Thymic Sling

This is Brittany from Cincinnati Children's Hospital, and today, we're gonna do something a little unconventional. We are going to recreate intricate, novel, and expert-level operations out of, well, Play-Doh. Yeah, yeah, I know, I know. It's a little bit confusing, but have you ever watched a surgical technique video, and you weren't exactly sure what you were looking at amongst the 50 shades of tan? And then, just when you're getting caught up, and you're getting oriented, the view changes, and then, you're looking at the next step of the operation, you don't know where you are again. Brutal. So today, we're gonna try this out. Plus, when you watch me flounder with my operating ability, I can just blame it on the Play-Doh, and that feels kind of like a win-win. All right, let's get started. This is a procedure performed by the Pediatric Otolaryngology Department at Cincinnati Children's Hospital Medical Center. It was presented by Cynthia Wang, Kim Kassity, Carol Lee, Sherry Torres Silver, Michael Rudder, and Charles Meyer. This was performed on a six-year-old patient, who was noted to have a post-Talat area of granulomatous change in her trachea. Ooh, post-Talat. That sounds not good. With pulsation visualized through the anterior tracheal wall, they continued an appropriate workup and identified a high riding innominate artery that caused compression on the trachea. All right, so let's get our model ready here. Okay, so it looks like we need to make a transverse incision, our landmark's being sternal notch, or prior tracheostomy. Okay. All right, first step, done. Woo. Okay, so next we're gonna open this up. Okay, so first step here, we're going to split the raphe. All right, using cautery by the equipment. Hope we discussed the fire risk in the timeout, so that feels good. Okay, we got that exposed there. All right, so anatomy time. Probably help if I oriented my model to match the picture. That would be good. Okay. All right, so here we go. So now we want to remove the attachments. Okay. So here comes the sternum up. Okay. Whoops. Oh my gosh, kids are crazy, man. That thymus is right on the innominate. Okay, I wish I had a Play-Doh kitner. Oh, cotton ball. Okay, that, that will be perfect. All right, so let's get this off here. Guys, I'm just watching this, and that palpating artery is giving me palpitations. Okay. All right, artery and vein. Okay, good. My artery stopped pulsating. That's probably good because it's Play-Doh, so that would be kind of concerning. All right, window. Okay. Yeah, a uh, right angle would have been the right tool for the job here, not quite a forecept, but we're doing what we can. All right, so we're going to pass a vessel loop. Whoever thought of vessel loops? Brilliant. Okay. Okay, so we're gonna try and tunnel the thymus. Okay, so the artery I'm gonna lift up here, and then, I'm gonna push the thymus. I'm gonna pull the thymus. Okay, hang on, I'm, I'm gonna need to see that one again. Once the innominate artery is completely isolated, we carefully tunnel the thymus through the window and under the artery. And here is the thymus reflected over the artery exposing the trachea. Next, we suture the thymus to the sternum with three horizontal mattress sutures using double-armed 4-0 PDS suture on an RB1 needle over a Teflon pledget. Okay, okay, let me, let me try that here. Okay, so we're gonna push the thymus underneath the artery. Huh. That's kind of cute. It's kind of this sling in a scary way. Okay. All right, so yeah, I see. Okay, so we're going to fold the thymus over. Oh, yeah, there's the trachea underneath. Ah, okay, I think I did it. All right, cool. So then we're going to put our pledget, let me just make those right here, simulated with this gauze. Okay, so we'll make the pledgets here, and we'll push the thymus back. All right, I see, so sutures and pledgets in place. Okay, so we're gonna simulate this with this suture, and then the gauze. Suture doesn't hold so well in uh, Play-Doh, so we'll just do one. Okay, so let's start at the sternum, go through the thymus and the pledget. Okay. Oh. Yeah, that kind of makes sense now. It's the innominate is slinging inside the thymus. That's the sling. Guys, that's the sling. So the innominate slings inside the thymus and it keeps everything off the trachea. Okay, great. Yeah, so the sutures don't hold so great in Play-Doh, so we'll just have to pretend that part, but it looks really good in their video. You can see it's not anywhere near the trachea. That's awesome. Okay, so we're move. Oops. Okay, and then we're going to close. Okay. It's not exactly a cosmetic closure here. Okay. Good. Oh, let's see how the patient did. Look, it's a month out. This is the same area on flexible bronchoscopy one month post-op, with markedly improved transmitted pulsations and improving granulation tissue. Wow. That's really cool. Thanks for tuning in for our anatomation. Remember, knowledge should be free. Four meetings in one. The quad conference is actually four different conferences combined over five days. And then after that, we're even going to have an airway dissection day and a flexible bronchoscopy day that you don't want to miss. So register today for the quad conference. It's going to be October 10th to the 14th in Cincinnati. Follow the link below for not only more information but also the link to register for the event. I'll see you there.