Collection
Mediastinum, Great Vessels and Diaphragm
Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
Content of this collection
Division of a vascular ring involving large caliber vessels can safely and effectively be accomplished with thoracoscopy and division using a 5-millimeter stapler. IPEG 2020 TOP ABSTRACT: Thoracoscopic Division of a Double Aortic Arch Vascular Ring Anomaly · 2:28
PDA ligation by Dr. Steven Rothenberg
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This is a thoracoscopic PDA ligation in a 2kg baby by Dr. Steven Rothenberg
video6:24 · Jun 2023
IPEG 2020 TOP ABSTRACT: Thoracoscopic Division of a Double Aortic Arch Vascular Ring Anomaly
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IPEG 2020 Annual Meeting - Top Abstract
Claire Gerall, MD1; Jennifer DeFazio, MD1; Vincent Duron, MD1; Steven Rothenberg, MD2; 1Morgan Stanley Children's Hospital/Columbia University Irving Medical Center; 2Rocky Mountain Hospital for Ch
video2:44 · Nov 2020
Thoracoscopic Stapled Division of a Double Aortic Arch
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Surgical content by Dr. Steve Rothenberg — Thoracic Surgery
video · May 2026
Vascular ring handout
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Surgical content by Dr. Steve Rothenberg — Thoracic Surgery
article · May 2026
Thoracoscopic Thymectomy
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Dr. Steve Rothenberg explains the detailed steps of thoracoscopic thymectomy.
video · Sep 2018
mediastinal masses 2014
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Surgical content by Dr. Steve Rothenberg — Thoracic Surgery
article · May 2026
The speaker finds the transabdominal laparoscopic technique preferable to thoracoscopic plication because of greater access and mobility with trocars placed through the abdominal wall. Laparoscopic Plication of a Right Diaphragmatic Eventration in a 3-Month-Old · 1:40
Thoracoscopic Ligation of the Thoracic Duct
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Surgical content by Dr. Steve Rothenberg — Thoracic Surgery
video · May 2026
thoracoscopic thoracic duct ligation presentation. MIS w video. 1.15
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Surgical content by Dr. Steve Rothenberg — Thoracic Surgery
article · May 2026
Thoracoscopic Diaphragmatic Plication
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Surgical content by Dr. Steve Rothenberg — Thoracic Surgery
video4:40 · May 2026
Laparoscopic Plication of a Right Diaphragmatic Eventration in a 3-Month-Old
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Surgical content by Dr. Steve Rothenberg — Thoracic Surgery
video6:01 · May 2026
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Thoracoscopic approaches to mediastinal and diaphragmatic pathology in infants prioritize nerve preservation and tissue handling. For PDA ligation, modified prone positioning with 30-degree left elevation and simple insufflation (without single-lung ventilation) provides adequate exposure in small patients. Monopolar cautery is avoided near the ductus; a pleural flap technique safely retracts the vagus and recurrent laryngeal nerves. Blunt dissection with gentle spreading in the direction of the ductus minimizes tearing risk, and test clamping with distal pulse oximetry confirms correct structure identification before clip deployment. For diaphragmatic plication, both thoracoscopic and transabdominal laparoscopic approaches are described, with some surgeons preferring transabdominal access for greater trocar mobility. CO2 insufflation compresses the lung and diaphragm; multiple-bite reefing sutures (typically 5–6 in the first row, 2-0 Prolene on RB-1) are tied extracorporeally with a knot pusher to manage tension. A second imbrication row may be required, and 10–15% loss of repair height is expected in early follow-up. Chest tubes are typically omitted when no air leak is present.
- Avoid monopolar cautery near the ductus during PDA ligation; use pleural flap retraction to protect the recurrent laryngeal nerve.
- Test clamping with distal pulse oximetry confirms correct ductus identification before clip deployment in thoracoscopic PDA ligation.
- Transabdominal laparoscopic plication offers greater trocar mobility than thoracoscopic approach for diaphragmatic eventration repair.
- Extracorporeal knot tying with a knot pusher manages high tension in diaphragmatic plication sutures without risk of tearing.
- Expect 10–15% loss of diaphragmatic repair height on early chest X-ray; this is typically not clinically significant.
For patients & families
The mediastinum, great vessels, and diaphragm are structures in the chest that sometimes need surgical repair in infants and children. Surgeons discussed procedures performed through small incisions using cameras and instruments, which allows faster recovery than open surgery. For babies born with a patent ductus arteriosus (PDA)—a blood vessel that should close after birth but sometimes stays open—surgeons can close it using tiny clips placed through small ports in the chest. The team carefully monitors blood flow during the procedure to ensure they are closing the correct vessel. Sometimes a lung biopsy is taken at the same time if doctors need to understand breathing problems. When the diaphragm (the breathing muscle separating chest from abdomen) becomes weak or elevated, surgeons can tighten it by placing a series of stitches that flatten and strengthen the muscle. This helps children breathe more easily and can allow them to come off the breathing machine sooner. The repair can be done through the chest or through the abdomen, depending on which side needs repair.
