# Pulmonary Hypoplasia — GCMD Library living collection

Everything in the library about pulmonary hypoplasia — built automatically from dossiers that name it.

Updated: n/a · 6 episodes · 205 cited statements

## Episodes
### Surgical Management
- [Controversies in Congenital Diaphragmatic Hernia: Update Course 2018](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338) — video · 41:42 · [machine version](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338.md)
- [Approach and component separation for suture closure and underlay mesh...](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430) — video · 31:03 · [machine version](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430.md)
- [Tricks - Omphalocele - Approach & Component Separation For Suture Closure &...](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635) — video · 32:30 · [machine version](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635.md)
- [Fetoscopic endoluminal tracheal occlusion and twin-twin transfusion: Fetal...](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025) — video · 149:16 · [machine version](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025.md)
- [Inside a FETO Procedure: Fetoscopic Balloon Tracheal Occlusion with Dr. Beth Rymeski](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570) — video · 4:30 · [machine version](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570.md)

### In-Depth Reviews
- [Congenital Diaphragmatic Hernia with Dr. Charlie Stolar](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303) — podcast · 82:05 · [machine version](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=0) Prenatal Counseling and Diagnosis (Ep 5)
- [7:14](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=434) Initial Neonatal Management and Respiratory Strategy (Ep 5)
- [17:48](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1068) ECMO Indications and Contraindications (Ep 5)
- [29:21](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1761) ECMO Technical Considerations (Ep 5)
- [36:24](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2184) Timing of Surgical Repair (Ep 5)
- [46:40](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2800) Surgical Approach: Open vs Thoracoscopic (Ep 5)
- [53:56](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3236) Technical Aspects of Repair (Ep 5)
- [59:19](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3559) Postoperative Management and Chest Tubes (Ep 5)
- [69:28](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4168) Long-term Complications and Follow-up (Ep 5)
- [74:54](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4494) Recurrence and Right-sided Hernias (Ep 5)
- [0:00](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=0) Introduction and Case 1: Timing of Repair in Stable CDH (Ep 1)
- [4:31](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=271) Surgical Approach: MIS versus Open Repair (Ep 1)
- [7:50](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=470) Technical Aspects of Thoracoscopic CDH Repair (Ep 1)
- [17:47](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=1067) Patch Materials and Recurrence Prevention (Ep 1)
- [25:02](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=1502) Case 2: ECMO Management and Repair Timing (Ep 1)
- [30:27](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=1827) ECMO Repair Strategies and David Kays' Results (Ep 1)
- [36:14](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=2174) Redo Repairs, Muscle Flaps, and Fetal Intervention (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=0) Introduction and first Duoderm silo technique video (Ep 2)
- [5:40](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=340) Component separation video presentation (Ep 2)
- [10:34](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=634) Faculty debate on early versus delayed closure (Ep 2)
- [17:22](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=1042) Biologic patch discussion and special cases (Ep 2)
- [26:16](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=1576) Dr. Abello's algorithm and decision framework (Ep 2)
- [0:00](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=0) Introduction and First Technique Overview (Ep 3)
- [3:01](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=181) Duoderm Silo Compression Demonstration (Ep 3)
- [5:11](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=311) Component Separation Case Presentation (Ep 3)
- [10:43](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=643) Faculty Discussion: Early vs Delayed Closure (Ep 3)
- [16:46](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=1006) Patch Techniques and Biologic Materials (Ep 3)
- [25:14](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=1514) Algorithm and Clinical Decision-Making (Ep 3)
- [0:00](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=0) Introduction and FETO Technique for Congenital Diaphragmatic Hernia (Ep 4)
- [23:20](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=1400) FETO Trial Design and Outcomes (Ep 4)
- [35:00](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=2100) Panel Discussion on FETO Trial Design and Challenges (Ep 4)
- [62:30](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=3750) Laser Photocoagulation for Twin-Twin Transfusion Syndrome (Ep 4)
- [105:50](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=6350) Technical Aspects of Laser Photocoagulation (Ep 4)
- [125:00](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=7500) Selective Intrauterine Growth Restriction in Monochorionic Twins (Ep 4)
- [0:01](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=1) Introduction and Procedure Overview (Ep 6)
- [1:03](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=63) Anatomical Navigation (Ep 6)
- [2:36](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=156) Balloon Positioning and Deployment (Ep 6)
- [3:48](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=228) Summary and Conclusion (Ep 6)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "CDH occurs in approximately 1 out of every 3,000-4,000 pregnancies" — Charlie Stolar (epidemiological) [Ep 5 · 2:45](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=165)
- "CDH diagnosis is typically made at the 20-week anatomy scan when ultrasonographers see the stomach in the same cross-sectional plane as the heart" — Charlie Stolar (clinical) [Ep 5 · 3:37](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=217)
- "CDH represents a growth arrest of both lungs, with the ipsilateral side more severely affected than the contralateral side" — Charlie Stolar (clinical) [Ep 5 · 4:14](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=254)
- "At birth, CDH lungs are affected by a mix of pulmonary hypoplasia and altered pulmonary vascular resistance with altered transitional circulation" — Charlie Stolar (clinical) [Ep 5 · 4:23](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=263)
- "CDH is a field defect; the most common neonatal comorbidity is foregut motility difficulty" — Charlie Stolar (clinical) [Ep 5 · 4:39](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=279)
- "CDH is a medical physiologic emergency but not a surgical emergency" — Charlie Stolar (clinical) [Ep 5 · 5:00](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=300)
- "The diagnosis of CDH alone is not an indication for cesarean section; elective spontaneous vaginal delivery is recommended assuming no obstetric issues" — Charlie Stolar (guideline) [Ep 5 · 5:24](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=324)
- "Antenatal interventions for CDH are no better than investigational and experimental at best" — Charlie Stolar (opinion) [Ep 5 · 6:35](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=395)
- "Babies with CDH should be born at a full-service children's facility with ECMO capability; maybe 10-15% will benefit from ECMO" — Charlie Stolar (guideline) [Ep 5 · 7:23](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=443)
- "In single-center experiences, presence of liver in the chest or stomach in the chest is of no prognostic value" — Charlie Stolar (clinical) [Ep 5 · 8:31](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=511)
