Atlas of Pediatric Surgical Techniques E-Book
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Atlas of Pediatric Surgical Techniques—a title in the new Surgical Techniques Atlas series edited by Drs Townsend and Evers—presents state-of-the-art updates on the full range of pediatric surgical techniques performed today. Dai H. Chung, MD and Mike Chen, MD offer you expert advice on a variety of procedures and help you expand your repertoire and hone your clinical skills.

  • Access the fully searchable contents of the book and procedural videos online at
  • Get coverage of hot topics like laparascopic techniques, ECMO cannulation, and bariatric surgery.
  • View 150 full-color anatomic drawings and step-by-step intraoperative photographs that highlight key surgical issues and techniques.
  • Master key techniques through videos that show them performed by the physicians who pioneered them.
  • Avoid complications thanks to discussions of pearls and pitfalls.
  • Choose between open and closed alternatives and get better patient outcomes.

Visually master a wide range of operative techniques, with authoritative guidance (series USP)


Surgical incision
Acute infectious thyroiditis
Stoma (disambiguation)
Colon cleansing
Surgical suture
Bariatric surgery
Choledochal cysts
Branchial cleft cyst
Neurogenic bladder
Urinary diversion
Sacrococcygeal teratoma
Abdominal distension
Annular pancreas
Imperforate anus
Congenital diaphragmatic hernia
Pulmonary sequestration
Pediatric surgery
Epidermoid cyst
Abdominal wall defect
Urinary retention
Tracheoesophageal fistula
Inguinal hernia
Trauma (medicine)
Gastric bypass surgery
Thyroglossal cyst
Pyloric stenosis
Nissen fundoplication
Biliary atresia
Pulmonary hypertension
Rectal prolapse
Abdominal pain
Hemolytic anemia
Rectal examination
Patent ductus arteriosus
Wilms' tumor
Mitral valve prolapse
Physician assistant
Weight loss
Idiopathic thrombocytopenic purpura
Bowel obstruction
Congenital disorder
Hirschsprung's disease
Testicular cancer
Testicular torsion
Heart failure
Tetralogy of Fallot
Gastroesophageal reflux disease
Esophageal atresia
Fecal incontinence
Medical ultrasonography
X-ray computed tomography
Cystic fibrosis
Atlas (anatomy)
Urinary tract infection
Radiation therapy
Magnetic resonance imaging
General surgery
Major depressive disorder
Down syndrome


Publié par
Date de parution 22 septembre 2010
Nombre de lectures 8
EAN13 9781437736205
Langue English
Poids de l'ouvrage 2 Mo

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Atlas of Pediatric Surgical Techniques
A Volume in the Surgical Techniques Atlas Series

Dai H. Chung, MD
Professor and Lee Endowed Chair in Pediatric Surgery, Department of Pediatric Surgery, Professor, Department of Cancer Biology, Vanderbilt Children’s Hospital, Vanderbilt University Medical Center, Nashville, Tennessee

Mike K. Chen, MD
Professor, Department of Surgery and Pediatrics, Director, Division of Pediatric Surgery, Program Director, Pediatric Surgery Fellowship, Children’s Hospital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
Forthcoming Volumes in the Surgical Techniques Atlas Series
Atlas of Endocrine Surgical Techniques
Edited by Quan-Yang Duh, MD, Orlo H. Clark, MD, and Electron Kebebew, MD
Atlas of Breast Surgical Techniques
Edited by V. Suzanne Klimberg, MD
Atlas of Surgical Techniques for the Upper Gastrointestinal Tract and Small Bowel
Edited by Jeffrey R. Ponsky, MD, and Michael J. Rosen, MD
Atlas of Thoracic Surgical Techniques
Edited by Joseph B. Zwischenberger, MD
Atlas of Cardiac Surgical Techniques
Edited by Frank W. Selke, MD, and Marc Ruel, MD
Atlas of Minimally Invasive Surgical Techniques
Edited by Stanley W. Ashley, MD, and Ashley Haralson Vernon, MD
Atlas of Trauma/Emergency Surgical Techniques
Edited by William Cioffi, Jr., MD
Atlas of Surgical Techniques for the Colon, Rectum, and Anus
Edited by James W. Fleshman, MD
Atlas of Surgical Techniques for the Hepatobiliary Tract and Pancreas
Edited by Reid B. Adams, MD
Front Matter

Atlas of Pediatric Surgical Techniques
A Volume in the Surgical Techniques Atlas Series
Dai H. Chung, MD
Professor and Lee Endowed Chair in Pediatric Surgery
Department of Pediatric Surgery
Professor, Department of Cancer Biology
Vanderbilt Children’s Hospital
Vanderbilt University Medical Center
Nashville, Tennessee
Mike K. Chen, MD
Professor, Department of Surgery and Pediatrics
Director, Division of Pediatric Surgery
Program Director, Pediatric Surgery Fellowship
Children’s Hospital of Alabama
University of Alabama at Birmingham
Birmingham, Alabama
Series Editors
Courtney M. Townsend, Jr., MD
Professor and John Woods Harris Distinguished Chairman
Robertson-Poth Distinguished Chair in General Surgery
Department of Surgery
The University of Texas Medical Branch
Galveston, Texas
B. Mark Evers, MD
Professor and Vice-Chair for Research
Department of Surgery
Markey Cancer Foundation Endowed Chair
Director, Markey Cancer Center
University of Kentucky
Lexington, Kentucky

1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
Atlas of Pediatric Surgical Techniques ISBN: 978-1-4160-4689-9
Copyright © 2010 by Saunders, Inc., an imprint of Elsevier Inc.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: .
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
ISBN: 978-1-4160-4689-9
Acquisitions Editor: Judith Fletcher
Developmental Editor: Rachel Miller
Publishing Services Manager: Patricia Tannian
Senior Project Manager: John Casey
Designer: Steven Stave
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Maria H. Alonso, MD, Associate Professor of Surgery Surgical Assistant Director Liver Transplantation Division of Pediatric & Thoracic Surgery Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

Richard G. Azizkhan, MD, PhD (Hon), Surgeon-in-Chief Lester W. Martin Chair in Pediatric Surgery Professor of Surgery and Pediatrics Cincinnati Children’s Hospital Medical Center University of Cincinnati College of Medicine Cincinnati, Ohio

Naira Baregamian, MD, MMS, Pediatric Surgery Research Fellow Department of Surgery The University of Texas Medical Branch Galveston, Texas

Elizabeth A. Beierle, MD, Associate Professor of Surgery and Pediatrics University of Alabama at Birmingham Birmingham, Alabama

Deborah F. Billmire, MD, Professor Department of Surgery, Section of Pediatric Surgery Indiana University Attending Surgeon James Whitcomb Riley Hospital for Children Indianapolis, Indiana

Mary L. Brandt, MD, Professor, Michael E. DeBakey Department of Surgery Baylor College of Medicine Houston, Texas

Mike K. Chen, MD, Professor, Department of Surgery and Pediatrics Director, Division of Pediatric Surgery Program Director, Pediatric Surgery Fellowship Children’s Hospital of Alabama University of Alabama at Birmingham Birmingham, Alabama

Dai H. Chung, MD, Professor and Lee Endowed Chair in Pediatric Surgery Department of Pediatric Surgery Professor, Department of Cancer Biology Vanderbilt Children’s Hospital Vanderbilt University Medical Center Nashville, Tennessee

Andrew M. Davidoff, MD, Professor, Department of Surgery and Pediatrics University of Tennessee College of Medicine Chairman, Department of Surgery St. Jude Children’s Research Hospital Memphis, Tennessee

Bryan J. Dicken, MSc, FRCSC, FAAP, Assistant Professor of Surgery Division of Pediatric Surgery Stollery Children’s Hospital Edmonton, Alberta, Canada

Belinda Hsi Dickie, MD, PhD, Colorectal Fellow Division of Pediatric General and Thoracic Surgery Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

Richard A. Falcone, Jr., MD, MPH, Associate Professor of Surgery Division of Pediatric and Thoracic Surgery Cincinnati Children’s Hospital Medical Center Department of Surgery, University of Cincinnati Cincinnati, Ohio

Mary E. Fallat, MD, Hirikati S. Nagaraj Professor and Division Chief Pediatric Surgery University of Kentucky Louisville, Kentucky

Jason S. Frischer, MD, Assistant Professor of Surgery University of Cincinnati College of Medicine Department of Pediatric General & Thoracic Surgery Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

John M. Gatti, MD, Associate Professor Director of Minimally Invasive Urology Department of Surgery and Urology Children’s Mercy Hospital University of Missouri at Kansas City School of Medicine Kansas City, Missouri; Staff Surgeon Department of Surgery Children’s Mercy South Overland Park, Kansas; Staff Surgeon Department of Urology University of Kansas Medical Center Kansas City, Kansas

Michael J. Goretsky, MD, Associate Professor of Clinical Surgery and Pediatrics Eastern Virginia Medical School Surgeon, Children’s Hospital of The King’s Daughters Norfolk, Virginia

Michael H. Hines, MD, FACS, Associate Professor, Cardiothoracic Surgery and Pediatrics Wake Forest University School of Medicine Director of ECMO and Perfusion Services Wake Forest University Baptist Medical Center Winston-Salem, North Carolina

Ronald B. Hirschl, MD, Professor of Pediatric Surgery Head, Section of Pediatric Surgery Surgeon-in-Chief, C.S. Mott Children’s Hospital University of Michigan Health System Ann Arbor, Michigan

Thomas H. Inge, MD, PhD, FACS, FAAP, Associate Professor of Surgery and Pediatrics Surgical Director, Comprehensive Weight Management Center Director, Center for Bariatric Research and Innovation Division of Pediatric General and Thoracic Surgery Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

Saleem Islam, MD, MPH, Associate Professor Director, Pediatric Minimally Invasive Surgery Division of Pediatric Surgery, Department of Surgery University of Florida, College of Medicine Gainesville, Florida

Michael D. Josephs, MD, Attending Physician Dell Children’s Medical Center of Central Texas Austin, Texas

Timothy D. Kane, MD, Clinical Director Associate Professor of Surgery Division, Pediatric General and Thoracic Surgery Children’s Hospital of Pittsburgh University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

