CDH-ECMO Routine Patient Preoperative Workup, Timing, Technique: Update...

Fire. OK, so this is a near term kid, some moderate respiratory distress, you know, Apgar's 4 and 6 intubated, brought to the NICU. This chest X-ray that you see here on relatively minimal support, no isotropes, and the other piece that I didn't talk about as much before, I think one of the key elements of management of diaphragmatic hernias are echoes. And you know, you're not going to be able to tell based on your pre and post ductal SATs and everything else, you know, how much pulmonary hypertension do they have. Obviously if they're going down the tubes, you know, it's bad, but it's hard to see exactly where it is. So an echo in the TR jet is very important to look at. So we'll say in this case that the pulmonary pressures are mildly elevated but not quite super systemic. So when do you elect repair? We get the pole up. So say as soon as an open OR, do you want to go around the room with rapid fire here or let everybody. So can you put that question back up on the screen again? Um, That question that was just up a second ago. Here we go. Um, so, let's first, uh, Jenny, if we can put that up as a poll, it's up. OK. Oh, they're the results. Can you, um, move it away for one second? OK, so When do you do the repairs, Jason? You want to go first? We usually wait. We use echo very judiciously and, and, um, we will, um, make sure that our pulmonary pressures are subsystemic, at least 70% systemic, hopefully even 50% systemic before we go to the operating room. So we will be aggressive at monitoring before going to the OR. No rush, no rush, no rush. I, but I'll, we'll like, we'll check again in a couple of days. But I, I'd say 2 days. Any comments? OK, before discharge, yeah, I mean, it's a cotton, yeah, yeah, yeah. And in this kid, how would you approach the repair? It's another poll question. Thoracotomy, laparotomy, thoracoscopy, laparoscopy. The thoracoscopically in a. Easy, you know, well-managed patient. I don't have to answer that one. I don't think. I do thoracoscopy. Does anyone do laparoscopy? You know, I, I did a few early on, and actually they were quite nice. But I do think it's an easier operation for. Do you, uh, does everyone here, sort of to make it analogous to the whole inguinal hernia thing, does anyone here, uh, dissect out the pleura so you have a raw edge around your, uh, hernia defect? Do you do that? I've started doing that, yeah. OK, I'm going to afterward today. Yeah, I think the, I think the same physiology as opposed to leaving the sack. Well, not even a sack, but just, so if you selling pleura to pleura, like you're just selling pleura to pleura, it's very much like the failure rate of doing a laparoscopic inguinal hernia, sewing peritum to peritoneum. I think you have to score it all the way around and unfurl all the pleura so that so that it comes together with more of a scar. Well, I know you did the study on angual hernia repairs in rabbits, as I recall. Have you, is there a similar study in? The diaphragm. So I called Alan Flake and asked him if he could help, help me with a model for a diaphragm macaronia so we could do the exact same study. So he can, it would be $5000 per lamb. So I don't think that's gonna happen unless you guys have money for me. So, uh, I, unless someone could come up with a way, we've been trying to figure out a way to study that, but I, I feel, I, I'm, I have a high degree of suspicion that that will make an impact.