- "Lung-to-head ratio is of limited prognostic value except when very low (less than 0.8), where prognosis is concerning" — Charlie Stolar (clinical) [Ep 5 · 8:42](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=522)
- "Associated congenital heart disease and central nervous system abnormalities augur for poor prognosis" — Charlie Stolar (clinical) [Ep 5 · 9:07](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=547)
- "If shown 100 children with CDH, 80-85% will survive to become teenagers" — Charlie Stolar (epidemiological) [Ep 5 · 10:13](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=613)
- "Antenatal steroids have tremendous value for preterm labor under 35 weeks but most CDH babies are near-term (37-39 weeks) where steroid role is arguable" — Charlie Stolar (clinical) [Ep 5 · 10:37](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=637)
- "Exit to ECMO for CDH is nonsense; it moves the goalposts on almost certainly non-viable babies" — Charlie Stolar (opinion) [Ep 5 · 12:06](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=726)
- "We are born with about 1/2 to 2/3 of our full complement of alveoli and can grow the balance sometime after birth" — Charlie Stolar (clinical) [Ep 5 · 13:00](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=780)
- "Initial evaluation of newborn with CDH includes looking for morphology, associated anomalies, respiratory distress, pre- and post-ductal oxygen gradients, and early cardiac echo for right heart function" — Charlie Stolar (clinical) [Ep 5 · 14:45](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=885)
- "Not every baby with CDH needs or is a candidate for ECMO; approximately 5% have insufficient lung to support life based on inability to saturate preductal blood" — Charlie Stolar (clinical) [Ep 5 · 15:55](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=955)
- "ECMO is a drug delivery system for oxygen; indication is when end organs aren't getting enough oxygen despite best care" — Charlie Stolar (clinical) [Ep 5 · 17:06](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1026)
- "The best way to assess end-organ function is urine output" — Charlie Stolar (clinical) [Ep 5 · 17:44](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1064)
- "ECMO indication is typically oxygenation index in excess of 40 for 4 hours or more" — Charlie Stolar (guideline) [Ep 5 · 18:21](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1101)
- "All therapy is guided by preductal oximetry, not postductal; if preductal saturation is 90% (PaO2 ~65 torr), the brain is doing fine with fetal hemoglobin" — Charlie Stolar (clinical) [Ep 5 · 19:06](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1146)
- "When managing dropping preductal saturation, first ensure adequate hemoglobin and circulating volume, then increase FiO2 or ventilator pressure, but avoid trying to control PCO2 as this will destroy the lungs" — Charlie Stolar (clinical) [Ep 5 · 20:25](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1225)
- "Neonatal ventilators would be thrown out as lethal devices if someone tried to invent them today" — Charlie Stolar (opinion) [Ep 5 · 21:38](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1298)
- "CDH babies are not paralyzed during ventilation; minimal sedation is used and babies should be awake and breathing spontaneously" — Charlie Stolar (clinical) [Ep 5 · 21:56](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1316)
- "Initial conventional ventilator settings (IMV rate ~40, peak pressure 25-28, PEEP ~5) are not tolerated by most CDH babies" — Charlie Stolar (clinical) [Ep 5 · 22:15](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1335)
- "Unconventional ventilation mode for CDH uses high rate (100 breaths/min), low peak pressure (turned down to zero due to stacking), and high gas flow rate with permissive hypercapnia" — Charlie Stolar (clinical) [Ep 5 · 22:53](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1373)
- "High-frequency oscillatory ventilation (HFOV) as rescue therapy rarely spares CDH babies from ECMO; when they get out the oscillator, it's time to prime an ECMO circuit" — Charlie Stolar (clinical) [Ep 5 · 24:30](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1470)
- "Nitric oxide is a waste of money for CDH; it's terrific for premature babies with immature lung disease but of no value in CDH" — Charlie Stolar (opinion) [Ep 5 · 25:45](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1545)
- "The best drug for CDH is oxygen" — Charlie Stolar (opinion) [Ep 5 · 26:07](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1567)
- "ECMO gestational age limit has been pushed from 36 weeks down to 35, maybe 34 weeks; below 32 weeks the intracranial hemorrhage rate takes off and neurologic outcomes become poor" — Charlie Stolar (clinical) [Ep 5 · 26:22](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1582)
- "The smallest ECMO arterial cannula is about 8 French; getting adequate flow out of small cannulas is problematic due to resistance related to both length and diameter" — Charlie Stolar (clinical) [Ep 5 · 27:40](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1660)
- "For ECMO candidacy, it's the gestational age that matters for intracranial hemorrhage risk (germinal matrix), not the size; size becomes an issue only when cannulas don't fit" — Charlie Stolar (clinical) [Ep 5 · 28:15](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1695)
- "The broad principle for ECMO candidacy is: do you have a reversible condition? Can you get out with reasonable confidence once you start?" — Charlie Stolar (clinical) [Ep 5 · 28:45](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1725)
- "VV ECMO is terrific if the heart works but problematic in CDH because heart function is often depressed and it's hard to get the cannula in with the shifted mediastinum" — Charlie Stolar (clinical) [Ep 5 · 30:27](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1827)
- "VV ECMO is for less sick patients who aren't in extremis; most CDH babies are sicker and do better on VA ECMO" — Charlie Stolar (clinical) [Ep 5 · 31:00](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1860)
- "VA bypass is basically dialing in a PaO2; VV has mixing issues, cannula position concerns, and is more annoying to manage" — Charlie Stolar (clinical) [Ep 5 · 31:53](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1913)
- "Echo guidance during ECMO cannulation is really helpful with the shifted mediastinum; the arterial cannula can go out the subclavian artery or the venous cannula into the innominate vein" — Charlie Stolar (clinical) [Ep 5 · 32:17](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1937)
- "If the arterial cannula goes out the subclavian artery, you'll have a well-perfused hand and think preductal sats look good, but the baby isn't seeing the oxygen" — Charlie Stolar (clinical) [Ep 5 · 33:01](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1981)
- "Using a guide wire to position the venous cannula into the right atrium is helpful when the mediastinum is distorted" — Charlie Stolar (clinical) [Ep 5 · 33:23](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2003)
- "Use 3 stay sutures (5-0 Prolene, rubber-shod) to lift the venotomy and arteriotomy open to avoid shearing off the intima and creating a false passage" — Charlie Stolar (clinical) [Ep 5 · 33:55](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2035)
- "In the first hours on ECMO, hyperkalemia can cause cardiac arrest if blood isn't washed; just perfuse through it and give calcium" — Charlie Stolar (clinical) [Ep 5 · 34:47](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2087)
- "ECMO flow must be increased slowly over 45-90 minutes to reduce intracranial hemorrhage incidence" — Charlie Stolar (clinical) [Ep 5 · 34:55](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2095)
- "Target VA ECMO flow is 100-125 cc/kg/min, which is about 80% of cardiac output assuming an open duct" — Charlie Stolar (clinical) [Ep 5 · 35:10](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2110)
- "At target ECMO flow, preductal saturation will be good and mixed venous (from venous drainage) will come up to 65-70%" — Charlie Stolar (clinical) [Ep 5 · 35:29](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2129)