Akemi L. Kawaguchi, MD, Assistant Professor of Clinical Surgery University of Southern California Keck School of Medicine Attending Surgeon, Pediatric Surgery Childrens Hospital Los Angeles Los Angeles, California

Anne C. Kim, MD, MPH, Pediatric Surgery Research Fellow University of Michigan Ann Arbor, Michigan

Eugene S. Kim, MD, FACS, FAAP, Assistant Professor of Surgery and Pediatrics Division of Pediatric Surgery Section of Hematology-Oncology Baylor College of Medicine Attending Surgeon Texas Children’s Hospital Houston, Texas

Keith A. Kuenzler, MD, Assistant Professor of Surgery New York University School of Medicine Director, Minimally Invasive Surgery Division of Pediatric Surgery New York, New York

Jacob C. Langer, MD, Professor of Surgery University of Toronto Faculty of Medicine Chief and Robert M. Filler Chair Paediatric General and Thoracic Surgery Hospital for Sick Children Toronto, Ontario, Canada

Marc Levitt, MD, Associate Professor of Surgery University of Cincinnati Associate Director, Colorectal Center Cincinnati Children’s Hospital Cincinnati, Ohio

Peter B. Manning, MD, Professor of Surgery and Pediatrics University of Cincinnati College of Medicine Director, Cardiothoracic Surgery Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

Tory A. Meyer, MD, Subspecialty Chief Pediatric Surgery Dell Children’s Medical Center of Central Texas Austin, Texas

Vincent Mortellaro, BS, MD, Department of Surgery College of Medicine University of Florida Gainesville, Florida

J. Patrick Murphy, MD, Professor of Surgery University of Missouri at Kansas City Chief of Section, Urology Department of Surgery Children’s Mercy Hospital Kansas City, Missouri

Jaimie D. Nathan, MD, Assistant Professor of Surgery and Pediatrics Division of Pediatric and Thoracic Surgery Cincinnati Children’s Hospital Medical Center Department of Surgery University of Cincinnati College of Medicine Cincinnati, Ohio

Donald Nuss, MB, ChB, FRCSC, FACS, Professor of Clinical Surgery and Pediatrics Eastern Virginia Medical School Surgeon, Children’s Hospital of The King’s Daughters Norfolk, Virginia

Daniel J. Ostlie, MD, Professor of Surgery Children’s Mercy Hospital and Clinics Kansas City, Missouri

Alberto Peña, MD, Professor of Surgery University of Cincinnati Director of Colorectal Center Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

Thomas Pranikoff, MD, Associate Professor of Surgery and Pediatrics Section of Pediatric Surgery Wake Forest University School of Medicine Attending Surgeon Department of Pediatric Surgery Brenner Children’s Hospital Winston-Salem, North Carolina

Frederick J. Rescorla, MD, Professor of Surgery Indiana University School of Medicine Surgeon-in-Chief Department of Surgery Riley Hospital for Children Indianapolis, Indiana

Marleta Reynolds, MD, Lydia J. Fredrickson Professor of Pediatric Surgery Northwestern University Feinberg School of Medicine Children’s Memorial Hospital Chicago, Illinois

Richard Ricketts, MD, Professor of Surgery Emory University School of Medicine Chief, Division of Pediatric Surgery Children’s Healthcare of Atlanta Atlanta, Georgia

Frederick C. Ryckman, MD, Professor of Surgery University of Cincinnati College of Medicine Pediatric Surgeon Division of Pediatric General and Thoracic Surgery Vice President for System Capacity and Peri-Operative Operations Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

Bradley J. Segura, MD, PhD, Assistant Professor of Surgery Department of Pediatric Surgery St. Louis Children’s Hospital St. Louis, Missouri

Robert C. Shamberger, MD, Robert E. Gross Professor of Surgery Department of Surgery Harvard Medical School Chief of Surgery Children’s Hospital Boston Boston, Massachusetts

Stig Somme, MD, Assistant Professor Department of Pediatric Surgery The Children’s Hospital University of Colorado, Denver Medical School Aurora, Colorado

Shawn D. St. Peter, MD, Director, Center for Prospective Clinical Trials Department of Surgery Children’s Mercy Hospital Kansas City, Missouri

Charles J.H. Stolar, MD, Director, Division of Pediatric Surgery Surgeon-in-Chief Morgan Stanley Children’s Hospital New York–Presbyterian Hospital Columbia University Medical Center New York, New York

Daniel H. Teitelbaum, MD, Professor of Pediatric Surgery Mott Children’s Hospital University of Michigan Ann Arbor, Michigan

Greg M. Tiao, MD, Associate Professor of Surgery Director, Liver Transplantation Division of Pediatric & Thoracic Surgery Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

Daniel von Allmen, MD, Director, Division of Pediatric General and Thoracic Surgery Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

Brad W. Warner, MD, Jessie L. Ternberg Distinguished Professor of Pediatric Surgery Department of Surgery Washington University School of Medicine Surgeon-in-Chief St. Louis Children’s Hospital St. Louis, Missouri

Mark L. Wulkan, MD, Surgeon-in-Chief Children’s Healthcare of Atlanta Associate Professor of Surgery and Pediatrics Program Director, Pediatric Surgery Emory University School of Medicine Atlanta, Georgia
To our families
Kimberleye, Camryn, Kaley, Elizabeth
And all infants and children we care for
“A picture is worth a thousand words.”
This atlas is for practicing surgeons, surgical residents, and medical students for their review and preparation for surgical procedures. New procedures are developed and old ones are replaced as technologic and pharmacologic advances occur. The topics presented are contemporaneous surgical procedures with step-by-step illustrations, along with the preoperative and postoperative considerations, as well as pearls and pitfalls taken from the personal experience and surgical practice of the authors. Their results have been validated in their surgical practices involving many patients. Operative surgery remains a manual art in which the knowledge, judgment, and technical skill of the surgeon come together for the benefit of the patient. A technically perfect operation is the key to this success. Speed in operation comes from having a plan and devoting sufficient time to completion of each step in order, one time. The surgeon must be dedicated to spending the time to do it right the first time; if not, there will never be enough time to do it right at any other time. Use this atlas, study it for your patients.
“An amateur practices until he gets it right; a professional practices until she can’t get it wrong.”

Pediatric surgery remains as a broad general surgical specialty caring for infants and children. Pediatric surgeons are faced with the challenges of dealing with a wide spectrum of complex pathology involving multiple organ systems in patients ranging from neonates to young adults. Despite surgeons having 2 years of rigorous clinical fellowship training, numerous pediatric surgical procedures are handled only occasionally due to the infrequency of a disease process. Conversely, other commonly performed procedures are not routine in a variety of patients, from very small premature neonates to extremely large adolescents, and therefore a thorough grasp of knowledge of surgical anatomy and physiology is required to operate safely. Mastery of all pediatric surgical procedures is a demanding lifelong learning process that requires refining operative techniques throughout a surgical career. For young surgical residents in training, as well as established surgeons who may only occasionally manage delicate pediatric surgical patients, concise and clear illustrations of pediatric surgical procedures can be instrumental to the careful preoperative planning and precise completion of operations.
In this first edition of Atlas of Pediatric Surgical Techniques , we have put together a collection of a broad spectrum of pediatric surgical operations. The key steps of the procedure are described in a concise bullet-style format, highlighted by colorful illustrations and intraoperative photographs. Each chapter includes interesting Pearls and Pitfalls and a short list of pertinent references. Contributing authors come from all facets of our field, from academic centers to private surgical groups, each sharing a wealth of knowledge acquired from years of experience to illustrate pediatric surgical techniques. We believe this comprehensive atlas will nicely complement standard textbooks in pediatric surgery.
We would like to thank our contributing authors and acknowledge the dedicated professionalism of our colleagues at Elsevier. Developmental Editors Rachel Miller and Sarah Myer, and Publishing Director Judith Fletcher have been instrumental to the completion of this atlas.

Table of Contents
Instructions for online access
Forthcoming Volumes in the Surgical Techniques Atlas Series
Front Matter
Section I: General
Chapter 1: Vascular Access
Chapter 2: Extracorporeal Membrane Oxygenation Cannulation
Section II: Head and Neck
Chapter 3: Thyroglossal Duct Cyst
Chapter 4: Branchial Anomalies
Section III: Thoracic
Chapter 5: Esophageal Atresia with Tracheoesophageal Fistula
Chapter 6: Cervical Esophagostomy
Chapter 7: Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula
Chapter 8: Esophageal Replacement
Chapter 9: Esophageal Replacement: Gastric Tube Pull-up
Chapter 10: Congenital Diaphragmatic Hernia and Eventration of the Diaphragm
Chapter 11: Surgical Treatment of Chest Wall Deformities: Nuss Procedure
Chapter 12: Surgical Treatment of Chest Wall Deformities: Open Repair
Chapter 13: Patent Ductus Arteriosus
Chapter 14: Congenital Lung Anomalies
Section IV: Abdomen
Chapter 15: Duodenal Obstruction
Chapter 16: Malrotation: Ladd Procedure
Chapter 17: Meconium Disease
Chapter 18: Hirschsprung Disease: Transanal Pull-Through
Chapter 19: Hirschsprung Disease: Soave (Open and Laparoscopic-Assisted) and Duhamel Techniques
Chapter 20: Hirschsprung Disease: Swenson Pull-Through Procedure
Chapter 21: Imperforate Anus
Chapter 22: Cloaca
Chapter 23: Biliary Atresia
Chapter 24: Choledochal Cysts
Chapter 25: Gastroschisis and Omphalocele
Chapter 26: Laparoscopic and Open Pyloromyotomy
Chapter 27: Anti-Reflux Procedures
Chapter 28: Bariatric Surgery
Chapter 29: Splenectomy
Section V: Genitourinary
Chapter 30: Inguinal Hernias and Hydroceles
Chapter 31: Cryptorchidism
Chapter 32: Testicular Torsion
Section VI: Tumors
Chapter 33: Wilms Tumor
Chapter 34: Neuroblastoma
Chapter 35: Sacrococcygeal Teratoma
Chapter 36: Hepatic Tumors
Section I
CHAPTER 1 Vascular Access

Deborah F. Billmire

Step 1: Surgical Anatomy

♦ The six central veins include the internal jugular, subclavian, and femoral veins. In most children, these are symmetric and paired.
♦ Children with congenital heart disease, splenia syndromes, and variants of esophageal atresia have an increased incidence of anatomic variants in the subclavian veins that are relevant to central access procedures ( Fig. 1-1 ).
♦ Children with congenital heart disease and situs abnormalities have an increased incidence of variants of the inferior vena cava that are relevant ( Fig. 1-2 ).

