From
StayCurrentMD
PDA ligation narrated
With Dr. Steve Rothenberg
Part of
Patent Ductus Arteriosus 3 items
Chapter 2 of 4 · Surgical Management
Ductus dissection
Dissection and mobilization of the ductus arteriosus
Cued at 4:30 · press play
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
The infant undergoing thoracoscopic PDA ligation weighs 2 kg.
The patient is placed in a modified prone position with the left side elevated approximately 30 degrees for thoracoscopic PDA ligation.
Port placement includes a 4 mm scope slightly behind and above the scapula tip, and 3 mm and 5 mm working ports.
Simple insufflation is used to collapse the lung; single lung ventilation is not required, although it can be used in larger patients.
A 3 mm port is initially placed in the posterior axillary line in approximately the fifth intercostal space to aid dissection, later changed to a 5 mm port for clip placement.
It is important not to use monopolar cautery near the ductus because of the risk of injuring the recurrent laryngeal nerve.
Creating a pleural flap over the mid portion of the aorta helps safely retract the vagus and recurrent laryngeal nerves out of the way.
In this case, the ductus is large, approximately two-thirds the diameter of the aorta.
Careful blunt dissection is used to dissect behind the ductus to avoid injuring the recurrent laryngeal nerve or tearing the ductus.
Gentle spreading with the 3 mm vessel sealer is an excellent way to achieve adequate mobilization of the ductus.
It is generally recommended to spread in the direction of the ductus to eliminate the risk of tearing it.
Test clamping of the ductus is performed with a distal pulse oximeter on the foot to ensure the correct structure is being occluded.
It is very important to have proximal and distal monitoring during PDA ligation.
A single 5 mm endoclip is placed on the ductus after the 3 mm trocar is changed to a 5 mm trocar.
It is important to deploy the clip into the clip applier before placing it onto the duct, as deploying while already around the duct can force the tissue away.
The clip application resulted in complete occlusion of the ductus.
No chest drain was left because there was no air leak at the end of the procedure.
All incisions were closed in layers with absorbable suture.
The patient had evidence of interstitial lung disease on CT scan, and the pulmonologist requested a lung biopsy for better evaluation.
A 5 mm stapler is appropriate in size for a 2 kg infant for performing a wedge lung biopsy.
Care must be taken to ensure tissue is far enough into the stapler so the staple line reaches across the entire line of the resected specimen.
A single firing of the stapler is all that is needed for the wedge biopsy.
The lung biopsy specimen is removed through the 5 mm port site without difficulty.