- "Regular cardiac echos during ECMO weaning are important to assess right heart function, dilation, tricuspid regurgitation, and pulmonary outflow tract jet" — Charlie Stolar (clinical) [Ep 5 · 36:12](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2172)
- "The hyperoxia test (turning ventilator FiO2 up to 1.0) demonstrates if the baby can use their lungs; if PaO2 rises, it gives courage to begin weaning ECMO" — Charlie Stolar (clinical) [Ep 5 · 36:34](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2194)
- "For babies unweanable from ECMO after 2+ weeks at high flow, ensure they are maximally dried out (bone dry, eyes sucked into head), making good urine, with good labs and chest X-ray before considering on-ECMO repair" — Charlie Stolar (clinical) [Ep 5 · 38:18](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2298)
- "Repairing the hernia on ECMO is unusual to get you out of trouble; the problem is lung growth arrest at 14-15 weeks gestation, not that bowel is in the chest" — Charlie Stolar (clinical) [Ep 5 · 39:05](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2345)
- "Heparin inhibits conversion of fibrinogen to fibrin, so only platelets (beat-up ones) are making clot; platelet thrombus lifespan is 48-72 hours" — Charlie Stolar (clinical) [Ep 5 · 40:40](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2440)
- "If operating on ECMO, you have about 48-72 hours to decannulate before bleeding starts; operate when nearly weanable (20 cc/kg/min), expect 1 day of post-op deterioration, then 2-3 days to get off" — Charlie Stolar (clinical) [Ep 5 · 41:07](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2467)
- "Operating off ECMO means the baby will get stiff post-operatively, pulmonary hypertension may relapse, and you risk needing a second ECMO run" — Charlie Stolar (clinical) [Ep 5 · 41:51](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2511)
- "When operating on ECMO, load with Amicar preoperatively, do abdominal approach, use low threshold for patch to avoid tension, place Jackson-Pratt drain under patch, and place chest tube" — Charlie Stolar (clinical) [Ep 5 · 42:39](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2559)
- "Futility on ECMO begins to rear its head after 2-3 weeks; it becomes easier to discuss withdrawal if there's been a CNS event like intracranial hemorrhage" — Charlie Stolar (clinical) [Ep 5 · 44:11](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2651)
- "For non-ECMO babies, repair timing is when they're on minimal ventilator settings (FiO2 0.4, conventional settings), which typically takes 3-4 days" — Charlie Stolar (clinical) [Ep 5 · 45:42](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2742)
- "Use the infant ventilator instead of anesthesia machine intraoperatively; infant anesthesia machines have high dead space and aren't very compliant" — Charlie Stolar (clinical) [Ep 5 · 46:07](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2767)
- "Anesthesia can be all intravenous (muscle relaxants and narcotics); you don't need an anesthesia machine" — Charlie Stolar (clinical) [Ep 5 · 46:28](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2788)
- "Pre-repair assessment includes pre/post-ductal gradient, echo showing RV not dilated, RV pressure no more than systemic (not super-systemic), acceptable tricuspid regurgitation, and acceptable pulmonary outflow tract acceleration times" — Charlie Stolar (clinical) [Ep 5 · 46:47](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2807)
- "Perioperative antibiotics (typically ampicillin-gentamicin) are given because a patch may be placed in a newborn" — Charlie Stolar (clinical) [Ep 5 · 47:57](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2877)
- "The thoracoscopic approach provides a gorgeous view and often the bowel reduces with chest insufflation, but only rock-stable kids are candidates because you're creating a tension pneumothorax in a potentially hypercapnic baby" — Charlie Stolar (clinical) [Ep 5 · 48:32](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2912)
- "In Dr. Stolar's series of 35 thoracoscopic CDH repairs in stable babies, recurrence rate was about 25% in under a year; APSA outcomes committee meta-analysis reached similar conclusions" — Charlie Stolar (clinical) [Ep 5 · 49:37](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2977)
- "Laparoscopic CDH repair is problematic because the scaphoid abdomen has loss of abdominal domain; insufflating just puts air up in the chest" — Charlie Stolar (opinion) [Ep 5 · 50:21](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3021)
- "For open repair, key is adequate subcostal incision (not a small two-finger incision); rotate liver out of chest and abdomen to see the defect" — Charlie Stolar (clinical) [Ep 5 · 54:58](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3298)
- "Critical repair points are all medial where structures with names are located; mobilize posterior leaflet by unrolling it like a window shade down to the body wall until you feel rib" — Charlie Stolar (clinical) [Ep 5 · 55:31](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3331)
- "The medial repair is hardest because sometimes the esophagus or aorta hangs out with nothing to sew to; use an upside-down U-shaped pericardial flap rotated down to where the diaphragm would be to begin the repair" — Charlie Stolar (clinical) [Ep 5 · 56:11](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3371)
- "Favor monofilament suture (like PDS) because it doesn't saw through tissue when pulled, unlike braided suture like Vicryl" — Charlie Stolar (opinion) [Ep 5 · 57:16](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3436)
- "For patches, favor non-biologic material like 1mm Gore-Tex; laterally, anchor the patch to the ribs by getting a needle around the rib and into the patch" — Charlie Stolar (clinical) [Ep 5 · 57:59](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3479)
- "Make the patch somewhat balloon-shaped with redundancy so the baby doesn't rip sutures out with a deep breath; over time it gets incorporated into fibrous tissue" — Charlie Stolar (clinical) [Ep 5 · 58:43](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3523)
- "For thoracoscopic repair, use 3 ports (4mm camera with 30-degree lens, 3mm neonatal instruments), insufflation peak pressure 5-7 cm (no more), and reduce spleen last as it obturates the hole and keeps bowel in the belly" — Charlie Stolar (clinical) [Ep 5 · 60:23](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3623)
- "Thoracoscopically, mobilizing the posterior leaflet is difficult because it's rolled into the abdomen and hard to see around the corner" — Charlie Stolar (clinical) [Ep 5 · 61:35](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3695)
- "For thoracoscopic patch placement, use extracorporeal-intracorporeal suture technique: come from outside through skin around rib into patch and back out, tie externally, and bury the knot under the skin" — Charlie Stolar (clinical) [Ep 5 · 62:03](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3723)
- "If you can see through the diaphragm (it's just pleura and peritoneum with no muscle), resect it back to something that looks like muscle; plication of see-through tissue will fail" — Charlie Stolar (clinical) [Ep 5 · 64:16](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3856)
- "The ipsilateral lung is small and not as big as the pleural space; that's how God made this lung. You won't inflate the lung to fill the chest" — Charlie Stolar (clinical) [Ep 5 · 66:47](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4007)
- "The pleural space will be obliterated either slowly by lung growth over 3-4 years or by filling with fluid; it's not a pneumothorax under pressure, it's pneumothorax ex vacuo" — Charlie Stolar (clinical) [Ep 5 · 67:01](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4021)
- "Chest tube on water-seal suction will distort the mediastinum and precipitate a pulmonary hypertensive crisis; there's no reason to put in a chest tube unless there's active air leak or bleeding" — Charlie Stolar (clinical) [Ep 5 · 67:18](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4038)