Figure 1-1

Figure 1-2

Step 2: Preoperative Considerations

♦ What is the purpose of the access, and could therapy be achieved without central access?
♦ How long will the access be needed, and would a nontunneled or tunneled line be more appropriate?
♦ Does the patient have current evidence of infection?
♦ Does the patient have clinical indicators of coagulopathy or receive any medications that impact coagulation status?
♦ Has the patient had previous central lines that may have resulted in venous thrombosis?
♦ Can the patient be taken to the operating room so that optimal sterile conditions and fluoroscopy will be available?

Step 3: Operative Steps

1 General Concepts

♦ In general, insertion of most central lines in children is best achieved in the operating room with the patient under anesthesia and using fluoroscopy. It is not uncommon, however, to be asked to provide a central line in the emergency room or intensive care unit for an unstable patient who requires immediate access and is not stable enough for transport.
♦ In these patients, the use of bedside Doppler examination or ultrasound may be helpful in assessing position and patency of veins. This is particularly useful in children who have had multiple previous central lines. With Doppler probe, a good venous signal that varies with respiration suggests patency of the jugular and femoral systems, and the path of the signal may be mapped out using a skin marker. Good augmentation of the venous signal with compression of the leg also suggests patency of the femoral system.
♦ Bedside ultrasound may also demonstrate a patent vein that can be mapped using a skin marker or observed directly during venipuncture if a sterile probe is available.
♦ Operative records should be reviewed for information regarding previous placement of central lines.
♦ Regardless of the method or site of placement, a confirming radiographic image of the final result should be obtained.
♦ Catheter size and number of lumens should be minimized to reduce risk of thrombosis and infection.

2 Temporary Central Lines

♦ Temporary lines are inserted by percutaneous Seldinger technique directly into the vein and are generally acceptable for 2 to 3 weeks.
♦ The vein is accessed percutaneously using a thin-walled needle. After aspiration of nonpulsatile venous blood, the wire is advanced well into the vein.
♦ Fluoroscopy is done to confirm proper wire placement in the central vein.
♦ If venous blood is obtained, but the wire does not advance easily and fluoroscopy is available, contrast solution may be injected either through the needle or after replacing the needle over the wire with an angiocatheter and confirming continued ability to aspirate blood. This may demonstrate previously unrecognized thrombosis or congenital anatomic variants. If fluoroscopy is not available, repeat venipuncture, or an alternative site is needed.
♦ Once the wire has easily passed, the dilator is placed over the wire just deep enough to allow the tip of the dilator to pass through the skin and soft tissues. The wire should remain inserted well beyond the tip of the dilator.
♦ The dilator is removed, and the preflushed catheter is placed to an appropriate depth.
♦ Precautions against venous embolism should be used at all sites.
♦ Ability to aspirate blood and flush easily in all lumens should be confirmed before securing the line in place.

3 Tunneled Central Lines

♦ Tunneled lines are preferred for access anticipated to be longer than 2 to 3 weeks.
♦ These lines end as external catheters or as subcutaneous reservoirs ( Fig. 1-3 ).
♦ Percutaneous or cutdown technique may be used.
♦ The entry site is enlarged enough to allow the catheter tubing to be brought from a separate exit site.
♦ The exit site should be chosen several centimeters away in a location that will create a smooth pathway and a convenient place for the dressing.
♦ The catheter may be either pulled through the tunnel antegrade with a blunt probe or pushed through the lumen of a Frazier tip sucker that is passed retrograde down the tunnel ( Fig. 1-4 ).
♦ The cuff is positioned 1 cm above the exit site to allow for later removal without the need for additional incision.
♦ Once the catheter is tunneled to the exit site, it is cut to length.
♦ For percutaneous access, the peelaway or obturator sheath is advanced over the wire with fluoroscopic assistance ( Fig. 1-5 ).
♦ The obturator and wire are removed, and the catheter is advanced down the sheath ( Fig. 1-6 ).
♦ The sheath is peeled away, and fluoroscopy is used again to confirm the proper course and position of the catheter ( Fig. 1-7 ).
♦ Ability to aspirate and flush the catheter is confirmed.
♦ The entry-site wound is closed with subcuticular monofilament suture.
♦ A single nonabsorbable monofilament suture is used to secure the catheter at the exit site after confirming ability to aspirate and flush all lumens.
♦ For subcutaneous reservoirs, the reservoir should be placed in a flat location and secured to the fascia.

Figure 1-3

Figure 1-4

Figure 1-5

Figure 1-6

Figure 1-7

4 Access by Anatomic Site


♦ The available sites in the neck include the internal jugular and external veins ( Fig. 1-8 ). The external jugular is accessed by cutdown technique and the internal jugular by either cutdown or percutaneous method.
♦ The patient is positioned with a transverse roll beneath the shoulders to achieve mild extension, and the head is turned slightly to the side opposite the planned access. Skin preparation should include the anterior chest and both sides of the neck.
♦ For all neck sites, the patient is placed in Trendelenburg position.

Figure 1-8

External Jugular Cutdown

♦ Most usable external jugular veins are visible on inspection. The vein overlies the sternocleidomastoid muscle. A small transverse incision is made in midneck directly over the visible vein.
♦ With a minimal amount of blunt dissection, the vein is identified and fine absorbable ties are passed for proximal and distal control.
♦ When the catheter is brought through the tunnel, care is taken to ensure that the tubing enters the neck incision in a gentle arc instead of a sharp turn that will kink the catheter.
♦ The tubing is cut to length by following the expected course from the incision, to the clavicle, to the midline, and to the angle of Louis. A bevel is made to facilitate introduction into the vein.
♦ The distal ligature is tied. It is helpful to place a few drops of lidocaine on the vessel to reduce vasospasm. An anterior venotomy is made, and the catheter is threaded into the vein.
♦ Occasionally the catheter will be difficult to pass at the subclavian junction. In this situation it is often helpful to withdraw the catheter until the bevel is seen, rotate it 180 degrees, and repass the catheter.
♦ Confirmation of the catheter in the superior vena cava by fluoroscopy should be obtained, and the catheter should aspirate and flush easily.
♦ The proximal tie is ligated around the catheter and vein, and the neck wound is closed.
♦ The catheter is secured at the exit site.

Internal Jugular Cutdown

♦ Preparation and position are similar to that for external jugular cutdown. If the procedure was initiated as an external jugular and the vein is not suitable, the same incision can be extended slightly for better exposure.
♦ Blunt dissection should be carried through the sternocleidomastoid muscle. If this is done between the sternal and clavicular heads, dissection is minimized and the vein is visible just deep to the muscle.
♦ Careful blunt dissection is done to isolate the vein, and proximal and distal control is achieved using silk ties. If a visible facial branch is seen, this may be controlled and is used as the point of access to the vein. In small neonates, this branch may be too small or angled for convenient use.
♦ The catheter is drawn through the tunnel to the neck wound, taking care to make a gentle arc.
♦ The catheter length is chosen as a path directly from the incision to the angle of Louis and cut with a slight bevel.
♦ There is no need to ligate the vein in almost all patients, including small premature infants. The stay sutures are placed under traction, and a pursestring suture of 6-0 Prolene is placed on the anterior wall of the vein.
♦ A small venotomy is made, and the catheter is introduced and threaded into the vein.
♦ Fluoroscopy is done to confirm catheter position, and ability to aspirate and flush the catheter is assured.
♦ The pursestring suture is tied down securely, but ability to slide the catheter at the venotomy site is confirmed.
♦ The muscle is closed over the arc of the catheter to minimize mobility of the catheter. The subcutaneous tissue and skin are closed.
♦ The catheter is secured at the exit site.

Internal Jugular, Percutaneous

♦ In adolescent patients, it is sometimes helpful to have the patient elevate the head from the bed before anesthesia is administered. The separate heads of the sternocleidomastoid muscle are more easily seen, and the triangular space formed by their adjacent bundles is visible for marking. This can be particularly helpful when placing the larger hemodialysis catheters.
♦ The patient is positioned supine with a generous transverse roll beneath the shoulders and the neck well extended. The head is turned to the opposite side.
♦ If ultrasound or Doppler is not used, the palpable carotid pulse serves as a landmark. The needle enters the skin at the apex of the muscular triangle lateral to the pulse at a 30-degree angle from the skin and is slowly advanced while aspirating. The trajectory should follow a course aiming at the ipsilateral nipple. When venous blood is obtained, the wire is placed through the needle, and fluoroscopy is used to confirm venous position.
♦ For a tunneled line, the exit site is planned for a flat area on the anterior chest wall below the clavicle.

Subclavian Vein, Percutaneous

♦ In children, the subclavian vein is the most commonly used percutaneous access. The right side is preferable, if possible. The left side may be used if there is a recent history of infected right-side line, ventriculoperitoneal shunt, venous occlusion, or difficulty in accessing the right side.
♦ The patient is positioned supine in Trendelenburg with a transverse roll beneath the shoulder to achieve a neutral position of the shoulders. The neck is extended with the head in the midline.
♦ Skin preparation should include both sides of the chest and the neck.
♦ By palpation, the “crook” of the clavicle is identified. The needle is introduced through the skin just lateral to the crook and directed at the inferior margin of the clavicle. As soon as the needle is under the margin of the clavicle, the tip should be aimed at the sternal notch and slowly advanced using continuous suction. The trajectory of the needle should be parallel with the floor, and no pressure on the needle should be needed to maintain position ( Fig. 1-9 ).
♦ When venous blood is obtained, the wire should be passed through the needle with fluoroscopic confirmation of venous position.
♦ If the wire passes to the opposite subclavian vein, withdraw the tip of the wire back to the ipsilateral subclavian, place a finger in the sternal notch, and press downward to distort the innominate junction and advance the wire.
♦ If the wire passes to the ipsilateral jugular, withdraw the tip back to the ipsilateral subclavian, rotate the head to the ipsilateral side, press downward with a finger at the base of the neck just medial to the sternocleidomastoid, and advance the wire.
♦ For tunneled lines, the exit site is most commonly on the anterior chest wall. For active toddlers, it is sometimes helpful to exit on the upper back by tunneling over the shoulder ( Fig. 1-10 ).

