2024 Update Course - Tips & Tricks for Gastostomies & Nissen - Miguel Guelfand

We have our least qualified surgeon talking now. Um, Miguel Gilfan, no, I'm just kidding. Miguel is, uh, chief of pediatric surgery at the Cleveland Clinic, um, and, uh, he is gonna talk, what are you gonna talk about gastrostomy? Listen. Go for it. Thank you, thank you for the invitation, and, uh, well, um, Todd asked me to talk about something he really understand first and actually that he actually can do in the, in the art. So that's going to level down everything, just simple little things so you can do it and actually understand. So we're, we're late, so we're going to be very fast. Next late, please. So we're going to do 22 little topics. Next one. Uh, liver retraction in N and sutureless gastrostomy to avoid some complications. So next one. So basically, To to protect the liver can be sometimes very cumbersome, uh, and there's different, you know, could be a 16 kg, a patient, a 45 or 1.8, so there's different ways to do it. Next one. So let's see what you do with, you know, what, how do you retract the liver in a cent. In what size in a, I, I use the same one in everyone. That's why. Can we get the pole? able to So they They used to have the diamond flex 3 millimeter liver retractor, which, OK, so you know, almost a third each one. So so that there's no, you can see here the different typical things you can use to protect the liver. And something could be cumbersome, can be not suitable for the size that you have the patient. So we basically, um, I learned this from Jorge Godoy from Chile actually. Next one. It's a very simple way, uh, to retract the, the Nissan. This actually is a, it's a real photo of Jorge. It's a, it's a Nissan done in a small baby without crocker, but this thing, can you come back? That little spread is basically doing the retraction of the liver, just a little simple thing. So basically what it does is here is a suture that is entrapped in a little stump of that will be a little silicon, uh, a folly, whatever, and goes into the abdomen and goes outside. Next one. Again, the same picture. This is the rubber, and this is the uh the uh the suture coming out. Next one. And this is basically, this was described by a a surgeon called Nakajima in '99. Next one. That that's how it looks. So basically, you're going. Can you stop it for a second? You go, usually you see the, the liver and you try to basically map where it's going to be the suture coming in from the left subscostal. You go in the go in, go, go, please. You go in left. This is left subcostal. You get to the right cross. Just, no, no, don't stop it. Go back. Yeah, start again. Then no, this one, yeah, go start. Yeah, so go to the right crosser lounge around 11 o'clock and then you go out to the right left of you or right of the right ligament of the patient and just go a little bit, you know, it's not a very deep suture and you go out against subcostal on the other side of the round ligament. And you pull that thread that will be stopped at the level of the skin and basically use, use those two threads to retract the liver as much as you want. In 90% of the patients you only only need one thread. It's never cuts the liver, no, never. If you're gentle Of course it's your chance. I, we use this in, in 1.8 kg babies and there's no problem. Next one. Next one. So again, we're going inside left subcostal. This is the suture stop. So you, you go across as some little, you know, rubber thing that stopped the suture going into the abdomen. The next one. And you hold it with a mosquito whatever in the outside so it's very easy to do. It takes actually one minute and actually the, the exposure is amazing and you don't have more truck cars or instrument and, and you have more space within any patient. Next one. The next one. Because of the time and basically you can see here the two things is it frozen next one. Or or not. Just keep going. Those are animations. So go ahead, go next one. So for big levers, no, go back, go back. Go back back. Or not. Now forward one. So this is the view you can put one in the left and the right course if the lever is too big or the left viewer is too big. So with that simple thing, you know, the exposure, this is the, the, the Nissan at the end is really simple to do. It takes, you know, it's no technology, those $2 and takes 1 minute. Next one. Any question on that? You understand, Todd? One more time. Thank you. OK, usually when you do a, this could be, uh, just a gastrostomy, a gastrostomy with Denicent usually you have what usually you do is put this node, these little sutures to prevent the mickey button of the gastrostomy tube pulling down from the stomach, and you, you, you know, um, uh, tie these knots on the outside, and usually you may have some problems. You can have infection, a removal, skin skin reaction, or all of the above. Any, anyone have all of the above or some of them both. And this is usually what you see at the