- "Typical stable post-op CDH baby will be unstable for about a day with increased ventilator requirements, then improve and get extubated in 4-5 days" — Charlie Stolar (clinical) [Ep 5 · 68:53](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4133)
- "CDH is a field defect affecting the entire foregut from pharynx to ligament of Treitz; these kids have disordered motility throughout" — Charlie Stolar (clinical) [Ep 5 · 69:34](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4174)
- "All CDH patients should have a GI series showing dilated, ectatic, abnormal esophagus; manometry and impedance show abnormal esophageal and gastric motility and emptying" — Charlie Stolar (clinical) [Ep 5 · 69:51](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4191)
- "The foregut problem is not really reflux; calling it reflux has suckered surgeons into doing fundoplications and pyloroplasties that are basically torture" — Charlie Stolar (opinion) [Ep 5 · 70:09](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4209)
- "CDH babies do well with continuous feedings slowly condensed to bolus; surgical intervention for foregut issues is unusual and should be approached as palliation" — Charlie Stolar (clinical) [Ep 5 · 70:28](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4228)
- "Nissen fundoplication is a poor operation for CDH kids (like for esophageal atresia) because their motility is abnormal; if surgery is needed, use a partial wrap with gastrostomy and real drainage procedure (Jaboulay-Finney type, not Heineke-Mikulicz)" — Charlie Stolar (opinion) [Ep 5 · 70:40](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4240)
- "Dr. Stolar's multidisciplinary CDH clinic follows 450-500 patients for life, addressing heart, lung, foregut, nutrition, neurodevelopmental, and axial skeleton issues that emerge over time" — Charlie Stolar (clinical) [Ep 5 · 72:11](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4331)
- "Dr. Stolar has 4 CDH teenagers with Barrett's esophagitis; he recommends lifelong proton pump inhibitors and regular endoscopic surveillance" — Charlie Stolar (clinical) [Ep 5 · 73:18](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4398)
- "CDH patients have increased incidence of attention deficit disorders and autism; early intervention for neuropsychiatric issues is recommended" — Charlie Stolar (clinical) [Ep 5 · 73:57](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4437)
- "As a field defect, CDH causes asymmetric chest growth leading to pectus-like distortion; some patients need Nuss-type operations to rebuild chest wall" — Charlie Stolar (clinical) [Ep 5 · 74:09](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4449)
- "Some CDH girls have no breast development on the hernia side as teenagers; combined Nuss operation and breast implant procedures have been performed" — Charlie Stolar (clinical) [Ep 5 · 74:29](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4469)
- "CDH patients develop thoracolumbar scoliosis (not idiopathic scoliosis, as it's mostly in boys); early bracing programs help minimize this" — Charlie Stolar (clinical) [Ep 5 · 74:34](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4474)
- "CDH recurrence is related to tension on tissues and tissue quality; it's a tough problem whether tissue-to-tissue or prosthetic repair" — Charlie Stolar (clinical) [Ep 5 · 75:16](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4516)
- "Recurrence is more common with left-sided CDH than right because the liver plugs up the hole on the right" — Charlie Stolar (clinical) [Ep 5 · 77:35](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4655)
- "For right-sided CDH, the most important consideration is determining where hepatic veins drain; not infrequently they enter directly into the right atrium, not the suprahepatic IVC" — Charlie Stolar (clinical) [Ep 5 · 77:51](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4671)
- "If hepatic veins enter the right atrium directly, attempting to reduce the liver into the abdomen will cause a troublesome moment; you should not try to put that liver in the abdomen" — Charlie Stolar (clinical) [Ep 5 · 78:09](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4689)
- "Hepatopulmonary fusion actually exists in right-sided CDH; the liver and lung are fused and cannot be separated surgically" — Charlie Stolar (clinical) [Ep 5 · 78:29](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4709)
- "Most patients with hepatopulmonary fusion don't survive; they often have associated severe congenital heart disease and IVC interruption with azygous continuation" — Charlie Stolar (clinical) [Ep 5 · 79:11](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4751)
- "For right-sided CDH, prep the baby for both thoracic and abdominal incisions; often need to be on both sides to figure out what's going on because the liver is in the way" — Charlie Stolar (clinical) [Ep 5 · 79:48](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4788)
- "For right-sided CDH, can put a scope through an open thoracotomy to see around corners where the liver might come up against the heart" — Charlie Stolar (clinical) [Ep 5 · 80:12](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4812)
- "FETO is a percutaneous intervention on the mother using one trocar placed through the abdominal wall into the uterus" — Beth Rymeski (clinical) [Ep 6 · 0:33](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=33)
- "The procedure uses a standard fetoscope with a side channel through which the balloon is worked" — Beth Rymeski (clinical) [Ep 6 · 0:42](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=42)
- "The goal of FETO is to allow fluid to stay in the lungs and allow the lungs to expand and grow" — Jill Knepprath (clinical) [Ep 6 · 0:47](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=47)
- "FETO helps prevent pulmonary hypoplasia, which is a big factor in poor outcomes for CDH babies" — Jill Knepprath (clinical) [Ep 6 · 0:53](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=53)
- "The tongue is an easy landmark during FETO because it is bumpy" — Beth Rymeski (clinical) [Ep 6 · 1:21](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=81)
- "Fluid is hooked up to the scope and can be intermittently turned on and off to push tissue away and allow easier advancement" — Beth Rymeski (clinical) [Ep 6 · 1:29](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=89)
- "If the baby's head is not perfectly aligned with the scope, twisting and turning is required to navigate through the mouth" — Beth Rymeski (clinical) [Ep 6 · 1:38](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=98)
- "The epiglottis is sought as a landmark to guide navigation" — Beth Rymeski (clinical) [Ep 6 · 1:58](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=118)
- "Excessive torquing of the membranes should be avoided because the scope goes through the abdominal and uterine walls and could cause membrane damage" — Beth Rymeski (clinical) [Ep 6 · 2:23](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=143)
- "The scope should always be advanced until the carina is visualized to confirm tracheal position and determine location within the trachea" — Beth Rymeski (clinical) [Ep 6 · 2:36](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=156)
- "The balloon should not be driven into one side of the trachea but should inflate in the main trachea" — Beth Rymeski (clinical) [Ep 6 · 2:56](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=176)
- "The scope is backed up as the balloon is inflated to allow visualization of balloon inflation" — Beth Rymeski (clinical) [Ep 6 · 3:03](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=183)
- "The balloon is filled with water, around 0.65 to 0.8 mL, depending on the size of the trachea" — Jill Knepprath (clinical) [Ep 6 · 3:08](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=188)
- "The balloon contains a small metal ball that can be visualized" — Beth Rymeski (clinical) [Ep 6 · 3:29](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=209)
- "Final confirmation requires visualizing that the balloon is below the vocal cords and in the main trachea" — Beth Rymeski (clinical) [Ep 6 · 3:48](https://library.globalcastmd.com/watch/inside-a-feto-procedure-fetoscopic-balloon-tracheal-occlusion-with-dr-beth-rymeski-13570?t=228)
