Atlas of Pediatric Surgical Techniques E-Book

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Description

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 expertconsult.com.
  • 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)


Sujets

Livres
Savoirs
Medecine
Médecine
Vómito
Surgical incision
Acute infectious thyroiditis
Ganglioneuroblastoma
Stoma (disambiguation)
Colon cleansing
Pyloromyotomy
Surgical suture
Emphysema
Bariatric surgery
Choledochal cysts
Hydrocolpos
Branchial cleft cyst
Neurogenic bladder
Cholangitis
Urinary diversion
Sacrococcygeal teratoma
Hepatectomy
Abdominal distension
Annular pancreas
Imperforate anus
Atresia
Herniorrhaphy
Congenital diaphragmatic hernia
Neuroblastoma
Pulmonary sequestration
Pediatric surgery
Ileostomy
Hydrocele
Epidermoid cyst
Neoplasm
Gastroschisis
Abdominal wall defect
Indometacin
Thoracotomy
Urinary retention
Splenomegaly
Tracheoesophageal fistula
Polyhydramnios
Cholangiocarcinoma
Inguinal hernia
Cholangiography
Orchiopexy
Trauma (medicine)
Gastric bypass surgery
Thyroglossal cyst
Pyloric stenosis
Nissen fundoplication
Biliary atresia
Pulmonary hypertension
Rectal prolapse
Hypertrophy
Abdominal pain
Hemolytic anemia
Rectal examination
Patent ductus arteriosus
Wilms' tumor
Mitral valve prolapse
Review
Physician assistant
Splenectomy
Fluoroscopy
Cryptorchidism
Weight loss
Childcare
Idiopathic thrombocytopenic purpura
Laparotomy
Echocardiography
Biopsy
Cannula
Anastomosis
Bowel obstruction
Congenital disorder
Cauterization
Hirschsprung's disease
Testicular cancer
Testicular torsion
Heart failure
Tetralogy of Fallot
Fistula
Gastroesophageal reflux disease
Cyst
Esophageal atresia
Fecal incontinence
Esophagus
Dehydration
Medical ultrasonography
Anemia
Electrocardiography
Hernia
Appendicitis
Laparoscopy
Intestine
Obesity
Diarrhea
Pneumonia
X-ray computed tomography
Cystic fibrosis
Philadelphia
Atlas (anatomy)
Stomach
Urinary tract infection
Radiation therapy
Pediatrics
Meconium
Mechanics
Magnetic resonance imaging
General surgery
Major depressive disorder
Down syndrome
Chemotherapy
Breast
ECMO
Acétylcystéine
Pneumothorax
Bypass
Intussusception
Dissection
Small
Reflux
Electronic
Torsion
Concise
Thorax
Ligature
Copyright
Colon

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Date de parution 22 septembre 2010
Nombre de lectures 3
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
S a u n d e r sForthcoming 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, MDFront Matter
Atlas of Pediatric Surgical Techniques
A Volume in the Surgical Techniques Atlas Series
Editors
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 ResearchDepartment of Surgery
Markey Cancer Foundation Endowed Chair
Director, Markey Cancer Center
University of Kentucky
Lexington, KentuckyCopyright
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: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under
copyright by the Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this 5eld 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 identi5ed, 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 Contributors
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 MedicineHouston, 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 CincinnatiCincinnati, 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 CarolinaRonald 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 ResearchFellow
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 SurgeryDell 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 PediatricsSection 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, MissouriRobert 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 SurgeryCincinnati 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, GeorgiaD e d i c a t i o n
To our families
Kimberleye, Camryn, Kaley, Elizabeth
And all infants and children we care for&
$
$
Foreword
“A picture is worth a thousand words.”
—Anonymous
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
stepby-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
bene t of the patient. A technically perfect operation is the key to this success.
Speed in operation comes from having a plan and devoting su cient time to
completion of each step in order, one time. The surgeon must be dedicated to
spending the time to do it right the rst 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.”
—Anonymous
COURTNEY M. TOWNSEND, JR., MD, B. MARK. EVERS,
MD!
!
Preface
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 re ning 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 eld, 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.
DAI H. CHUNG, MD, MIKE K. CHEN, MDTable of Contents
Instructions for online access
Forthcoming Volumes in the Surgical Techniques Atlas Series
Front Matter
Copyright
Contributors
Dedication
Foreword
Preface
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 RepairChapter 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
LaparoscopicAssisted) 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
IndexSection I
GeneralCHAPTER 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 1-1Figure 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 signalthat 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 1-4Figure 1-5
Figure 1-6
Figure 1-7
4 Access by Anatomic Site
Neck
♦ The available sites in the neck include the internal jugular and external veins (Fig.
18). 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 mildextension, 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 whenplacing 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 theshoulder (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 AccessRadial 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
24gauge 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 acompressed 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.
Bibliography
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. 1992CHAPTER 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 for3 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. Althoughjugular 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
Preoperative
♦ 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.
Anesthesia
♦ Local anesthesia is administered by infiltration of 1% lidocaine.
Operation
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 splitlengthwise 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.
Incision
♦ 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
selfretaining 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.
Arteriotomy/Venotomy
♦ 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 pointequal 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
backbleeding 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.
Decannulation
♦ 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
doublelumen 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.