Figure 1-9

Figure 1-10

Femoral Vein

♦ The femoral vein is used less often because of concerns regarding contamination in infants and toddlers and concern about kinking and obstruction in patients who are old enough to sit. It is more likely to be used in emergent situations in the intensive care unit or in patients with a coagulopathy. Access by cutdown or percutaneous technique is possible ( Fig. 1-11 ).
♦ Femoral cutdown via the saphenous vein
The patient is placed supine with the hips flat.
A wide preparation is done to include both groins and the abdomen up to the umbilicus.
A small transverse incision is made medial to the pulse 1 cm below the inguinal ligament in infants and 2 to 3 cm below the inguinal ligament in children or adolescents.
Dissection is carried down through subcutaneous tissue to identify the saphenous vein.
The vein is isolated and controlled proximally and distally with fine absorbable ties. Lidocaine is dripped onto the vessel to reduce spasm.
A tunneled line of matched size is brought through a separate exit site to the incision. In most cases, it is advantageous to have the tunnel on the abdominal wall so that the exit site is above the diaper.
The vein is ligated distally, and a small venotomy is made.
The catheter is trimmed to length (incision to costal margin) and introduced through the venotomy.
Fluoroscopy is used to confirm position in the inferior vena cava below the diaphragm.
The catheter should aspirate and flush easily.
The proximal tie is ligated around the vein and catheter.
The incision is closed in layers with absorbable suture.
The catheter is secured at the exit site with monofilament suture and a secure sterile dressing is applied.
♦ Percutaneous femoral access
Puncture the skin 1 or 2 cm below the inguinal ligament and medial to the palpable pulse. The needle should be angled 30 degrees above the skin, and the trajectory should point toward the umbilicus. Advance slowly, aspirating continually until venous blood is obtained. The wire is advanced under fluoroscopic guidance into the inferior vena cava.
The catheter is secured at the exit site with monofilament suture, and a secure sterile dressing is applied.

Figure 1-11

Step 4: Postoperative Care

♦ A confirming radiographic image should be done after all access procedures either with fluoroscopy or plain radiography.

Arterial Access

Radial Artery

♦ The radial artery is the most frequently accessed peripheral artery.
♦ Before cannulation, an Allen’s test should be done to confirm patency of collateral circulation. The radial and ulnar arteries are compressed simultaneously, followed by release of the ulnar compression. If the collateral circulation is adequate, the hand will become pink.
♦ The hand should be taped to a padded arm board with a roll under the wrist to aid in extension.
♦ The area is prepped with antiseptic. Using palpation of the pulse medial to the radial head or ultrasound guidance, the artery is accessed percutaneously with a 22- or 24-gauge angiocatheter, depending on the size of the patient. The catheter is advanced.
♦ The angiocatheter is secured with tape, leaving the fingers exposed for monitoring.
♦ The line should be removed as soon as it is no longer needed and should be removed promptly if there is any evidence of ischemia.

Posterior Tibial Artery

♦ The posterior tibial artery is a peripheral access site that is often used in small infants. It is palpable just posterior to the medial malleolus at the ankle.
♦ The foot is restrained on a padded armboard with a roll under the ankle and the foot in gentle plantar flexion.
♦ The area is prepared with antiseptic. Using palpation of the pulse posterior to the medial malleolus or ultrasound guidance, a 22- or 24-gauge angiocatheter is used to access the artery and is then advanced.
♦ The catheter is taped in place, leaving the toes exposed for monitoring.
♦ The line should be removed as soon as it is no longer needed and should be removed promptly if there is any evidence of ischemia.

Step 5: Pearls and Pitfalls

♦ Tunneled silicone catheters that remain intravascular but become malpositioned with the tip in the internal jugular or opposite subclavian vein in many cases may be repositioned without return to the operating room. Under fluoroscopy, a burst injection of normal saline with volume limited to 2 to 5 mL through a Luer lock syringe may “flip” the tip back to proper position in the superior vena cava. Success of this technique has been seen with catheter sizes ranging from 2.7 to 7 French.
♦ “Pinch-off sign” occurs when a subclavian catheter is inserted medially, causing compression of the catheter between the clavicle and first rib. This is visible on x-ray as a compressed segment of the catheter. It is associated with increased risk of catheter fracture with leakage or embolization.
♦ Cardiac tamponade, although rare, may occur during placement of a central line by any approach or as a delayed complication from catheter migration. Any unexplained, abrupt change in cardiopulmonary status should raise suspicion of this problem, even if the chest x-ray is unchanged.
♦ Femoral lines placed by percutaneous or cutdown technique may enter the lumbar venous plexus through the ascending lumbar veins. This may be suspected on plain x-ray by a catheter path in the midline overlying the spine and confirmed by a lateral film showing the catheter path posterior to the vertebral bodies.


Aitken DR, Minton JP. The “pinch-off sign”: A warning of impending problems with permanent subclavian catheters. Am J Surg . 1984;148:633-636.
Bagwell CE, Salzberg AM, Sonnino RE, et al. Potentially lethal complications of central venous catheter placement. J Pediatr Surg . 2000;35(5):709-713.
Lavandosky G, Gomez R, Montes J. Potentially lethal misplacement of femoral central venous catheters. Crit Care Med . 1996;24(5):893-896.
Mowery N, Billmire DF, Schamberger M, et al. Incidence of persistent left superior vena cava in esophageal atresia. J Pediatr Surg . 2006;41:484-486.
Singer RL, Wolfson PJ. Experience with umbilical artery cutdowns in neonates. Pediatr Surg Int . 1990;5:295-297.
Skandalakis JE. The superior and inferior venae cavae. In: Skandalakis JE, Gray SW, editors. Embryology for surgeons . 2nd ed. Baltimore: Williams & Wilkins; 1994:1032-1051.
Van Engelenburg KCA, Festen C. Cardiac tamponade: A rare but life-threatening complication of central venous catheters in children. J Pediatr Surg . 1998;33:1822-1824.
Warner BW, Ryckman FC. A simple technique to redirect malpositioned Silastic central venous catheters. J Parenter Enter Nutr . 1992;16(5):473-476. 1992
CHAPTER 2 Extracorporeal Membrane Oxygenation Cannulation

Thomas Pranikoff, Michael H. Hines

Step 1: Surgical Anatomy

♦ Within the carotid sheath, the internal jugular vein is anterior and lateral and the common carotid artery is medial and posterior. The vagus nerve lies posterior and between these two structures.
♦ In the femoral triangle, below the inguinal ligament, the femoral vein lies medial to the artery. More distally, the vein moves posterior to the artery.

Step 2: Preoperative Considerations—Patient Management before Extracorporeal Life Support

♦ Patients who require extracorporeal life support (ECLS) are critically ill, and proper preparation before initiating ECLS is challenging.
♦ Adequate monitoring and nursing care are essential, and required equipment (cannulas, surgical instruments, circuit and components) and personnel (operating room and ECLS) must be available.
♦ The ability to transport the patient safely with adequate ventilation and hemodynamic support should be considered.
♦ The decision of where to cannulate the patient (e.g., in the intensive care unit [ICU], operating room [OR], emergency department) needs to be thought out carefully.
♦ Most institutions will have pre-ECLS orders that need to be initiated, including ordering blood and platelets.
♦ The patient should be anesthetized to facilitate safe cannulation, avoid anxiety and discomfort, and reduce the likelihood of air embolus. We use a combination of fentanyl and rocuronium.
♦ After the vessels have been surgically exposed or a guidewire placed for percutaneous access, the patient is anticoagulated with heparin (100 units/kg for 3 minutes) before cannulation.

Type of Support

♦ Extracorporeal support is provided in two principal ways:
Venovenous (VV) bypass, which provides excellent respiratory support
Venoarterial (VA) bypass, which provides both cardiac and respiratory support.
♦ VA bypass removes blood from the systemic venous circulation, usually from the right atrium via the right internal jugular vein, and returns the blood to the systemic arterial circulation in the aortic arch via the right common carotid artery.
♦ In VV bypass, blood is drained from the venous circulation and returned to the venous circulation either through a single double-lumen catheter in the right atrium via the jugular vein or by using two cannulas in the jugular and femoral veins.
♦ Most cases of respiratory failure can be managed with VV bypass if cardiac function is adequate. This may be difficult to determine in the typical hypoxemia patient who is on high-pressure ventilation, which depresses cardiac function.
♦ After ECLS is begun and airway pressures are decreased, cardiac output increases and inotropic support can usually be weaned. VV bypass offers several advantages over VA bypass:
The avoidance of arterial cannulation eliminates potential arterial embolization and ischemia.
VV bypass eliminates need for arterial ligation or repair,
It preserves blood flow and improves oxygenation to pulmonary circulation with beneficial vasodilatory effect.
It produces no hemodynamic effects, particularly no increase in afterload.