- "A Columbia paper showed high recurrence rates with MIS CDH repair, creating resistance to the approach" — Wolfan (host_summary) [Ep 1 · 1:11](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=71)
- "For stable CDH patients not on ECMO, waiting 24-48 hours allows transitional circulation to stabilize and provides ventilator reserve before repair" — Ron (clinical) [Ep 1 · 2:49](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=169)
- "Bowel distention in unreduced CDH compromises pulmonary and cardiac function over time, favoring earlier repair" (clinical) [Ep 1 · 3:40](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=220)
- "Echocardiography to assess pulmonary hypertension guides timing of CDH repair" — David (clinical) [Ep 1 · 3:53](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=233)
- "Charlie Stoller showed approximately 30% recurrence rate with thoracoscopic CDH repair" — Ron (host_summary) [Ep 1 · 6:36](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=396)
- "Recurrence rates improve with surgical experience and technique refinement in thoracoscopic CDH repair" — Ron (opinion) [Ep 1 · 6:49](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=409)
- "Surgeons may unconsciously avoid placing adequate sutures in MIS repair if knot-tying is time-consuming, contributing to recurrence" — Wolfan (opinion) [Ep 1 · 9:49](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=589)
- "Cauterizing the edge of the CDH defect promotes inflammation and healing, similar to unfolding the posterior leaflet in open repair" — Wolfan (clinical) [Ep 1 · 10:17](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=617)
- "Excessive tension during thoracoscopic CDH closure can create an overly flat diaphragm, though Avi Schleger's work suggests post-op bowing may not significantly affect outcomes" — Wolfan (clinical) [Ep 1 · 10:49](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=649)
- "Using buttress material reduces recurrence rates in CDH repair, per data from Rusty and Craig's institution" — Wolfan (host_summary) [Ep 1 · 12:31](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=751)
- "Liberal use of absorbable mesh as underlay beneath primary repair reduces CDH recurrence" — Wolfan (clinical) [Ep 1 · 12:48](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=768)
- "MIS approach to CDH repair greatly reduces small bowel obstruction compared to laparotomy" — Wolfan (clinical) [Ep 1 · 22:53](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=1373)
- "In the speaker's series, MIS and open CDH repairs showed similar recurrence rates, with patch use being a major factor" — Wolfan (epidemiological) [Ep 1 · 23:24](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=1404)
- "For CDH with agenesis or near-agenesis (type C or D defects), open repair is preferred due to complexity and proximity to esophagus" — Wolfan (clinical) [Ep 1 · 23:53](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=1433)
- "Severe CDH patients (O-to-E ratios 25% or below) often have small left ventricles causing hemodynamic problems in addition to pulmonary issues" — Ron (clinical) [Ep 1 · 25:35](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=1535)
- "VV ECMO may not work well in CDH patients with small left ventricles; VA ECMO is preferred in those cases" — Ron (clinical) [Ep 1 · 26:02](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=1562)
- "Inhaled nitric oxide (iNO) should not be trialed before ECMO in severe CDH; data show it does not work pre-ECMO" — Ron (clinical) [Ep 1 · 26:20](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=1580)
- "After birth, severe CDH patients may initially have high CO2 that falls over the first couple hours; this response guides ECMO cannulation timing" — Ron (clinical) [Ep 1 · 26:51](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=1611)
- "A recent Pediatric Surgery International paper showed low rates of return to ECMO and death following CDH repair, not justifying routine repair on ECMO" — Wolfan (host_summary) [Ep 1 · 29:43](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=1783)
- "Timing of CDH repair has no real influence on ultimate survival" — Wolfan (host_summary) [Ep 1 · 30:08](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=1808)
- "David Kays in Saint Petersburg achieves 100% survival in CDH (last 75 patients, all comers including preemies and heart disease), with 80% requiring ECMO and all repaired immediately on ECMO" (host_summary) [Ep 1 · 31:19](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=1879)
- "David Kays switched to using bivalirudin for ECMO anticoagulation and reports decreased bleeding rates with immediate CDH repair on ECMO" — Ron (host_summary) [Ep 1 · 32:34](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=1954)
- "When repairing CDH on ECMO, leaving the abdomen open or using a silo prevents compromised pulmonary compliance from increased intra-abdominal pressure" — Ron (clinical) [Ep 1 · 34:21](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=2061)
- "Transversalis muscle flap repair for CDH shows very low recurrence rates but results in abdominal wall bulge" — Wolfan (clinical) [Ep 1 · 36:41](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=2201)
- "Overall mortality for any CDH patient requiring ECMO is approximately 50%" — Ron (epidemiological) [Ep 1 · 37:34](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=2254)
- "Midgut volvulus after CDH repair is surprisingly low in incidence; routine Ladd's procedure is not performed" — Wolfan (epidemiological) [Ep 1 · 38:33](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=2313)
- "Indications for the FETO trial (fetal tracheal occlusion) are liver herniation and lung-to-head ratio (LHR) greater than 0.9" — Wolfan (guideline) [Ep 1 · 41:18](https://library.globalcastmd.com/watch/controversies-in-congenital-diaphragmatic-hernia-update-course-2018-338?t=2478)
- "In patients without pulmonary hypoplasia or bad heart problems, first choice is to try early coverage because it is quicker and easier." — Bob Langer (opinion) [Ep 3 · 0:51](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=51)
- "For patients with pulmonary hypoplasia, bad hearts, prematurity, or where the omphalocele is too big and there isn't enough skin to get over, the escharotic technique is used." — Bob Langer (clinical) [Ep 3 · 1:05](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=65)
- "Silver sulfadiazine (Flamazine in Canada) has been used for many years for omphalocele escharization, as taught by Sigy Ein." — Bob Langer (clinical) [Ep 3 · 1:09](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=69)
- "Silver-impregnated sponges offer the same advantage as Silvadene but are less messy and don't require painting." — Bob Langer (clinical) [Ep 3 · 1:44](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=104)
- "Silver Aquacel stuck to the omphalocele sac and became incorporated, failing to fall off as expected once it hardened underneath." — Todd Ponsky (clinical) [Ep 3 · 1:54](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=114)
- "Component separation requires going up every day to adjust the compression, which is work-intensive." — Bob Langer (clinical) [Ep 3 · 5:12](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=312)
- "The most difficult cases are patients with pulmonary hypoplasia or bad hearts where intra-abdominal pressure cannot be safely increased." — Bob Langer (clinical) [Ep 3 · 5:12](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=312)
- "The objectives of component separation are to minimize postoperative risk of abdominal hypertension and compartment syndrome, increase abdominal capacity at closure, facilitate anatomically definitive midline closure regarding rectus muscles, and limit evisceration and incisional hernias." (host_summary) [Ep 3 · 6:19](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=379)
- "The case presented was a 28-week gestation, 1,130g premature female with giant omphalocele including the liver, identified by prenatal ultrasound." (host_summary) [Ep 3 · 6:42](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=402)
- "After 10 days of manipulation with the Duoderm silo, the peritoneal sac was still covered, thick, and manageable." (host_summary) [Ep 3 · 7:12](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=432)