The mediastinum, great vessels, and diaphragm are structures in the chest that sometimes need surgical repair in infants and children. Surgeons discussed procedures performed through small incisions using cameras and instruments, which allows faster recovery than open surgery. For babies born with a patent ductus arteriosus (PDA)—a blood vessel that should close after birth but sometimes stays open—surgeons can close it using tiny clips placed through small ports in the chest. The team carefully monitors blood flow during the procedure to ensure they are closing the correct vessel. Sometimes a lung biopsy is taken at the same time if doctors need to understand breathing problems. When the diaphragm (the breathing muscle separating chest from abdomen) becomes weak or elevated, surgeons can tighten it by placing a series of stitches that flatten and strengthen the muscle. This helps children breathe more easily and can allow them to come off the breathing machine sooner. The repair can be done through the chest or through the abdomen, depending on which side needs repair.
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IPEG 2020 TOP ABSTRACT: Thoracoscopic Division of a Double Aortic Arch Vascular Ring Anomaly
The patient is a 43-day-old male born at 36 weeks gestation with multiple congenital anomalies consistent with VACTERL association.
clinical0:00 ↗
Echocardiogram revealed a vascular ring comprised of a right-sided dominant double aortic arch with left carotid and subclavian arteries arising from the right arch.
clinical0:30 ↗
An atretic left proximal arch was present between the origin of the left subclavian artery and left-sided patent ductus arteriosus.
clinical0:50 ↗
A right dorsalis pedis arterial line was obtained prior to the procedure.
clinical1:00 ↗
A blood pressure cuff was placed on the right arm and pulse oximeters on upper and lower extremities for monitoring.
clinical1:05 ↗
A bronchial blocker was placed in the left main bronchus for single lung ventilation.
clinical1:10 ↗
The patient was placed in right lateral decubitus position for the thoracoscopic approach.
clinical1:15 ↗
Three ports were used: a 4-millimeter camera port in the fifth intercostal space posterior to the scapula tip, and two 3-millimeter working ports in the seventh intercostal space posterior axillary line and third intercostal space inferior to the axilla.
clinical1:20 ↗
A pleural flap was elevated over the descending thoracic aorta and extended superiorly to the thoracic inlet and along the left subclavian artery.
clinical1:35 ↗
Both the left ductus arteriosus and left recurrent laryngeal nerve were identified during dissection.
clinical1:45 ↗
A test clamp on the ductus arteriosus was performed to ensure stability of vital signs prior to sealing and transecting.
clinical1:50 ↗
The left aortic arch was bluntly dissected and encircled, with the atretic segment at the level of the left subclavian artery takeoff visualized.
clinical2:00 ↗
A test clamp was performed on the atretic segment of the left aortic arch with unchanged blood pressures and saturations.
clinical2:10 ↗
The posterior port was upsized to a 5-millimeter trocar to accommodate the stapler.
clinical2:18 ↗
The left aortic arch was transected using a 5-millimeter stapler, releasing the vascular ring.
clinical2:22 ↗
Division of a vascular ring involving large caliber vessels can safely and effectively be accomplished with thoracoscopy and division using a 5-millimeter stapler.
opinion2:28 ↗
There were no intraoperative complications.
clinical2:36 ↗
The patient returned to the NICU intubated and was extubated on postoperative day one.
clinical2:38 ↗
PDA ligation by Dr. Steven Rothenberg
The patient is a 2 kg infant undergoing thoracoscopic PDA ligation.
clinicalSteven Rothenberg0:02 ↗
Modified prone position with left side elevated approximately 30 degrees is used for thoracoscopic PDA ligation.
clinicalSteven Rothenberg0:20 ↗
Port placement includes a 4mm scope slightly behind and above the scapula tip, with 3mm and 5mm working ports.
clinicalSteven Rothenberg0:50 ↗
Simple insufflation is used to collapse the lung; single lung ventilation is not required, although it can be carried out in larger patients.
clinicalSteven Rothenberg1:20 ↗
A 3mm port is initially placed in the posterior axillary line in approximately the fifth intercostal space, later changed to 5mm for clip placement.
clinicalSteven Rothenberg1:50 ↗
It is important not to use monopolar cautery near the ductus because of the risk of injuring the recurrent laryngeal nerve.
clinicalSteven Rothenberg2:40 ↗
Creating a pleural flap over the mid portion of the aorta helps safely retract the vagus and recurrent laryngeal nerves out of the way.
clinicalSteven Rothenberg3:20 ↗
In this case, the ductus is large, approximately 2/3 the diameter of the aorta.
clinicalSteven Rothenberg4:00 ↗
Careful blunt dissection is used to dissect behind the ductus to avoid injuring the recurrent laryngeal nerve or tearing the ductus.
clinicalSteven Rothenberg4:20 ↗
Gentle spreading with the 3mm vessel sealer is an excellent way to achieve adequate mobilization.
opinionSteven Rothenberg4:40 ↗
It is generally recommended to spread in the direction of the ductus to eliminate the risk of tearing.
clinicalSteven Rothenberg5:10 ↗
Test clamping of the ductus is performed with a distal pulse oximeter on the foot to ensure the correct structure is being occluded.
clinicalSteven Rothenberg5:50 ↗
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