Cannula Considerations

♦ During ECLS it is important to use a drainage (venous) cannula with the largest lumen and shortest length possible because venous drainage is achieved only by gravity siphon.
♦ In this system, if preload is adequate, the limiting factor determining maximum flow is cannula resistance, which is directly proportional to the length and inversely proportional to the fourth power of the luminal radius. This simple relationship becomes more complicated for devices that are not uniformly shaped.
♦ Cannula size is based on the outer diameter. Identically sized cannulas may vary in inner diameter according to the wall thickness of the material used.
♦ Venous cannulas generally have both end and side holes to allow flow even if the end of the cannula is occluded.
♦ Arterial cannulas generally have only end holes to prevent arterial injury from ejected blood.
♦ The cannula should resist kinking while remaining flexible and thin-walled to offer the least resistance possible.
♦ Wire-wound cannulas (e.g., Biomedicus) are resilient to kinking, whereas the thin-walled double-lumen cannulas are more prone to kink.
♦ Vascular access for ECLS in neonates is particularly challenging because of their small vessels. The route of access depends on the method used. VA bypass is indicated when both cardiac and pulmonary support is required and in neonates if access for VV support cannot be obtained (i.e., the vein is too small to accept a 12 French cannula).
♦ For VA access, the preferred site for venous drainage is the right atrium via the right internal jugular vein. The arterial infusion is directed at the aortic arch via the right common carotid artery.
♦ For VV access, a double-lumen cannula is placed into the right atrium via the right internal jugular vein. This technique is limited by the size of the vein because the smallest double-lumen VV cannula available is 12 French. For larger children (>10 kg), single-lumen cannulas may be placed into the right internal jugular vein and left or right femoral vein.
♦ Single-lumen cannulas are available in sizes ranging from 8 French for neonates to 29 French for adult-sized patients.
♦ Double-lumen cannulas are available in various sizes: 12 to 18 French (Origen Biomedical, Inc., Austin, TX) and 31 French (Avalon Laboratories, LLC, Rancho Dominguez, CA).

Selection of Technique

♦ The VA bypass requires an open technique for arterial ligation to prevent leakage around the cannula and possible distal embolization from flow past the cannula.
♦ In infants and small children, the carotid artery is usually safe to ligate distally without major sequelae.
♦ VV bypass can be performed via a percutaneous or open technique. Although jugular vein ligation is usually tolerated, there is evidence that it may produce high venous pressure, which can lead to cerebral ischemia.
♦ Because the size of the vessel in relation to the cannula is unknown, vessel disruption is a risk when percutaneous access is used. For this reason, our preferred method is the semi-open technique. This technique requires a small incision to see the size of the vein as an aid to selecting the correct cannula size (usually 12 or 15 French in a newborn).
♦ Cannula insertion can also be viewed through this incision if desired.
♦ With this technique, vessel ligation is not used; this has several advantages: cephalad flow into the cannula increases the amount of deoxygenated blood available to enter the bypass circuit, the vessel may remain patent after decannulation (and can be recannulated if needed), and kinking of the cannula at the vessel is reduced because the vessel is not fixed to the cannula with a ligature, which can act as a fulcrum around which the cannula kinks. Also, adjustment of cannula depth is much simpler.

Step 3: Operative Steps—Cannula Insertion for Neonatal ECLS

VV/VA Cannulation: Open Technique


♦ Vascular cannulation and decannulation are performed in the neonatal ICU with the patient under adequate sedation and neuromuscular blockade.
♦ Neuromuscular blockade is especially important in preventing the potentially lethal complication of an air embolus during introduction of the venous cannula.
♦ Heparin sodium (100 units/kg) is drawn up for subsequent administration.


♦ Local anesthesia is administered by infiltration of 1% lidocaine.


Position of Patient

♦ The patient is placed supine with the head turned to the left. A roll is placed transversely beneath the shoulders.
♦ The endotracheal tube is positioned to prevent kinking under the drapes during the procedure. This can be accomplished by using a piece of suction tubing split lengthwise and placed over the tube at the connector to prevent kinking.
♦ The chest, neck, and right side of the face are aseptically prepared and draped.


♦ A transverse cervical incision about 2 to 3 cm long is made one fingerbreadth above the clavicle over the lower aspect of the right sternocleidomastoid muscle.

Exposure of the Carotid Sheath

♦ The platysma muscle and subcutaneous tissues are divided with electrocautery, and the sternocleidomastoid muscle is exposed.
♦ Dissection is continued bluntly between the sternal and clavicular heads of the muscle.
♦ The omohyoid muscle will be seen superiorly. It may be necessary to divide the omohyoid muscle tendon to expose the carotid sheath. Two alternating self-retaining retractors are placed.

Dissection of the Vessels

♦ The carotid sheath is opened and the internal jugular vein, common carotid artery, and vagus nerve are identified and isolated.
♦ Manipulation of the vein should be minimized to avoid inducing spasm, which makes introduction of a large venous cannula difficult.
♦ There is often a branch on the medial aspect of the internal jugular vein, and this branch must be ligated. Ligatures of 2/0 silk are placed proximally and distally around the internal jugular vein. The common carotid artery lies medial and posterior and has no branches, which makes its dissection proximally and distally safe. Ligatures of 2/0 silk are also placed around the carotid artery. The vagus nerve should be identified.
♦ Once vessel dissection is completed, heparin (100 units/kg) is administered intravenously and 3 minutes allowed for circulation. During this waiting period, papaverine is instilled into the wound to enhance vein dilatation.


♦ For VA bypass, the arterial cannula is chosen (usually 10 French) and marked with a 2-0 silk ligature, left uncut, at a point that will allow the tip of the cannula to lie at the ostium of the brachiocephalic artery (about 2 to 2.5 cm).
♦ The venous cannula (usually 12 to 14 French) is similarly marked at a point equal to the distance from the venotomy to the right atrium (roughly 6 to 7 cm).
♦ An obturator is placed into the venous cannula to prevent blood from flowing out through the side holes during introduction into the vessel.
♦ The common carotid artery is ligated distally. Proximal control is obtained with the use of an angled ductus clamp.
♦ A transverse arteriotomy is made near the distal ligature. Full-thickness stay sutures of 6-0 polypropylene are placed on the proximal edge of the artery to prevent subintimal dissection during cannula insertion.
♦ Following arterial cannulation, a venotomy is performed in similar fashion. Gentle retraction of the caudal ligature around the vein precludes the need for a ductus clamp during venotomy and venous cannulation. Stay sutures are also not routinely necessary for venous cannulation.

Cannula Placement ( Fig. 2-1 )

♦ The cannulas are carefully placed into the artery and vein and secured using two circumferential 2-0 silk ligatures.
♦ A small piece of Silastic vessel loop can be left inside the ligatures to protect the vessels from injury during decannulation, when the ligatures are sharply divided. The ends of the marking ligatures are tied to the most distal circumferential ligature for extra security.
♦ Immediately after each cannula is secured, it is carefully de-aired via back-bleeding and filling with heparinized saline.
♦ For VV bypass, the double-lumen cannula is placed into the venotomy and advanced to place the tip in the mid-right atrium. It is crucial to maintain the arterial reinfusion (red) port anteriorly while securing for proper orientation to minimize recirculation.

Fig. 29-1 Surgeon’s view from head

Wound Closure

♦ The wound is irrigated with saline, and hemostasis is obtained. The skin is closed with continuous monofilament suture. The wound is dressed with gauze.
♦ The cannula is sutured to the skin with several 2-0 silk sutures; special attention should be directed to affixing the cannulas securely to the bed.

VV Cannulation: Semi-open Technique

Incision and Vein Exposure

♦ A transverse cervical incision approximately 1.5 to 2 cm long is made 2 cm above the right clavicle between the heads of the sternocleidomastoid muscle.
♦ The platysma is divided with electrocautery, and the anterior surface of the internal jugular vein is exposed with minimal dissection. The vessel is observed, and an appropriately sized VV ECMO cannula is selected.

Guidewire Placement ( Fig. 2-2 )

♦ The cannula skin exit position is selected so that the cannula will lie behind the right ear when the head is returned to the midline.
♦ The needle and catheter are placed through the skin 2 cm superior to the incision and into the internal jugular vein to enter either under the skin flap or just inside the incision. The needle is removed, and a 0.035-inch-diameter guidewire is advanced and the catheter withdrawn.
♦ A Teflon guiding obturator is placed over the guidewire into the vessel and right atrium. The skin exit is slightly enlarged with a scalpel.
♦ Fluoroscopy is very helpful to observe appropriate guide wire placement, as well as during dilation and cannula advancement.

Figure 2-2

Cannula Placement ( Fig. 2-3 )

♦ Heparin (100 units/kg) is administered and 3 minutes allowed for circulation.
♦ The selected cannula is advanced over the Teflon obturator into the vein under direct vision to confirm entrance into the vein.
♦ The arterial (red) port of the cannula must be directed anteriorly to allow the arterial blood to cross the tricuspid valve and minimize recirculation of circuit blood.
♦ The tip of the cannula is placed 6 to 8 cm from the skin.

Figure 2-3

Wound Closure and Cannula Fixation

♦ The relatively low venous pressure allows adequate hemostasis around the venotomy site without any ligature. This prevents kinking of the thin-walled cannula, which often occurs at the area of a ligature if it is used around the vessel.
♦ Repositioning of the cannula requires only removing the skin sutures, repositioning the cannula, and replacing skin sutures.
♦ The cannula is fixed to the skin with several 2-0 silk sutures. The incision is closed using a monofilament suture.


♦ After respiratory failure has resolved to allow ventilation without extracorporeal support, decannulation can be performed by removing the skin sutures, pulling the venous cannula, and holding pressure on the catheter exit site for 5 minutes or until bleeding stops.
♦ Care must be taken to remove the entire cannula rapidly to prevent air from entering the side holes while the end of the cannula remains in the vessel.

Cannula Insertion for Pediatric ECLS

♦ Children older than infants have different bypass needs, similar to those of adults. Vessels are larger and make more options available for access.
♦ VV bypass is still used preferentially for respiratory support. VA bypass is preferred for cardiac support, including postoperative patients who do not wean from cardiopulmonary bypass after heart surgery.
♦ Children who are not yet old enough to walk have very small femoral vessels that are unsuitable for use in bypass access. For this reason, in this group (weight less than 10 kg), a double-lumen cannula in the jugular vein for VV bypass or single cannulas in the jugular vein and carotid artery must be used for VA bypass.
♦ Occasionally a small child with respiratory failure has a jugular vein that is too small to allow a large enough double-lumen cannula for adequate flow on VV bypass and must be placed on VA bypass.