- "The incision is made 0.5 to 1 centimeter outside the semilunar line, with dissection of the lateral fascia towards the external oblique." (host_summary) [Ep 3 · 7:57](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=477)
- "By dissecting the fascia to the mid-axillary line, you can gain between 2 and 4 centimeters of advancement." (host_summary) [Ep 3 · 8:26](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=506)
- "This case represents the probable smallest patient with lowest weight and giant omphalocele treated with Abello method and component separation for definitive anatomic closure without evisceration." (host_summary) [Ep 3 · 10:19](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=619)
- "Concern exists about whether abdominal wall musculature after component separation in a 1.3kg infant will function normally at 20 years of age." — Bob Langer (opinion) [Ep 3 · 11:41](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=701)
- "Using an absorbable patch leaves the abdominal wall musculature intact, and as the child grows, the patch becomes a smaller percentage of the abdominal wall area." — Bob Langer (clinical) [Ep 3 · 12:00](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=720)
- "Surgisis was used for a long time but had many recurrences; now Strattice is used with better results." — Bob Langer (clinical) [Ep 3 · 12:00](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=720)
- "Many omphaloceles have defects that go right up to the costal margin, making it difficult to close that area even with component separation." — Bob Langer (clinical) [Ep 3 · 12:36](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=756)
- "Often the lower part of the defect is closed primarily, but a patch is needed along the costal margin." — Bob Langer (clinical) [Ep 3 · 12:50](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=770)
- "Component separation dissection to the mid-axillary line is necessary to adequately mobilize tissue and achieve closure." — Todd Ponsky (clinical) [Ep 3 · 13:20](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=800)
- "Six-ply Surgisis with 22 tension lines works better, allowing tension on the patch while bringing the fascia together." — Todd Ponsky (clinical) [Ep 3 · 13:31](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=811)
- "Dr. Abello has long-term follow-up with the Duoderm technique showing all patients healed well without problems." (host_summary) [Ep 3 · 14:07](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=847)
- "Component separation is technically highly complicated with a huge surgical area in such a small child, and complications would be very big." (opinion) [Ep 3 · 14:55](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=895)
- "Delayed primary closure at 6-7 months after escharization with fatty gauzes is a safer alternative to early complex surgery." (opinion) [Ep 3 · 14:55](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=895)
- "With escharization and delayed closure, children go home, play, are active regular kids, epithelialize the whole omphalocele, and can be fixed when older with component separation techniques." — Todd Ponsky (clinical) [Ep 3 · 16:02](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=962)
- "Most patients managed with painting and delayed primary closure can be closed without using a patch when they are older." — Holly Williams (clinical) [Ep 3 · 16:46](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=1006)
- "The Duoderm technique was successful on two giant omphaloceles with liver out, performed over a longer period with gradual progress, redoing the Duoderm patch only every 3 days." — Holly Williams (clinical) [Ep 3 · 17:31](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=1051)
- "Babies with giant omphaloceles managed with Duoderm can be kept on nasal cannula with morphine during manipulation and don't need intubation until the actual repair." — Holly Williams (clinical) [Ep 3 · 17:53](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=1073)
- "In neonates, the Duoderm can pull the rectus out laterally when cut into diamonds, allowing primary closure at the edges so the defect requiring a patch is much smaller." — Holly Williams (clinical) [Ep 3 · 19:07](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=1147)
- "Alloderm is used as a bridge patch, and leaving the amnion provides a protective layer; the patch appears to turn into thick fascia over time, resulting in a relatively small central defect similar to rectus diastasis." — Holly Williams (clinical) [Ep 3 · 19:46](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=1186)
- "The benefit of early closure with Duoderm and patch is that muscle edges don't continue to get farther apart, whereas with painting and waiting, the muscle stays way out laterally and over time the defect appears bigger." — Holly Williams (clinical) [Ep 3 · 24:49](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=1489)
- "The most challenging situation is smaller defects with the whole liver out, where the liver doesn't go back in with painting and waiting because it's locked out, requiring enlargement of the fascial defect to reduce the contents." — Bob Langer (clinical) [Ep 3 · 25:24](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=1524)
- "Livers in small-defect omphaloceles can have a mushroom or dumbbell shape, making reduction very difficult." — Todd Ponsky (clinical) [Ep 3 · 25:55](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=1555)
- "Dr. Abello's algorithm starts with a relaxation test to determine how much the patient can tolerate and how much silo manipulation is needed to achieve primary closure." (host_summary) [Ep 3 · 27:15](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=1635)
- "If primary closure is not possible after Duoderm silo, the next step is component separation; if intra-abdominal pressure is still too high after component separation, a mesh can be placed." (host_summary) [Ep 3 · 29:12](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=1752)
- "If at any moment intra-abdominal pressure is too high or pulmonary hypertension occurs, the procedure can be aborted and traditional painting and waiting can be used." (host_summary) [Ep 3 · 30:13](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=1813)
- "Dr. Abello has never had to abort the process due to patient intolerance, including in patients with cardiomyopathy or pulmonary hypertension." (host_summary) [Ep 3 · 31:32](https://library.globalcastmd.com/watch/tricks-omphalocele-approach-component-separation-for-suture-closure-635?t=1892)
- "spk_0 uses escharotic painting (escharization) followed by epithelialization for giant omphaloceles" — Todd Ponsky (clinical) [Ep 2 · 0:27](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=27)
- "Jack's first choice for omphalocele without pulmonary hypoplasia or cardiac problems is early skin coverage" — Jack (clinical) [Ep 2 · 0:42](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=42)
- "For patients with pulmonary hypoplasia, bad hearts, prematurity, or defects too large for skin coverage, Jack uses escharotic technique" — Jack (clinical) [Ep 2 · 0:56](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=56)
- "Jack's team uses silver sulfadiazine (Flamazine in Canada) for escharotic treatment, a technique taught by Sigy Ein" — Jack (clinical) [Ep 2 · 1:11](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=71)
- "Silver-impregnated sponges offer same advantage as Silvadene but are less messy and don't require painting" — Jack (clinical) [Ep 2 · 1:32](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=92)
- "spk_0 tried silver-impregnated Aquacel which stuck to the sac, became incorporated, and could not be removed - described as a disaster" — Todd Ponsky (clinical) [Ep 2 · 1:45](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=105)
- "Dr. Abello's Duoderm technique involves creating T-shaped Duoderm pieces that form an external silo, which is progressively compressed like gastroschisis reduction over approximately 1-2 weeks" — Todd Ponsky (host_summary) [Ep 2 · 3:16](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=196)
