Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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8 items
Supine Positioning for Bilateral VATS: Pediatric Surgery Difficult...
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During the Pediatric Surgery Tricks of the Trade and Difficult Cases: Innovative Solutions to Common Problems Course in 2013, Dr. Nick Bruns presents a clinical case of supine positioning for bilateral video-assisted thorascopic surgery (VA
video15:50 · Sep 2018
Tricks - Supine Positioning For Bilateral VATS
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Dr. Nick Bruns gives a presentation of a clinical case of supine positioning for bilateral video-assisted thorascopic surgery (VATS). Dr. Brun's demonstration includes topics of open thoracotomy versus VATS, pleurodesis, blood patch techniq
video17:04 · Nov 2018
Update Course Rewind 2021 - Updates in Pectus
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In this session from the 2021 Update Course, Dr. Steven Lee, MD presents updates in the perioperative care of patient with pectus excavatum including perioperative pain control, Nuss bar length measurements, right vs left approach, and much
video1:01:14 · May 2022
Spontaneous Pneumothorax Rapid Fire: Update Course 2015
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Dr. Samir Pandya, Assistant Professor, Department of Surgery, Children's and Women's Physicians of Westchester, presents on spontaneous pneumothorax. He discusses pneumothorax size, thoracentesis reoccurrence, and pleurodesis versus fibrin
video9:45 · Jan 2019
Spontaneous Pneumothorax: Update Course 2014
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Dr. Dan Ostlie, Division of Pediatric Surgery, American Family Children's Hospital, presents on spontaneous pneumothorax. He discusses initial diagnostic evaluation, and different treatment options, including chest tube insertion, VATS, and
video15:59 · Jan 2019
Spontaneous Pneumothorax
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This podcast is an interactive discussion about the management of spontaneous pneumothorax between Dr. Todd Ponsky and Dr. Dan Ostlie. Intro and outro tracks are adapted from "I dunno" by grapes, featuring J Lang, Morusque. Artist URL: ccmi
podcast33:31 · Dec 2020
Thoracoscopic Treatment of Spontaneous Pneumothorax
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This video appears in a new pediatric surgery textbook, Clinical Pediatric Surgery: A Case-Based Interactive Approach," by Dr. Sherif Emil. The book is an innovative educational resource that focuses on judgment and decision-making in pedia
video3:16 · Feb 2020
Thoracoscopic Treatment of Spontaneous Pneumothorax
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This video appears in a new pediatric surgery textbook, Clinical Pediatric Surgery: A Case-Based Interactive Approach," by Dr. Sherif Emil. The book is an innovative educational resource that focuses on judgment and decision-making in pedia
video3:16 · Feb 2020
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Spontaneous pneumothorax in adolescents and young adults is predominantly a male disease (3:1 ratio) with mean presentation age 15.5–22 years. Apical blebs are universally present on thoracoscopic examination, though their congenital nature and propensity to reform after resection remain debated. Initial management strategies vary: chest tube placement succeeds in only 50% of cases, with 25–30% recurrence even after subsequent VATS, whereas primary VATS achieves 10–15% recurrence. Simple aspiration shows 59% immediate success but 40% eventual recurrence in those discharged. The role of pleurodesis is controversial: large randomized trials demonstrate no recurrence benefit from mechanical pleurodesis after bleb resection, though talc pleurodesis may be more effective at the cost of severe postoperative pain and a treacherous reoperative field. Supine bilateral VATS is feasible for well-selected cases with bilateral disease, reducing operative time and positioning morbidity. CT imaging does not alter treatment parameters or outcomes and may identify incidental blebs in patients who never develop pneumothorax.
- Primary VATS (10–15% recurrence) outperforms chest tube followed by VATS (25–30% recurrence), suggesting immediate surgical intervention for appropriate candidates.
- Randomized trials show mechanical pleurodesis after bleb resection does not reduce recurrence; talc is more effective but creates difficult reoperative conditions.
- Simple aspiration achieves 59% immediate success but 40% of discharged patients recur; positive predictive value 83%, negative predictive value only 56%.
- Blebs are universally present at surgery and may reform after resection due to underlying lung anatomy and overstretch mechanics, not just point-in-time pathology.
- Supine bilateral VATS is safe for well-defined bilateral disease, reducing operative time and positioning morbidity versus sequential lateral decubitus procedures.
