Thoracoscopic Management of Patent Ductus Arteriosus and Vascular RingsSteven S Rothenberg MD FACS FAAPThe Rocky Mountain Hospital for ChildrenDenver, Colorado
Room set-up•Modified Right lateral decubitus position•3 Ports•4mm 30 degree scope•5 mm endoscopic clips•Proximal and distal pulse oxymeter
Seal overlying vein
Create Pleural Flapand Protect RLN
Test clamp ductus
Apply clip
Clip in place
Video
Results•1994 – 2012•4 days – 48 years•800 gm – 62 Kg•158 pts attempted/ 155 completed thoracoscopically•First procedure 120 min•Average time last 30 : 18 minutes•CT in 4 pts•Conversion for bleeding: 3 pts, 2 from PDA & 1 from intercostal vessel•0 recurrent laryngeal nerve injury•Avg hospital stay: 1.1 days
Vascular Rings January 2000 – December 201311 patientsAge: 6 weeks – 8 years Weight: 3.6 - 38 KGW/U : ECHO, CT Angio, MRA 2 patients had a double arch and TEF5 Patients Right Arch with Diverticulum of Kommerelli3 patients right dominant arch and aberrant left subclavian and atretic left arch1 right arch and suspected ring
Methods•CO2 insuffla+on +/- right mainstem•Mobilize Ligametum Arteriosus and divide•Mobilize atre+c L arch and divide•Place suture/vessel loop around ligament/arch to achieve added length•Assume all vessels patent Ligamentum
Results•10/ 11 completed thoracoscopically•5 division of ligamentum•4 division atre+c leG arch and ligamentum•1 complete double arch: converted to open aGer successful division of ligamentum•1 explora+on only , followed by laparoscopic Nissen and G-buNon L eft arch Ligamentum
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Results•Operative time: 30-170 minutes•Without EA times 30-70 minutes•CT only in 2 patients with TEF•7 patients were outpatients•LOS 1-2 days, average 1.2•All patients symptomatically improve
Conclusion•Thoracoscopic division of vascular rings is safe and effecPve, especially in cases of a right arch and or atrePc leQ arch•This approach avoids the morbidity of an open thoracotomy•A double aorPc arch without a dominant arch is the most difficult to handle