Venovenous Bypass

♦ As described, VV bypass in small children can be achieved using a double-lumen cannula either placed by a modified Seldinger technique, as described already, or entirely percutaneously if the vein is judged to be adequate to receive the cannula.
♦ Children who weigh more than 10 kg usually have large enough veins to use a two-cannula technique by placing cannulas in both the femoral and jugular veins.
♦ The selection of cannulas is again based on two criteria: (1) the largest cannula that the vein will accept based on judgment and (2) a large enough drainage cannula to allow for enough flow (100 mL/kg/min), which can be estimated by the M number provided by the manufacturer.
♦ The issue of which cannula to use for drainage and reinfusion has two options. The jugular vein cannula will often allow more drainage. If the end of this cannula is in the atrium and preload is adequate, it can drain until the atrium collapses around the cannula and the pump flow is interrupted by servoregulation. Flow is thought to be greater in this situation because the atrium is spherical compared with the cylindrical shape of the femoral or iliac vein. However, if pump blood is reinfused into the femoral vein cannula, recirculation is often significant. This may be due to the direction of blood draining into the right atrium from the inferior vena cava being directed preferentially into the jugular cannula before mixing occurs.
♦ Rich and colleagues showed that draining blood from the femoral cannula and reinfusing into the jugular cannula result in higher arterial saturation (i.e., oxygen delivery), even though the total flow achievable is less because recirculation is minimal.
♦ We prefer this method of bypass and try to use a femoral cannula that reaches the intrahepatic vena cava, which is large and does not collapse.

Venoarterial Bypass

♦ For cardiac failure, most pediatric patients are cannulated through the neck using the jugular vein and carotid artery by cutdown.
♦ Patients placed on bypass after cardiac surgery may use their cannulation sites in the chest that are used for cardiopulmonary bypass.

Cannula Insertion for Adolescent ECLS

Venovenous Bypass

♦ Cannulation for adolescent VV bypass uses two cannulas placed in the jugular and femoral veins. These cannulas can be placed safely by a percutaneous method. A large cannula (23 to 29 French) should be placed for drainage and a somewhat smaller cannula (21 to 23 French) for venous reinfusion.
♦ It is especially important for the drainage cannula to have side holes in addition to an end hole to maximize flow and allow flow to continue if the end becomes obstructed.
♦ An adult-sized double-lumen cannula has been introduced by Avalon Laboratories and is available in sizes up to 31 French, which is suitable for most adult patients, even those who are obese.
♦ Recirculation is a problem that can be solved as described in the preceding section on pediatric cannulation.

Venoarterial Bypass

♦ In adolescents VA bypass can be achieved using many different cannulation schemes.
Jugular vein to carotid artery bypass as used in infants has been used successfully and works well, especially for combined cardiac and pulmonary support. It provides very good perfusion to all branches of the aortic arch and distal aorta, but it increases afterload by increasing aortic pressure. Ligation of the cerebral artery may cause cerebral edema.
Jugular vein to femoral artery bypass provides adequate distal perfusion, but this approach can fail to perfuse the aortic arch in situations where the native cardiac function is good. If the blood ejected from the left ventricle is desaturated because of pulmonary dysfunction, the aortic arch might not receive well-oxygenated pump blood, and the result will be hypoxemia in the upper half of the body. This problem can be solved by adding an additional perfusion cannula to the venous circulation to create venoarteriovenous bypass, which increases oxygenation of the right ventricular blood much like VV bypass and provides the hemodynamic support of VA bypass. The increased afterload from VA bypass may prevent the failing left ventricle from ejecting blood and result in high left atrial pressure, causing pulmonary edema. This situation can be managed by draining blood from the left atrium into the venous side of the bypass circuit either from direct cannulation of the left atrium by thoracotomy or by catheter-based balloon atrial septostomy.
Arterial cannulation can be performed either percutaneously or by direct cutdown of the vessel. With either method, if the cannula is large enough to diminish flow, distal ischemia may result. Several methods of managing this type of ischemia have been described.
Placement of a distal perfusion catheter can be used with the open technique by placing a connector with a side port and placing small tubing directed into the vessel distally at the cutdown site. With the percutaneous technique, an arterial line can be placed into either the dorsalis pedis or posterior tibial artery by cutdown and the distal pressure measured. If the pressure is less than 50 mm Hg, the catheter can be perfused by a line from the perfusion limb of the circuit.
♦ Decannulation can be performed similarly to previously described methods for the vein (direct pressure for percutaneously placed line, ligation of the jugular vein for cutdown placement).
Arterial decannulation is more complicated. Direct pressure may be all that is needed for percutaneously placed arterial cannulas. The larger the cannula is in relation to the artery, the more likely that a pseudoaneurysm or arterial stenosis will result.
An alternative to this method is venous patch angioplasty, a technique used for removing arterial cannulas placed by cutdown. In this technique, the vessel is controlled by a clamp, and the cannula is removed. A diamond-shaped patch of vein is then sutured into the defect, which both closes the hole and prevents stricture at the repair site.

Transthoracic Cannulation

♦ In certain circumstances, cervical or femoral access for VA extracorporeal support is either not possible or not practical, particularly when treating patients who have not been weaned from cardiopulmonary bypass or who have undergone post-sternotomy resuscitation. In these circumstances direct cannulation of the arterial and venous system is performed using techniques and cannulas that are standardly used with cardiopulmonary bypass.
♦ Pursestring sutures of some sort are placed in the ascending aorta, usually directly in the right atrium, and brought through snares that allow the suture to be tightened around the cannula and secured, preventing leaking of blood around the cannula, and, in the case of the venous side, preventing entraining of air into the system.
♦ While in the operating room, the cannulas are usually lightly secured to the drapes or left lying on the field; it is critical to secure the cannulas in a more “permanent” fashion when providing more prolonged extracorporeal support, particularly for safety during transport. In general, this involves suturing the cannula to the chest wall at some point and then closing the wound with an artificial dressing usually made of some sort of plastic or elastic, with the cannulas exiting between the suture line between the material and the skin.
♦ If the patient becomes more lightly sedated and moves or attempts to breathe or cough, the sternal edges can separate and put tension on the cannulas, risking dislodgement. This can be prevented by either using continuous neuromuscular blockade or by using one or two heavy sutures or sternal wires to bridge the distance between the sternal edges. This prevents spreading of the distance between the edges if the patient coughs or fights the endotracheal tube. We have found this to provide more than adequate stabilization of the support apparatus and prefer it over neuromuscular blockade with their potential sequelae.

Step 4: Postoperative Care

♦ It is critical that the cannulas are well secured to the patient’s skin as well as to the bed so that tension does not pull on the cannula. Failure to adequately secure the cannula may cause malpositioning or inadvertent decannulation.
♦ The wound should be dressed with a dry, sterile dressing.

Step 5: Pearls and Pitfalls

♦ Cannulation of patients for ECMO can be quite challenging, and problems are frequently encountered. By adequately preparing the patient, complications can usually be avoided.
♦ Proper training and support of the surgeon performing these procedures will allow most of these problems to be managed without poor outcomes.

Difficulty Threading the Venous Cannula

♦ This type of difficulty can occur because the vein is too small, the catheter is too large, or there is a left-sided superior vena cava without an innominate vein.
♦ The clavicle or first rib can sometimes obstruct if the patient’s head is hyperextended or hyperrotated.
♦ Try to reposition the head. Also, severe mediastinal shift may be present with diaphragmatic hernia or pneumothorax or effusion.

Vein Division

♦ Especially in small newborns, it may be difficult to introduce the venous cannula. During attempts to do this, the vein may become divided, which will make further attempts to introduce the cannula more difficult.
♦ Vascular control is the primary goal, which is best done using a vascular clamp.
♦ Once vascular control has been achieved, placing a guidewire may be helpful to introduce the cannula.
♦ Placing stay sutures to provide traction during cannula placement will help.
♦ A ligature should be placed around the vein to tie in the cannula.
♦ At decannulation, a pursestring suture may be used to control bleeding.

Proximal Vein Lost in Mediastinum

♦ During a difficult venous cannulation, when the cannula does not thread easily, sudden loss of resistance may be due to division of the vein, which may invert into the mediastinum.
♦ Bleeding can be controlled by using direct pressure with a finger. If the vein end can be retrieved with a forceps, cannulation may be performed as above with vein division.
♦ Otherwise, if no other suitable vein is available for access, median sternotomy and access via a thoracic approach may be needed.
♦ If other access is available, control can almost always be achieved by suturing fascia to cover the hole where the vein was lost and applying direct pressure.

No Flow After Catheter Placement

♦ If there is no flow after placement of the cannula, the cannula and circuit tubing should be examined for kinking.
♦ Chest radiography or fluoroscopy should be used to assess the position of the venous cannula and reposition or replace as needed.

Intrathoracic Vein Perforation

♦ Sudden cessation of flow with hemodynamic instability is of concern for intrathoracic vessel perforation. This situation requires immediate median sternotomy and vascular repair, with subsequent open cannulation.


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Sinard JM, Merz SI, Hatcher MD, et al. Evaluation of extracorporeal perfusion catheters using a standardized measurement technique—the M-number. Trans Am Soc Artif Intern Organs . 1991;37:60-64.
Streltz LJ, Bej MD, Graziani LJ, et al. Utility of serial EEGs in neonates during extracorporeal membrane oxygenation. Pediatr Neurol . 1992;8:190-196.
1996 UK collaborative randomized trial of neonatal extracorporeal membrane oxygenation. UK Collaborative ECMO Trial Group. Lancet . 1996;348:75-82.
Walker LK, Short BL, Traystman RJ. Impairment of cerebral autoregulation during venovenous extracorporeal membrane oxygenation in the newborn lamb. Crit Care Med . 1996;24:2001-2006.
Section II
Head and Neck
CHAPTER 3 Thyroglossal Duct Cyst

Michael D. Josephs

Step 1: Surgical Anatomy

♦ Thyroglossal duct cyst traditionally manifests as a painless midline anterior cervical mass that often moves with swallowing ( Fig. 3-1 ).
♦ The cyst occasionally communicates with the skin as a draining sinus, and its tract always extends through the center of the hyoid bone to terminate at the tongue base ( Fig. 3-2 ). Operative extirpation of the entire cyst and sinus tract, including the involved portion of the hyoid bone, is critical to avoid a recurrence.
♦ The greater horns of the hyoid bone may be palpated bilaterally and moved side to side, which will result in cyst movement ( Fig. 3-3 ) and help to ensure a proper anatomic resection and avoid injuring the larynx.