For patients & families
When a child has a spontaneous pneumothorax — air leaking into the space around the lung — physicians face decisions about how to treat it and whether it might happen again. Doctors discussed that these air leaks come from small blister-like structures called blebs at the top of the lung [e432-c2, e638-c3, e1044-c17, e1044-c19]. The condition is more common in teenage boys, particularly those with thin body types [e1521-c1, e1044-c18, e1521-c10]. Treatment options range from simple observation with oxygen for very small leaks to placing a chest tube to remove the air [e1044-c6, e1521-c3], to surgery using small cameras (called VATS) to remove the blebs and help the lung stick to the chest wall [e432-c3, e638-c4, e1521-c6]. Physicians debated whether additional procedures to make the lung adhere to the chest wall — called pleurodesis — actually prevent the pneumothorax from coming back, with some studies showing no difference in recurrence rates [e1521-c20, e1521-c21, e1521-c22]. The chance of the pneumothorax returning varies depending on the treatment chosen, ranging from about 10-50% [e1521-c4, e1521-c5, e1521-c6, e1521-c18]. If blebs are seen on both sides of the chest on a CT scan, some surgeons offer to treat both lungs at once to prevent a future collapse on the other side [e986-c6, e432-c3].
When a child has a spontaneous pneumothorax — air leaking into the space around the lung — physicians face decisions about how to treat it and whether it might happen again. Doctors discussed that these air leaks come from small blister-like structures called blebs at the top of the lung [e432-c2, e638-c3, e1044-c17, e1044-c19]. The condition is more common in teenage boys, particularly those with thin body types [e1521-c1, e1044-c18, e1521-c10]. Treatment options range from simple observation with oxygen for very small leaks to placing a chest tube to remove the air [e1044-c6, e1521-c3], to surgery using small cameras (called VATS) to remove the blebs and help the lung stick to the chest wall [e432-c3, e638-c4, e1521-c6]. Physicians debated whether additional procedures to make the lung adhere to the chest wall — called pleurodesis — actually prevent the pneumothorax from coming back, with some studies showing no difference in recurrence rates [e1521-c20, e1521-c21, e1521-c22]. The chance of the pneumothorax returning varies depending on the treatment chosen, ranging from about 10-50% [e1521-c4, e1521-c5, e1521-c6, e1521-c18]. If blebs are seen on both sides of the chest on a CT scan, some surgeons offer to treat both lungs at once to prevent a future collapse on the other side [e986-c6, e432-c3].
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Every expert statement below comes from the recorded discussions, with its speaker and moment.
Update Course Rewind 2021 - Updates in Pectus
In a randomized trial of 110 patients comparing epidural to PCA, maximum pain scores did not drop off in the epidural group due to day 2-3 transition pain, whereas PCA group pain decreased over 4.5 days.
clinicalShawn St. Peter3:27 ↗
Cryotherapy technique involves freezing ribs 4 through 7 for two minutes per rib; should not go to rib 8 or below due to risk of abdominal wall paralysis.
clinicalShawn St. Peter6:20 ↗
In prospective observational cryoanalgesia study, six of nine patients in initial retrospective cohort went home on post-op day one.
clinicalShawn St. Peter7:20 ↗
With cryoanalgesia, length of stay that couldn't get below four days became one day, with tight range except for occasional failures that look like traditional four-day stays.
clinicalShawn St. Peter7:55 ↗
Median morphine equivalents with cryoanalgesia versus traditional approaches are not on the same planet in terms of magnitude of difference.
clinicalShawn St. Peter8:30 ↗
Medical devices and implants are not required to undergo clinical trials before market introduction, unlike drugs.
guidelineVictor Garcia10:40 ↗
Cryotherapy devices received FDA approval via 510(k) predicate pathway based on similarity to devices from 1976, not based on clinical trials.
guidelineVictor Garcia14:10 ↗
With erector spinae catheters, hospital stay is two days with reduced opioid requirements both in-hospital and post-discharge.
clinicalVictor Garcia28:20 ↗
When bars flip, it is always technical - related to bar sitting in funky inner space, bad spot, not wrapped tight enough, or not secured well - not related to patient activity or pain modality.
opinionShawn St. Peter30:50 ↗
Activity restrictions beyond two weeks post-Nuss can be liberalized to anything the patient can handle, including bull riding, boxing, football, and hockey.
clinicalShawn St. Peter29:24 ↗
In Texas Children's study, 50% of patients still take opioids two weeks after Nuss procedure.
