscopic Diaphragmatic Plication](https://library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974) — video · 4:40 · [machine version](https://library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974.md)
- [Laparoscopic Plication of a Right Diaphragmatic Eventration in a 3-Month-Old](https://library.globalcastmd.com/watch/laparoscopic-plication-of-a-right-diaphragmatic-eventration-in-a-3-month-old-11994) — video · 6:01 · [machine version](https://library.globalcastmd.com/watch/laparoscopic-plication-of-a-right-diaphragmatic-eventration-in-a-3-month-old-11994.md)

### Access and incisions
- [Thoracoscopy](https://library.globalcastmd.com/watch/thoracoscopy-11975) — article · [machine version](https://library.globalcastmd.com/watch/thoracoscopy-11975.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=0) Patient presentation and vascular anatomy (Ep 2)
- [1:00](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=60) Operative setup and port placement (Ep 2)
- [1:40](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=100) Dissection and test clamping (Ep 2)
- [2:20](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=140) Vascular ring division and outcomes (Ep 2)
- [0:02](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=2) Patient positioning and port placement (Ep 1)
- [2:00](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=120) Pleural dissection and ductus identification (Ep 1)
- [4:00](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=240) Ductus mobilization and clip preparation (Ep 1)
- [5:00](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=300) Test clamping and clip deployment (Ep 1)
- [5:30](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=330) Lung biopsy and closure (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974?t=0) Patient positioning and port placement (Ep 9)
- [1:00](https://library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974?t=60) First row of reefing sutures (Ep 9)
- [3:00](https://library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974?t=180) Second row of sutures and closure (Ep 9)
- [0:00](https://library.globalcastmd.com/watch/laparoscopic-plication-of-a-right-diaphragmatic-eventration-in-a-3-month-old-11994?t=0) Laparoscopic Diaphragmatic Plication Technique (Ep 10)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- The patient is a 43-day-old male born at 36 weeks gestation with multiple congenital anomalies consistent with VACTERL association. (clinical) [Ep 2 · 0:00](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=0)
- Echocardiogram revealed a vascular ring comprised of a right-sided dominant double aortic arch with left carotid and subclavian arteries arising from the right arch. (clinical) [Ep 2 · 0:30](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=30)
- An atretic left proximal arch was present between the origin of the left subclavian artery and left-sided patent ductus arteriosus. (clinical) [Ep 2 · 0:50](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=50)
- A right dorsalis pedis arterial line was obtained prior to the procedure. (clinical) [Ep 2 · 1:00](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=60)
- A blood pressure cuff was placed on the right arm and pulse oximeters on upper and lower extremities for monitoring. (clinical) [Ep 2 · 1:05](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=65)
- A bronchial blocker was placed in the left main bronchus for single lung ventilation. (clinical) [Ep 2 · 1:10](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=70)
- The patient was placed in right lateral decubitus position for the thoracoscopic approach. (clinical) [Ep 2 · 1:15](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=75)
- Three ports were used: a 4-millimeter camera port in the fifth intercostal space posterior to the scapula tip, and two 3-millimeter working ports in the seventh intercostal space posterior axillary line and third intercostal space inferior to the axilla. (clinical) [Ep 2 · 1:20](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=80)
- A pleural flap was elevated over the descending thoracic aorta and extended superiorly to the thoracic inlet and along the left subclavian artery. (clinical) [Ep 2 · 1:35](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=95)
- Both the left ductus arteriosus and left recurrent laryngeal nerve were identified during dissection. (clinical) [Ep 2 · 1:45](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=105)
- A test clamp on the ductus arteriosus was performed to ensure stability of vital signs prior to sealing and transecting. (clinical) [Ep 2 · 1:50](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=110)
- The left aortic arch was bluntly dissected and encircled, with the atretic segment at the level of the left subclavian artery takeoff visualized. (clinical) [Ep 2 · 2:00](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=120)
- A test clamp was performed on the atretic segment of the left aortic arch with unchanged blood pressures and saturations. (clinical) [Ep 2 · 2:10](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=130)
- The posterior port was upsized to a 5-millimeter trocar to accommodate the stapler. (clinical) [Ep 2 · 2:18](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=138)
- The left aortic arch was transected using a 5-millimeter stapler, releasing the vascular ring. (clinical) [Ep 2 · 2:22](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=142)
- Division of a vascular ring involving large caliber vessels can safely and effectively be accomplished with thoracoscopy and division using a 5-millimeter stapler. (opinion) [Ep 2 · 2:28](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=148)