Figure 3-1

Figure 3-2

Figure 3-3

Step 2: Preoperative Considerations

♦ The diagnosis of thyroglossal duct cyst is made by a history and physical examination, although an ultrasound may help to differentiate this lesion from a dermoid cyst, epidermoid cyst, or median ectopic thyroid. An extensive radiographic and laboratory evaluation is unnecessary.
♦ Surgical excision is indicated on identification and is easiest in the absence of infection. Most infections can be treated with oral antibiotics targeting Haemophilus influenzae , Staphylococcus aureus , and Staphylococcus epidermidis , but occasionally the abscess is medically refractory and requires drainage. Elective resection is then best reserved for a time when the wound has healed and the inflammation is minimized.

Step 3: Operative Steps

Anesthetic Induction

♦ General endotracheal intubation is preferred for safe airway management. Because of the possibility of digital palpation of the tongue base during the operation (see next comment), the endotracheal tube should be secured in a reliable fashion.
♦ A laryngeal mask airway (LMA) may also be considered, although its use is discouraged. Because the origin of the cyst’s tract must be ligated, the anesthesiologist or an assistant may need to insert a finger into the mouth to reflect the tongue base anteriorly. This maneuver would disrupt the seal on the LMA and hinder ventilation if the patient is not breathing spontaneously.


♦ The patient is placed supine with the neck extended. This is facilitated by placing a roll transversely behind the shoulders. The bed is then tilted into the reverse Trendelenburg position ( Fig. 3-4 ).
♦ Draping should allow easy access to the mouth if transoral palpation of the base of the tongue becomes necessary.

Figure 3-4


♦ The Sistrunk procedure remains the operation of choice for the management of thyroglossal duct cysts.
♦ A transverse incision is made directly over the mass and along a natural skin crease for improved cosmesis. Care should be taken to avoid entering the wall of the cyst.
♦ If previous drainage was required for an infected cyst, the skin may be quite adherent to the cyst. Excising a bit of adherent skin may be helpful.
♦ The length of the incision is usually limited to the diameter of the mass, although this length can be increased if additional exposure is required ( Fig. 3-5 ).
♦ Self-retaining retractors are generally not required and, if used, tend to necessitate a larger incision.
♦ The cyst is separated from the surrounding tissue nearly circumferentially, and the sinus tract to the hyoid bone is identified posteriorly and preserved ( Fig. 3-6 ).
♦ The strap muscles are reflected off the body of the hyoid adjacent to where it is penetrated by the sinus tract. The hyoid is dissected circumferentially on both sides and then divided with scissors or bone cutters just lateral to the penetrating sinus tract ( Fig. 3-7, A ).
♦ Dissection of the tract is continued proximally and cephalad toward its origin at the foramen cecum, where it is suture ligated ( Fig. 3-7, B ). This facilitates a complete en bloc resection.

Figure 3-5

Figure 3-6

Figure 3-7


♦ If the cyst wall is violated, then the wound is copiously irrigated ( Fig. 3-8 ).
♦ The platysma muscle is reapproximated using interrupted absorbable sutures. The subcutaneous tissue and skin are then closed by the surgeon’s method of choice. For this I prefer subdermal sutures of 4-0 Vicryl followed by 5-0 Monocryl subcuticular closure. Finally, a dry, sterile occlusive dressing is applied.
♦ If the surgical field remains dry, consideration can be given toward intraoperative administration of ketorolac in addition to the usual narcotic analgesics.

Figure 3-8

Step 4: Postoperative Care

♦ Narcotic analgesics are often required in the recovery room.
♦ Almost uniformly, patients can be discharged home on the day of surgery with oral narcotics, nonsteroidal anti-inflammatory agents, or both.

Step 5: Pearls and Pitfalls

♦ Despite the low incidence of carcinoma and recurrence, every effort should be made to resect the entire thyroglossal duct cyst and tract to prevent the development of these occurrences.
♦ Recurrent disease is related to incomplete resection and postoperative infection and can be managed by secondary Sistrunk operation with limited base-of-tongue resection, central neck dissection with core resection of the tongue base, or suture-guided transhyoid pharyngotomy.
♦ Although surgeons dislike reporting this, inadvertent resection of a portion of the thyroid cartilage or tracheal ring is a serious complication that must be avoided. Meticulous attention to and identification of anatomic landmarks, particularly the greater horns of the hyoid bone, ensure that this complication is averted.


Kaselas C, Tsikopoulos G, Chortis C, Kaselas B. Thyroglossal duct cyst’s inflammation. When do we operate? Pediatr Surg Int . 2005;1:991-993.
Ostlie DJ, Burjonrappa SC, Snyder CL, et al. Thyroglossal duct infections and surgical outcomes. J Pediatr Surg . 2004;39:396-399.
Perkins JA, Inglis AF, Sie KC, Manning SC. Recurrent thyroglossal duct cysts: a 23-year experience and a new method for management. Ann Otol Rhinol Laryngol . 2006;115:850-856.
Tracy TFJr, Muratore CS. Management of common head and neck masses. Semin Pediatr Surg . 2007;16:3-13.
CHAPTER 4 Branchial Anomalies

Tory A. Meyer

Step 1: Surgical Anatomy

♦ The course of branchial cysts, sinuses, and fistulas depend on the branchial arch from which they are derived (first, second, third, or fourth).
♦ The extent of branchial anomalies varies considerably, from small sinuses or cysts limited to the subcutaneous tissue ( Figs. 4-1 and 4-2 ) to large inflammatory masses extending to the pharynx.
♦ First branchial anomalies appear in the preauricular or submandibular area and may course through the parotid gland, insinuate around the facial nerve trunk or branches, and connect to the external auditory canal.
♦ Second branchial anomalies are seen along the anterior border of the sternocleidomastoid muscle and may ascend through the deep tissues of the neck above the hyoid, between the internal and external carotid arteries, adjacent to the hypoglossal and glossopharyngeal nerves, and terminate in the tonsillar fossa or other nasopharyngeal areas.
♦ Although the theoretical course of third and fourth branchial anomalies has been described as descending into the mediastinum, this course has not been noted in vivo. These rare lesions have more recently been described by their pharyngeal terminus as pyriform fossa sinuses. Externally they may be evident along the anterior border of the sternocleidomastoid, usually on the left side of the neck, and pass through the thyroid, posterior to the internal carotid, adjacent to the recurrent laryngeal nerve, through the inferior constrictor muscle, and connecting to the pyriform fossa.
♦ Branchial anomalies may contain keratinizing or nonkeratinizing squamous epithelium or pseudostratified columnar respiratory epithelium.

Figure 4-1

Figure 4-2

Step 2: Preoperative Considerations

♦ Most common initial signs of branchial anomalies are an asymptomatic cystic mass, chronically draining sinus, or recurrently infected lesion of the neck.
♦ Occasionally it may manifest in infants with respiratory distress or stridor resulting from the swelling of cyst, impinging on the airway.
♦ Sinuses of the pyriform fossa may manifest as recurrent neck abscesses or acute thyroiditis.
♦ Preoperative imaging may help distinguish a branchial anomaly from other lesions, such as a cystic hygroma, lymphoma, neurofibromatosis, lymphadenopathy, carotid body tumor, tuberculous adenitis, lipoma, hemangioma, thyroglossal duct cyst, ectopic thyroid, thymic cyst, or a dermoid.
♦ Ultrasound or computed tomography scan with intravenous contrast may demonstrate gas in a cystic structure and may be useful to delineate the course of the lesion and possible thyroid involvement.
♦ Barium swallow may show the origination and extent of fistula or sinus.
♦ Antibiotics (with drainage, if necessary) should be administered until clinical signs of infection have resolved and before removal to minimize risks of complications and recurrence.
♦ Removal of a branchial anomaly before repeat infections will aid dissection in clean surgical planes.
♦ Goal of surgery is complete excision to prevent recurrence.
♦ Laryngoscopy or telescopic pharyngoscopy is useful for identification or cannulation of a pharyngeal fistula.
♦ Recent studies suggest that chemical or thermal cauterization of the internal opening may be adequate treatment for pyriform fossa sinus anomalies.
♦ Resection of all but the simplest anomalies limited to the subcutaneous tissue should be done with the patient under general anesthesia with an endotracheal tube rather than a laryngeal mask airway.

Step 3: Operative Steps

First Branchial Anomalies

♦ Intraoperative facial nerve monitoring should be considered.
♦ Injection of the tract through the external auditory canal with methylene blue or instrumentation with a small probe facilitates tract identification.
♦ A preauricular cervicomastoid incision is made and may be extended as necessary.
♦ The superficial lobe of the parotid is mobilized with clear identification of the facial nerve as it emerges from the stylomastoid foramen and enters the parotid.
♦ Lateral parotidectomy may be necessary to see the nerve and branchial anomaly adequately.
♦ The cyst is dissected free from surrounding tissues and the tract followed along its course, which may be posterior to the parotid (type I), or intraparotid (type II) ( Fig. 4-3 ). The tract may ultimately connect with the external auditory canal.
♦ A segment of the external auditory canal, including skin and cartilage, is taken with the cyst. The external auditory canal wound may be packed open.
♦ The wound is closed in layers with a subcuticular skin closure and appropriate dressing applied.

Figure 4-3

Second Branchial Anomalies

Large Cysts

♦ With the neck extended, large cysts are approached through an oblique neck incision following Langer lines along the superior portion of the swelling (see Fig. 4-5 ).
♦ The cyst is freed up circumferentially, paying careful attention to the jugular and carotid vessels and the hypoglossal nerve (XII) posteriorly.
♦ The facial vein and branches of the jugular vein may be ligated as necessary.
♦ If a tract is present, it should be freed up from attachments as it courses over the hypoglossal nerve (XII), between the internal and external carotid arteries, beneath the posterior belly of the digastric muscle, and over the glossopharyngeal nerve (IX) to enter the pharynx in the tonsillar fossa.
♦ The tract is suture ligated at the level of the pharynx with absorbable suture.
♦ The wound is closed in layers, and a drain is not usually necessary.