- "The Duoderm compression technique requires daily adjustments and significant work" — Jack (clinical) [Ep 2 · 5:02](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=302)
- "The Duoderm technique cannot be used in patients with pulmonary hypoplasia or bad hearts where intra-abdominal pressure cannot be safely increased" — Jack (clinical) [Ep 2 · 5:02](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=302)
- "Case presented: 28-week gestation, 1130g premature female with giant omphalocele including liver, identified by prenatal ultrasound" (host_summary) [Ep 2 · 6:32](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=392)
- "Component separation as described by Ramirez involves incision parallel to semilunar line with dissection of lateral fascia toward external oblique to mid-axillary line, gaining 2-4 centimeters" (host_summary) [Ep 2 · 8:07](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=487)
- "In the presented case, rectus muscles were joined centrally and umbilical cord mobilized caudally to create future umbilicus" (host_summary) [Ep 2 · 9:30](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=570)
- "Dr. Abello reports this as probably the smallest patient with lowest weight and giant omphalocele treated with his method and component separation for definitive anatomic closure without eventration" (host_summary) [Ep 2 · 10:19](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=619)
- "Component separation in small babies is not easy, especially if the omphalocele has been on a silo for a long period and tissues are scarred together" — Todd Ponsky (clinical) [Ep 2 · 11:07](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=667)
- "Jack's concern about component separation: uncertain what the abdominal wall will be like when the patient is 20 years old and whether they will be able to function normally" — Jack (opinion) [Ep 2 · 11:38](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=698)
- "Jack uses absorbable patches (previously Surgisis with many recurrences, now Strattice with better results) to leave abdominal wall musculature intact" — Jack (clinical) [Ep 2 · 11:51](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=711)
- "Advantage of patch approach: as child grows, the patch becomes a smaller percentage of the abdominal wall area" — Jack (clinical) [Ep 2 · 12:07](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=727)
- "Many omphaloceles have defects extending to the costal margin, making complete closure difficult even with component separation" — Jack (clinical) [Ep 2 · 12:27](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=747)
- "Jack often closes the lower defect primarily but requires a patch along the costal margin" — Jack (clinical) [Ep 2 · 12:40](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=760)
- "Component separation requires dissection to the mid-axillary line to adequately mobilize tissue" — Todd Ponsky (clinical) [Ep 2 · 13:10](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=790)
- "spk_0 now uses six-ply Surgisis which has 22 tension lines, allowing tension on the patch while bringing fascia together" — Todd Ponsky (clinical) [Ep 2 · 13:22](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=802)
- "Dr. Abello has long-term follow-up with the Duoderm technique showing all patients healed well without problems, but no long-term follow-up yet with component separation" (host_summary) [Ep 2 · 14:00](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=840)
- "Delayed closure approach: apply fatty gauzes until epithelialization, wait until 6-7 months, then perform delayed primary closure" (clinical) [Ep 2 · 15:00](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=900)
- "Suad manages most giant omphaloceles with painting followed by delayed primary closure when older, usually achieving closure without patch" (clinical) [Ep 2 · 16:27](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=987)
- "Holly Williams successfully used Duoderm technique on two giant omphaloceles with liver out, maintaining patients on nasal cannula with morphine during manipulation, avoiding intubation until repair" (clinical) [Ep 2 · 17:22](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=1042)
- "Holly Williams applied Duoderm and redid it only every 3 days, making very gradual progress" (clinical) [Ep 2 · 18:03](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=1083)
- "Holly Williams previously used multi-stage operations with patches over a couple of years rather than painting" (clinical) [Ep 2 · 18:33](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=1113)
- "In neonates, tissue compliance allows significant reduction with Duoderm pulling; the amnion is left (usually stuck to liver centrally), Duoderm applied over it, then skin closed" (clinical) [Ep 2 · 18:57](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=1137)
- "Holly Williams uses Alloderm as bridging material, which over time turns into thick fascia resembling rectus diastasis" (clinical) [Ep 2 · 19:36](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=1176)
- "Benefit of Alloderm approach: muscle edges don't continue to separate over time, unlike painting-and-waiting where muscle stays lateral and defect may enlarge" (clinical) [Ep 2 · 24:40](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=1480)
- "Most challenging cases are smaller defects with entire liver out - these don't reduce with painting-and-waiting because the liver is 'locked out' with a mushroom shape" — Jack (clinical) [Ep 2 · 25:15](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=1515)
- "For locked-out liver cases, the fascial defect must be enlarged to allow reduction" — Jack (clinical) [Ep 2 · 25:39](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=1539)
- "spk_0 had one massive omphalocele case with muscle only at lateral edge requiring combination of lateral component separation, Gore-Tex attachment, and serial stretching over 3 sessions (like Witzman patch) to achieve muscle-to-muscle closure" — Todd Ponsky (clinical) [Ep 2 · 21:57](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=1317)
- "Biologic dressings are not meant to be bridged - they turn into liquid as temporary material, not muscle, unless permanent" — Todd Ponsky (clinical) [Ep 2 · 22:57](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=1377)
- "Cardiac surgeons report biologic patches in VSD closure turn into cardiac muscle" — Todd Ponsky (host_summary) [Ep 2 · 23:10](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=1390)
- "spk_0 observed one pediatric case where biologic patch appeared to turn into muscle or scar" — Todd Ponsky (clinical) [Ep 2 · 23:25](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=1405)
- "Dr. Abello's algorithm: first perform relaxation test under sedation to assess how much stretching is needed and determine silo size requirements" (host_summary) [Ep 2 · 27:04](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=1624)
- "Dr. Abello's decision tree: if primary closure tolerated, proceed; if not, perform component separation; if intra-abdominal pressure still too high after component separation, add mesh" (host_summary) [Ep 2 · 29:03](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=1743)
- "If at any point pressure becomes too high or pulmonary hypertension occurs, Dr. Abello aborts the procedure and reverts to traditional painting-and-waiting" (host_summary) [Ep 2 · 30:33](https://library.globalcastmd.com/watch/approach-and-component-separation-for-suture-closure-and-underlay-mesh-430?t=1833)
- "Congenital diaphragmatic hernia occurs in 10-20% of monochorionic twin pregnancies and is responsible for large amounts of perinatal mortality and morbidity, with 80-100% mortality if untreated in the past." — Jan Deprest (epidemiological) [Ep 4 · 0:45](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=45)
- "Patient selection for FETO is based on lung-to-head ratio (LHR) corrected for gestational age (observed/expected) and presence of liver herniation, with severe hypoplasia defined as maximum 20% survival, moderate 50%, and mild 85% survival." — Jan Deprest (clinical) [Ep 4 · 1:20](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=80)