- There were no intraoperative complications. (clinical) [Ep 2 · 2:36](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=156)
- The patient returned to the NICU intubated and was extubated on postoperative day one. (clinical) [Ep 2 · 2:38](https://library.globalcastmd.com/watch/ipeg-2020-top-abstract-thoracoscopic-division-of-a-double-aortic-arch-vascular-r-3262?t=158)
- The patient is a 2 kg infant undergoing thoracoscopic PDA ligation. — Steven Rothenberg (clinical) [Ep 1 · 0:02](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=2)
- Modified prone position with left side elevated approximately 30 degrees is used for thoracoscopic PDA ligation. — Steven Rothenberg (clinical) [Ep 1 · 0:20](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=20)
- Port placement includes a 4mm scope slightly behind and above the scapula tip, with 3mm and 5mm working ports. — Steven Rothenberg (clinical) [Ep 1 · 0:50](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=50)
- Simple insufflation is used to collapse the lung; single lung ventilation is not required, although it can be carried out in larger patients. — Steven Rothenberg (clinical) [Ep 1 · 1:20](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=80)
- A 3mm port is initially placed in the posterior axillary line in approximately the fifth intercostal space, later changed to 5mm for clip placement. — Steven Rothenberg (clinical) [Ep 1 · 1:50](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=110)
- It is important not to use monopolar cautery near the ductus because of the risk of injuring the recurrent laryngeal nerve. — Steven Rothenberg (clinical) [Ep 1 · 2:40](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=160)
- Creating a pleural flap over the mid portion of the aorta helps safely retract the vagus and recurrent laryngeal nerves out of the way. — Steven Rothenberg (clinical) [Ep 1 · 3:20](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=200)
- In this case, the ductus is large, approximately 2/3 the diameter of the aorta. — Steven Rothenberg (clinical) [Ep 1 · 4:00](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=240)
- Careful blunt dissection is used to dissect behind the ductus to avoid injuring the recurrent laryngeal nerve or tearing the ductus. — Steven Rothenberg (clinical) [Ep 1 · 4:20](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=260)
- Gentle spreading with the 3mm vessel sealer is an excellent way to achieve adequate mobilization. — Steven Rothenberg (opinion) [Ep 1 · 4:40](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=280)
- It is generally recommended to spread in the direction of the ductus to eliminate the risk of tearing. — Steven Rothenberg (clinical) [Ep 1 · 5:10](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=310)
- Test clamping of the ductus is performed with a distal pulse oximeter on the foot to ensure the correct structure is being occluded. — Steven Rothenberg (clinical) [Ep 1 · 5:50](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=350)
- It is very important to have proximal and distal monitoring during PDA ligation. — Steven Rothenberg (clinical) [Ep 1 · 6:10](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=370)
- It is important to deploy the clip into the clip applier before placing it onto the duct, as deploying while already around the duct can force tissue away. — Steven Rothenberg (clinical) [Ep 1 · 6:35](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=395)
- A single 5mm clip achieved complete occlusion of the ductus. — Steven Rothenberg (clinical) [Ep 1 · 7:00](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=420)
- The patient had evidence of interstitial lung disease on CT scan, prompting a lung biopsy request from the pulmonologist. — Steven Rothenberg (clinical) [Ep 1 · 7:10](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=430)
- A 5mm stapler fits appropriately for the size of a 2 kg infant for lung biopsy. — Steven Rothenberg (clinical) [Ep 1 · 7:50](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=470)
- Care must be taken to ensure tissue is far enough in the stapler so the staple line reaches across the entire resected specimen. — Steven Rothenberg (clinical) [Ep 1 · 6:24](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=384)
- No chest drain was left because there was no air leak at the end of the procedure. — Steven Rothenberg (clinical) [Ep 1 · 6:24](https://library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=384)
- Patient was a 3-month-old child with eventration of the right hemidiaphragm and significant respiratory issues. (clinical) [Ep 10 · 0:00](https://library.globalcastmd.com/watch/laparoscopic-plication-of-a-right-diaphragmatic-eventration-in-a-3-month-old-11994?t=0)
- The initial stitch is placed to take tension off the diaphragm; once surface tension is broken with the needle, 2 to 3 bites are performed to reef in the diaphragm. (clinical) [Ep 10 · 0:30](https://library.globalcastmd.com/watch/laparoscopic-plication-of-a-right-diaphragmatic-eventration-in-a-3-month-old-11994?t=30)
- A series of sutures are placed from medial to lateral to complete the first row of the plication. (clinical) [Ep 10 · 1:00](https://library.globalcastmd.com/watch/laparoscopic-plication-of-a-right-diaphragmatic-eventration-in-a-3-month-old-11994?t=60)
- Even in cases of right eventration, the diaphragm can easily be reached over the dome of the liver. (clinical) [Ep 10 · 1:20](https://library.globalcastmd.com/watch/laparoscopic-plication-of-a-right-diaphragmatic-eventration-in-a-3-month-old-11994?t=80)