end is a small baby. I said a 1 kg baby. And usually you have some problem in some of the patients. So to, to avoid this, and this is from, I learned this from my hospital for a surgeon called Marcela Santos. I know it's published already when we start doing it. It's a very simple thing. Try to avoid those complications. Next one. Next one. So usually, this is the usual problem that you can see. Next one. Even to that. Next one. So basically what we're doing is doing exactly the same, but instead of putting the, the, the sutures and, and tie them outside, we're doing it under, under the skin and, and just leaving the knot under the skin, usually with PDS or microbe. Next one. And basically, when you decide to do the, the gastrostomy, you do a little incision in the skin on the in each side of the gastrostomy site. Next one, you dissect a little bit of the skin and you can pull an angiocat or whatever. It's like a, it's like a ingual hernia thread to pull the, the suture uh uh out. Next one. You pull the two sutures inside I'm going to see the store video. Next one. And then basically you have the two sutures here under the skin. Next one, it's a short video. So basically you decide that you will do a gastrostomy site. You do very small, you know, skin incision in the other side you dissect with the mosquito. Just to leave a space to to for the note. You put one suture down through that little skin incision. You grab it from the inside. This is actually doing a nescent and a gastrostomy at the same time, obviously. You decide where you put the those stitches in the gastrostomy side, one side first, the other side again, and then you put this, you try to, you know, pick up the, the thread that you put from the outside and coming up out actually in the same side of the little incit so it's easily to do it with this technique. This is the same as the ingual hernia repair. And you pull it out, and you do that in the same side, each one. And then basically. So you have the truth, the one stitch there coming out both ends. You do the same on the other side. Coming out again with the angiocat or, you know, a spinal catheter loop with usually PDS is easily to. To get that that uh suture back. And then you do the whatever you do to do the gastrostomy, you can do it percutaneously. We do basically, we put a bobby inside, burn a little bit the, the stomach and pull and put the, the G tube or the uh mickey button directly. So the two threats are there. We Bobby, the, the stomach, usually this, this is the way we do it. Do a little incision with a mosquito and then put the the mickey bottle, the GG tube, and then you basically what you do is not this tight under the skin so at the end you, you won't have those knots outside around going around the mickey button of the G tube but whatever and basically you avoid all this, mostly all the complication having this knot in the outside in the first weeks. And this is the final. Next one, please. This finally. And Jeff, before I'm, I'm, I'm, I have the, the opportunity and the honor that Jeffrey Ponsky, you know, Jeffrey Bonsky, OK. I, I, I invite him about 2 or 3 weeks, uh, because I was honored to have you, to have him in my OR to help me in a, in a, in a peck, OK? I, I want to have a pec done with the, we invented the pec, so I invite him to the OR and I, I, I told, please teach me all the small details about what doing a peg in a, in a big was a 19 year old patient, and now I understand why you don't understand anything. Because you're how you were, you know, taught in your life, can you show the video, please? Oh wait does this have audio? Yeah, we need, we need an audio please. So he was teaching me how to do a beg basically. I've done it all the time, but I want to know the little des. Go. We need a lot, a lot of audio please. Noise is deer. It's in the next one. Sure. Doctor Ponsky video. While we're waiting for that. Yeah, and, uh, that's a, that's a nice suture technique in the kids under 10 kg you can take those sutures with the needle through the abdominal wall and get the stomach directly by holding up on the stomach through the G tube's, it's too difficult to come out in the same incision. So it's the way you do that is you come out through the skin, but you don't take the needle all the way out of the abdominal wall. And then once it's above fascia, you back it out under the skins and come out the same hole you went in. It, it works really well under 10 kg. I like it. So when you start to get thick, you can't do that. No, you're almost out of the skin. If the swdge of the needle comes out, you have to redo it because you'll never get it to dunk. I like, I like it very much. Thank you. Do you have it? Or yeah, go put some oil in it. A tiny A 4 millimeter transverse skin only. You went in? No, OK, OK, you're done. That's enough. What are you making a whipple? All right, now take the needle. I love it. That was awesome. Nice job, all right. Thanks to Miguel. Great presentation.