Figure 4-5

Fistulas and Small Cysts

♦ With the neck extended, a small transverse elliptical incision is made around the skin opening in the lower neck.
♦ A small probe or Prolene suture may be passed along the course of the tract and into the pharynx to help with identification of the tract. The suture can be tied to a wad of gauze and used for traction on the tract.
♦ As the tract ascends in the neck, it is dissected free from surrounding tissues as far superiorly as possible, at which time an additional transverse incision is made (stair-step incision) and the fistulous remnant is delivered through this more superior wound ( Fig. 4-4 ).
♦ This process is repeated until the tract turns into the deep tissues, at which point the incision may need to be extended to allow deeper dissection.
♦ Similar to large second branchial cysts, dissection continues around the fistulous tract, paying careful attention to preservation of the hypoglossal and glossopharyngeal nerves at the lower margin and the branches of the carotid arteries medially and laterally ( Fig. 4-5 ).
♦ The fistulous tract is ligated at the level of the pharynx with absorbable suture, and the wounds are closed and dressed.

Figure 4-4

Third and Fourth Branchial Anomalies (Pyriform Fossa Sinus Tracts)

♦ The traditional approach is open excision of the entire fistulous tract; however, recent studies have shown that cauterization of the pyriform sinus opening alone can be effective.

Open Operation

♦ With the neck extended, direct laryngoscopy is performed to identify the sinus tract opening in the pyriform sinus.
♦ A Fogarty catheter is inserted into the sinus and secured to aid with identification of the tract ( Fig. 4-6 ).
♦ If an external opening is present, it may be injected with methylene blue or instrumented with a lacrimal duct probe to facilitate identification during dissection.
♦ A generous oblique neck incision is made at the level of the thyroid cartilage.
♦ The strap muscles are retracted, and the cyst or tract is dissected circumferentially to the thyroid gland, through which it passes.
♦ Resection of the lateral portion of the thyroid or a thyroid lobectomy is performed to include the fistulous tract.
♦ The recurrent laryngeal nerve is clearly identified and preserved because the course of the fistula may be parallel to the recurrent laryngeal nerve.
♦ The superior parathyroid gland is identified and preserved.
♦ The most commonly seen tract courses superiorly into the pyriform sinus.
♦ Alternatively, the tract is followed superior to the hypoglossal nerve and posterior to the carotid. It will pass superior or inferior to the superior laryngeal nerve, depending on its cause as a third or fourth branchial anomaly, respectively.
♦ The tract is then dissected as it courses inferiorly, anterior, or lateral to the recurrent laryngeal nerve, then piercing the inferior constrictor muscle at the level of the base or apex of the pyriform sinus.
♦ A portion of the thyroid cartilage may be removed, or the inferior constrictor may be opened to adequately view this portion of the tract.
♦ Using absorbable suture, the tract is closed where it enters the pyriform sinus.
♦ The wound is closed in layers, and a drain is not generally necessary.

Figure 4-6

Endoscopic Sinus Cauterization

♦ Cauterization may be performed at the time of drainage of neck abscess or subsequently when acute infection has resolved.
♦ Laryngoscopy is used to visualize the pyriform sinus ( Fig. 4-7 ).
♦ A small Fogarty catheter is passed into the opening of the sinus, and the tract is dilated enough to allow passage of a coagulating instrument into the opening.
♦ An insulated probe or ball coagulating tip is passed into the sinus opening and activated on low power till tissue blanching occurs.
♦ The superficial portion of the opening is coagulated again to ensure closure of the tract.
♦ To prevent perforation of the hypopharynx, avoid overcoagulation.

Figure 4-7

Step 4: Postoperative Care

♦ Recurrence is much more likely if the pathology specimen does not contain an epithelium-lined tract.
♦ Long-term follow-up is necessary to monitor for recurrence.

Step 5: Pearls and Pitfalls

♦ Infection should be treated before surgical intervention for removal of branchial anomalies.
♦ Mastery of the anatomy of the neck and possible courses of these anomalies are essential for successful resection.
♦ Complete surgical extirpation is the traditional approach for preventing recurrence.
♦ Complications include injury to the hypoglossal, glossopharyngeal, vagus, superior laryngeal, and recurrent laryngeal nerves. In addition, injury to the carotid or jugular vessels and formation of a pharyngocutaneous fistula may occur.
♦ Although the long-term recurrence rate is not well established, endoscopic sinus cauterization may be adequate treatment for pyriform sinus anomalies (third and fourth branchial anomalies) with a lower complication rate.


Acierno SP, Waldhausen JHT. Congenital cervical cysts, sinuses, and fistulas. Otolaryngol Clin North Am . 2007;40:161-176.
Houck J. Excision of branchial cysts. Operative Techn Otolaryngol . 2005;16:213-222.
James A, Stewart C, Warrick P, Tzifa C, Forte V. Branchial sinus of the piriform fossa: reappraisal of third and fourth branchial anomalies. Laryngoscope . 2007;117(11):1920-1924.
Jordan JA, Graves JE, Manning SC, McClay JE, Biavati MJ. Endoscopic cauterization for treatment of fourth branchial cleft sinuses. Arch Otolaryngol Head Neck Surg . 1998;124(9):1021-1024.
Liberman M, Kay S, Emil S, et al. Ten years’ experience with third and fourth branchial remnants. J Pediatr Surg . 2002;37:685-690.
Pereira KD, Davies JN. Piriform sinus tracts in children. Arch Otolaryngol Head Neck Surg . 2006;132:1119-1121.
Sai Prasad TR, Chong Cl, Mani A, et al. Acute suppurative thyroiditis in children secondary to pyriform sinus fistula. Pediatr Surg Int . 2007;23(8):779-783.
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Section III
CHAPTER 5 Esophageal Atresia with Tracheoesophageal Fistula

Richard Ricketts

Step 1: Surgical Anatomy

♦ The proximal esophagus will be of variable length, and the distal tracheoesophageal fistula (TEF) is usually at or slightly above the carina.
♦ The vagus nerve courses along the trachea, tracheoesophageal groove, and the distal esophagus ( Fig. 5-1 ).
♦ The proximal esophagus receives its blood supply from the thyroid arteries, and the distal esophagus from segmental branches directly off the aorta.

Figure 5-1

Step 2: Preoperative Considerations

♦ The diagnosis is frequently established in utero because of associated maternal polyhydramnios.
♦ The neonate may present with coughing, drooling, and respiratory distress shortly after delivery.
♦ Infants with pure esophageal atresia (EA) will be scaphoid because of absence of gas in the gastrointestinal tract.
♦ Neonates with a TEF may become distended, especially if they are placed on positive pressure ventilation.
♦ A babygram radiograph with a tube in the upper pouch establishes the diagnosis of EA or EA-TEF in a vast majority of neonates ( Fig. 5-2 ). Contrast studies are rarely required.
♦ One must evaluate the baby for the VACTERL complex.
V ertebral: Spine films
A norectal: Physical examination for patent anus
C ardiac: Echocardiogram to evaluate cardiac anatomy as well as identify position of the aortic arch. Surgical approach through the right or the left side of the chest is determined by the side of the aortic arch. In general, the arch is on the left and access for repair is through the right side of the chest.
TE : Plain babygram radiograph with a catheter (bougie or nasogastric [NG]) in upper pouch is sufficient. Many surgeons routinely perform a rigid bronchoscopy as part of the operative procedure before proceeding with the repair to assess for a possible proximal TEF.
R enal: Ultrasound
L imb: Physical examination for radial hypoplasia ( Fig. 5-3 )
♦ The distance between the two ends of the esophagus can be estimated by placing a blunt tipped bougie (Hurst dilator or small chest tube) into the upper pouch (with mild downward pressure) and taking a chest x-ray; assume that the distal esophagus is at or slightly above the level of the carina. In patients with pure EA who have already had a gastrostomy tube placed, instilling contrast into the stomach during the same maneuver will demonstrate the level of the distal esophagus ( Fig. 5-4 ).
♦ The timing of repair depends on the infant’s size and condition:
Primary repair : Infant has no significant cardiac or pulmonary problems and weighs more than 1000 g.
Delayed primary repair
• Infant weighs less than 1000 g
Support with total parenteral nutrition (TPN) or G-tube feeds
Constant suction on upper pouch
• Short-term cardiac or pulmonary problems (pneumonia) that can be resolved in 2 to 3 weeks
• “Long gap”
TPN or G-tube feeds and bouginage with suction on upper pouch
Staged repair : Divide TEF and repair EA later
• Extremely premature infant
• Severe pneumonia
• Requirement for high-pressure ventilation
• Complex congenital heart disease (CHD) with cardiac decompensation (cyanotic CHD)
Esophageal substitution : Cervical esophagostomy with substitution at a later date
• Extremely long gap (EA with no distal esophagus in chest and upper pouch at the thoracic inlet)
• Failed repair

Figure 5-2

Figure 5-3

Figure 5-4

Step 3: Operative Steps

Anesthetic Considerations

♦ End of the endotracheal tube should be in the midtrachea to reduce likelihood of intubating the distal TEF.
♦ Use low ventilatory pressures to minimize distention of the stomach.


♦ The infant is placed in an extreme lateral decubitus position (almost prone) with the side opposite the aortic arch up ( Fig. 5-5 ).

Figure 5-5

Incision and Access

♦ The incision extends from just below the tip of the scapula posteriorly to a point midway between the scapula and vertebral column ( Fig. 5-6 ).
♦ The 4th intercostal space is entered; the serratus anterior muscle is spared.
♦ An extrapleural approach is used. The plane is developed with a freer elevator initially and then with moistened “micro-Kittner” dissectors (folded neuropatties on a mosquito clamp) until a small Finochietto retractor can be placed.
♦ The parietal pleura is rolled off the azygos vein, which is then divided between suture ligatures. The TEF will usually be located at or slightly above the level of the azygos vein.
♦ The TEF, distal esophagus, vagus nerve, and proximal esophagus are then identified, and a determination is made about the feasibility of primary repair.

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