- "External validation from Children's Hospital Philadelphia (2006-2010 cohort) and Toronto confirmed that outcomes remain dependent on lung-to-head ratio and these selection criteria are still valid." — Jan Deprest (host_summary) [Ep 4 · 2:36](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=156)
- "The FETO procedure is done at 26-28 weeks (now 29 weeks in updated protocol) under local anesthesia with fetal analgesia and immobilization, lasting 6-10 minutes on average when fetal position is favorable." — Jan Deprest (clinical) [Ep 4 · 3:19](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=199)
- "The median gestational age at birth after FETO was 35 weeks, similar to open fetal surgery, with 20-22% experiencing ruptured membranes by 34 weeks." — Jan Deprest (clinical) [Ep 4 · 8:32](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=512)
- "Balloon removal in utero at least 24 hours prior to birth is associated with better survival and early morbidity compared to removal at delivery." — Jan Deprest (clinical) [Ep 4 · 11:19](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=679)
- "FETO increased survival from around 0% to 20% in the smallest lung group and by 30-35% on average in the severe hypoplasia group compared to historical controls." — Jan Deprest (clinical) [Ep 4 · 12:42](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=762)
- "Independent predictors of survival after FETO are initial lung size prior to operation, gestational age at delivery, and ability to remove balloon in utero at least 24 hours before birth." — Jan Deprest (clinical) [Ep 4 · 13:44](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=824)
- "Even with delivery prior to 32 weeks after FETO, survival rate is as high as predicted at term without fetal therapy; for delivery at 32 weeks or later, survival is 60%, which doesn't increase beyond 34 weeks." — Jan Deprest (clinical) [Ep 4 · 14:37](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=877)
- "There is an apparent decrease in bronchopulmonary dysplasia after FETO, with no evidence of substituting mortality by morbidity based on oxygen need, ventilator days, time to full enteral feeding, and NICU days." — Jan Deprest (clinical) [Ep 4 · 15:50](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=950)
- "The TOTAL trial in Europe compares tracheal occlusion at 27-29 weeks to expectant management, with survival as primary outcome in severe cases and survival without BPD in moderate cases." — Jan Deprest (clinical) [Ep 4 · 16:41](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=1001)
- "Centers offering FETO must have an active fetoscopy program (minimum 36 interventions per year or 3 per month), experience with 15 balloon occlusion cases (at least 5 done locally), and 24-hour balloon removal capability." — Jan Deprest (guideline) [Ep 4 · 19:45](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=1185)
- "In the moderate TTTS trial, 54 cases have been recruited beyond the first interim analysis, with all participating centers agreeing not to offer fetal therapy outside the trial." — Jan Deprest (clinical) [Ep 4 · 25:05](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=1505)
- "The severe FETO trial has been hampered by too long offering the procedure outside trial settings while trying to optimize technique, though the last 100 cases showed no improvement in outcomes." — Jan Deprest (opinion) [Ep 4 · 25:44](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=1544)
- "Ruben Quintero's 1997 staging system for TTTS actually describes physiologic states: stage 1 reflects initial volume transfer, stage 2 represents cephalization of blood flow, stage 3 represents increasing placental resistance, and stage 4 represents cardiac failure in the recipient." — Todd Ponsky (clinical) [Ep 4 · 86:57](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=5217)
- "Only 30-35% of stage 1 TTTS progresses to stage 2 or higher; 28% stay at stage 1 throughout pregnancy, and 40% regress completely or resolve." — Todd Ponsky (epidemiological) [Ep 4 · 89:21](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=5361)
- "Amnio-reduction in severe polyhydramnios improves fetal hypoxia and reverses acidemia by decreasing amniotic fluid pressure, which reduces placental compression and improves blood flow." — Todd Ponsky (host_summary) [Ep 4 · 90:22](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=5422)
- "The recipient twin in TTTS develops progressive hypertrophic cardiomyopathy due to both preload (volume) and afterload (peripheral vasoconstriction from renin-angiotensin activation) issues." — Todd Ponsky (clinical) [Ep 4 · 92:14](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=5534)
- "Huber's 2006 study of over 200 laser cases showed 84% survival of at least one twin, 60% both-twin survival, and average delivery at 34 weeks, compared to 29 weeks with amnio-reduction." — Todd Ponsky (host_summary) [Ep 4 · 102:07](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=6127)
- "High-volume laser centers achieve 93-94% survival of at least one twin, 88% overall survival, 78% both-twin survival, with average delivery at 34 weeks." — Todd Ponsky (host_summary) [Ep 4 · 103:26](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=6206)
- "Major and minor neurologic deficits occur in 55% after amnio-reduction versus less than half that rate after laser, with most recent studies showing 5-6% major neurodevelopmental delays and 7-8% minor delays after laser." — Todd Ponsky (host_summary) [Ep 4 · 104:15](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=6255)
- "CHOP's cardiovascular score significantly drops within 1 week to 10 days after laser photocoagulation in the vast majority of cases, showing the recipient twin's heart has great potential to heal." — Todd Ponsky (clinical) [Ep 4 · 105:01](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=6301)
- "CHOP's miss rate for vascular anastomoses is 0.8% based on placental injection studies, compared to 10-15% miss rates reported in literature." — Todd Ponsky (clinical) [Ep 4 · 110:00](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=6600)
- "Diode laser is much safer than argon laser with lower penetration depth and no vessel rupture cases since switching to diode at CHOP." — Todd Ponsky (clinical) [Ep 4 · 107:05](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=6425)
- "Eduardo Gratacos classified selective IUGR into three types: Type 1 with positive end-diastolic flow (good prognosis), Type 2 with persistent absent/reversed flow (progressive deterioration), and Type 3 with intermittent cycling (unpredictable with high IUFD and 20% PVL risk in normal twin)." — Todd Ponsky (host_summary) [Ep 4 · 128:56](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=7736)
- "Type 3 sIUGR fetuses have the smallest placental share and characteristic very large arterio-arterial anastomoses that cause episodic acute fetal-to-fetal transfusions." — Todd Ponsky (host_summary) [Ep 4 · 131:00](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=7860)
- "With purely expectant management of Type 2 sIUGR, there is 48% loss in the smaller twin and 33% in the normal twin, with only 37% intact survival in the smaller twin." — Todd Ponsky (host_summary) [Ep 4 · 136:04](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=8164)
- "Type 3 sIUGR with expectant management shows 38.5% intact survival in the normal twin and 60% in surviving smaller twins, with very high morbidity and mortality in both groups." — Todd Ponsky (host_summary) [Ep 4 · 136:36](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=8196)
- "CHOP has performed about 80 bipolar cord cauterizations with 86% singleton survival and over 90 radiofrequency ablations with 83% singleton survival for selective cord occlusion." — Todd Ponsky (clinical) [Ep 4 · 141:19](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=8479)
- "In Type 3 sIUGR, after laser photocoagulation to separate circulations, the smaller twin dies in 75% of cases within 48 hours because it was surviving on blood from the normal twin." — Eduardo Gratacos (clinical) [Ep 4 · 146:21](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-and-twin-twin-transfusion-fetal-1025?t=8781)

## Changelog
- Sep 8: 1 item added automatically
- Sep 8: 1 item no longer name pulmonary hypoplasia
- Sep 7: 6 items added automatically

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