- The speaker finds the transabdominal laparoscopic technique preferable to thoracoscopic plication because of greater access and mobility with trocars placed through the abdominal wall. (opinion) [Ep 10 · 1:40](https://library.globalcastmd.com/watch/laparoscopic-plication-of-a-right-diaphragmatic-eventration-in-a-3-month-old-11994?t=100)
- When performing thoracoscopic plication, trocars are fixed by the rib cage and motility and space are limited. (clinical) [Ep 10 · 2:10](https://library.globalcastmd.com/watch/laparoscopic-plication-of-a-right-diaphragmatic-eventration-in-a-3-month-old-11994?t=130)
- It is useful to tie the knots extracorporeally and use a knot pusher, allowing the assistant to hold down the liver with the left hand operating port while the knot pusher is being placed. (clinical) [Ep 10 · 2:50](https://library.globalcastmd.com/watch/laparoscopic-plication-of-a-right-diaphragmatic-eventration-in-a-3-month-old-11994?t=170)
- There is no risk of tearing these sutures out or causing other injury, so there is no reason to tie these sutures (which are under significant tension) intracorporeally. (clinical) [Ep 10 · 3:20](https://library.globalcastmd.com/watch/laparoscopic-plication-of-a-right-diaphragmatic-eventration-in-a-3-month-old-11994?t=200)
- Trocars are placed with the camera port in the umbilicus and right and left operating ports in the right and left mid quadrants. (clinical) [Ep 10 · 3:50](https://library.globalcastmd.com/watch/laparoscopic-plication-of-a-right-diaphragmatic-eventration-in-a-3-month-old-11994?t=230)
- When approaching the right hemidiaphragm, the left-sided port is placed slightly above the umbilicus to allow better angulation; the reverse is true for an elevated left hemidiaphragm. (clinical) [Ep 10 · 4:20](https://library.globalcastmd.com/watch/laparoscopic-plication-of-a-right-diaphragmatic-eventration-in-a-3-month-old-11994?t=260)
- A series of sutures are placed until adequate tension is felt to have been achieved on the diaphragm. (clinical) [Ep 10 · 4:50](https://library.globalcastmd.com/watch/laparoscopic-plication-of-a-right-diaphragmatic-eventration-in-a-3-month-old-11994?t=290)
- If one is not careful, the chest wall can be deformed in small infants because of the tension which can be placed on the diaphragm. (clinical) [Ep 10 · 5:10](https://library.globalcastmd.com/watch/laparoscopic-plication-of-a-right-diaphragmatic-eventration-in-a-3-month-old-11994?t=310)
- After the initial row of sutures is placed, it may be necessary to place a secondary row to achieve further plication. (clinical) [Ep 10 · 5:40](https://library.globalcastmd.com/watch/laparoscopic-plication-of-a-right-diaphragmatic-eventration-in-a-3-month-old-11994?t=340)
- In almost all cases, the speaker prefers to use a 2-0 Prolene suture on an RB-1 needle. (opinion) [Ep 10 · 6:00](https://library.globalcastmd.com/watch/laparoscopic-plication-of-a-right-diaphragmatic-eventration-in-a-3-month-old-11994?t=360)
- Single lung ventilation is generally not required for thoracoscopic diaphragmatic plication (clinical) [Ep 9 · 1:00](https://library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974?t=60)
- CO2 is used to compress the lung as well as help compress the diaphragm during the procedure (clinical) [Ep 9 · 1:00](https://library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974?t=60)
- A knot pusher is generally used to tie the reefing sutures down because of the tension and the small spaces and difficult angles (clinical) [Ep 9 · 1:20](https://library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974?t=80)
- At least 3 bites of the diaphragm are taken with each stitch, which helps roll the diaphragm in and flatten it out (clinical) [Ep 9 · 2:00](https://library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974?t=120)
- In general, 5 or 6 sutures are placed in line for the initial set of plication sutures (clinical) [Ep 9 · 2:20](https://library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974?t=140)
- With each suture, more room develops within the chest cavity and makes the placement of further sutures easier (clinical) [Ep 9 · 2:40](https://library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974?t=160)
- Care should be taken not to apply too much tension on any one suture as these stitches can tear through the diaphragmatic muscle (clinical) [Ep 9 · 3:00](https://library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974?t=180)
- A knot pusher works well because the tissues are relatively strong and there is a fair amount of tension while trying to flatten the diaphragm (clinical) [Ep 9 · 3:20](https://library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974?t=200)
- A second row of sutures is placed, imbricating the first row, to bring in more tissue and decrease the laxity in the diaphragm (clinical) [Ep 9 · 3:40](https://library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974?t=220)
- In general, you will lose about 10 to 15% of your repair after the first few weeks as measured on chest X-ray, but this is not usually significant (clinical) [Ep 9 · 4:00](https://library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974?t=240)
- A chest tube is generally not left after this procedure (clinical) [Ep 9 · 4:20](https://library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974?t=260)
- Patients can often be weaned quickly from the ventilator and extubated after thoracoscopic diaphragmatic plication (clinical) [Ep 9 · 4:30](https://library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974?t=270)

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