PDA ligation by Dr. Steven Rothenberg

This video demonstrates a thoracoscopic PDA ligation in a 2 kg infant. The baby is placed on the baby in a modified prone position with the left side elevated approximately 30 degrees. The surgeon and the assistant stand at the front of the baby. Here you see the port placement with a 4 millimeter scope placed slightly behind and slightly above the tip of the scapula and a 3 and 5 millimeter working port placed as shown. We simply use insufflation to collapse the lung in these cases. Single lung ventilation is not required, although it can be carried out in larger patients. Initially we put a 3 millimeter port in the posterior axillary line in approximately the fifth intercostal space to aid in the dissection. This is later changed out to a 5 millimeter port when it is time for placing the clip. At the level of the ductus, the pleura overlying the aorta, aorta is sealed and then spread using the 3 millimeter vessel sealer. It is important not to use monopolar cautery in this area because of the risk of injuring the recurrent laryngeal nerve. Once the ductus is identified. Very careful, blunt dissection is used to dissect out the duct. It's usually helpful to create a pleural flap over the uh mid portion of the aorta in order to safely retract the vagus and recurrent laryngeal nerves out of the way. Or you can see blunt dissection starting to show. That The upper crotch of the ductus between the ductus and the aortic arch. We now concentrate on the lower portion of the ductus. This ductus isn't quite in fact large and, and probably 2/3 of diameter of the aorta. Again, careful blunt dissection is used to dissect behind the ductus, uh. In order not to injure the recurrent laryngeal nerve or to tear the ductus. Gentle spreading with the 3 millimeter vessel sealer is an excellent way to get adequate mobilization. The left hand again is using the pleural flap to retract the vagus and recurrent laryngeal nerves medially without risk of injury to those structures. Further development of the upper portion of the ductus. Is performed to separate the ductus from the aorta and allow for safe placement of the 5 millimeter endoclip. Generally recommended to spread in the direction of the ductus to eliminate the risk of tearing the ductus. Occasionally The upper crotch is further developed using the 3 millimeter Maryland, coming in at a more superior angle. As shown here Here you can see the plane developed, and this ensures that the posterior aspect of the ductus is free from all structures. Again, the 3 millimeter vessel sealer is passed behind the ductus, ensuring that it is free from all other structures. And further care is taken to make sure that the vagus and recurrent laryngeal nerves, which can be visualized here. Are well out of the way of the endoscopic cliff. A test clamping of the ductus is then performed, and there is a distal pulse oximeter present on the foot to ensure that We're including the right structure. It's very important to have proximal and distal monitoring for this. A single 5 millimeter clip is in place. The 3 millimeter trock car was changed to a 5 millimeter trock car. And then the clip is deployed as seen here. It is important to deploy the clip into the clip applier before placing it onto the duct, as this can force the tissue away if you try to put the clip in while it is already around the duct. This resulted in complete occlusion of the clip. This patient also had evidence of interstitial lung disease on its CT scan, and the pulmonologist requested a lung biopsy in order to better evaluate this. Using the same 5 millimeter port. And slightly changing the orientation. Uh, towards the. Lingula A 5 millimeter stapler is inserted. And a wedge biopsy is performed. What is key here is that the 5 millimeter stapler fits appropriately in the size. Of this 2 kg infant. Care is taken to ensure the tissue is far enough in the stapler to make sure the staple line will reach across the entire line of the resected specimen. A single firing is all that is needed. And now the specimen can be removed. The specimen is brought out through the 5 millimeter port site. Without difficulty. The lung is reinflated with a chest drain in place, and as there was no air leak at the end of the procedure, no drain was left, and all the incisions were closed uh in layers with absorbable suture.