Host summaryJustin Wagner summarizing the discussion — not the host's own clinical position24:10 ↗
In past five years, hospital length of stay for Nuss procedures has been cut in half through protocol improvements.
Host summaryJustin Wagner summarizing the discussion — not the host's own clinical position24:40 ↗
In Nebraska protocol without epidurals, catheters, or cryo, length of stay is under two days and patients are off opioids by one week.
Host summaryJustin Wagner summarizing the discussion — not the host's own clinical position25:20 ↗
In Texas Children's study, urinary retention was 8% in cryo group versus 34% in non-cryo group.
Host summaryJustin Wagner summarizing the discussion — not the host's own clinical position26:00 ↗
Bar flippage occurs almost eight times more commonly in cryo group, and allodynia/neuropathy occurs about six times more frequently in cryo group.
Host summaryJustin Wagner summarizing the discussion — not the host's own clinical position26:25 ↗
In randomized epidural trial, epidural could either not be placed or was removed after one day in approximately 25% of patients.
Host summaryWhit summarizing the discussion — not the host's own clinical position26:55 ↗
Adult experience using cryotherapy with thoracotomies goes back 20 years without high enough incidence of complications to warrant backing away from the treatment advantage.
epidemiologicalShawn St. Peter19:00 ↗
With cryoanalgesia, 70% of patients go home on post-op day one without narcotics.
clinicalSteven Rothenberg34:00 ↗
Sternal elevator is used in about 10% of cases, primarily in older males with deep, stiff pectus where flexibility is limited.
clinicalSteven Rothenberg45:50 ↗
In updated series of 554 patients, bar rotation rate was 0.7%, with most occurring within first few years of surgeon experience.
epidemiologicalShawn St. Peter39:16 ↗
Pilegaard technique uses shorter bars placed asymmetrically with right side covering two rib spaces and left side with single stabilizer, resulting in well below 1% bar flip rate.
Host summaryJustin Wagner summarizing the discussion — not the host's own clinical position37:19 ↗
Computational modeling shows flatter bars focus stress on sternum while bigger curved bars have parasitic forces causing unwanted horizontal and torque action at bar ends.
Host summaryJustin Wagner summarizing the discussion — not the host's own clinical position38:10 ↗
Sub-xiphoid dissection technique allows palpation-guided bar passage and has resulted in 0% incidence of pericarditis.
clinicalShawn St. Peter43:20 ↗
Many patients have normal anterior chest sensation even in early post-op phase (two to three weeks) after cryoanalgesia, suggesting nerve stunning rather than complete death.
clinicalShawn St. Peter18:20 ↗
Gabapentin is most commonly given once pre-op then 200-300mg three times daily for up to one week post-op; pharmacokinetics suggest starting several days before operation for peak effect.
clinicalJustin Wagner22:40 ↗
When passing bar from left chest to right chest, the angle avoids pointing directly at the ventricle compared to right-to-left passage.
clinical41:20 ↗
In 15-patient magnetic repair trial, magnets were safe to place in children's chests and well-tolerated, but results were not as effective as hoped; appears most effective in young children with flexible chests.
clinicalShawn St. Peter59:24 ↗
Supine Positioning for Bilateral VATS: Pediatric Surgery Difficult...
Lateral decubitus positioning was adopted from the transition from open thoracotomy to VATS but may add unnecessary morbidity including brachial plexus injury and decubitus ulcers.
Host summaryThe host summarizing the discussion — not the host's own clinical position0:03 ↗
The presented case involved a 17-year-old male with asthma presenting with shortness of breath and chest tightness when running, found to have bilateral apical blebs and a large right spontaneous pneumothorax treated with chest tube, followed by a small left spontaneous pneumothorax that resolved with observation.
Host summaryThe host summarizing the discussion — not the host's own clinical position0:30 ↗
Bilateral VATS with bilateral apical bleb resections and mechanical pleurodesis was performed in supine position with single sterile preparation, reducing operative time.
Host summaryThe host summarizing the discussion — not the host's own clinical position1:30 ↗
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