Closure of a Patent Ductus Arteriosus
Patients with an isolated patent ductus arteriosus are candidates for thoracoscopic closure. Position and draping of the patient are similar to the open procedure. Three ports are utilised; two 5 mm ports below and behind the tip of the scapula for the in
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Closure of a Patent Ductus Arteriosus Kari Vanamo
21.1
Operation Room Setup
Surgical Team Position
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Chapter 21 Closure of a Patent Ductus Arteriosus
21.2
Patient Positioning
Right lateral position with bent table/support under the right chest to open the left intercostals spaces; left shoulder in 90° of flexion and freely movable.
21.4
Location of Access Points
Port Placement Sites
21.3
• • • •
Special Instruments
Cotton swabs Nerve hooks Dissection hook Endoscopic clip applicator
Kari Vanamo
21.5
Indications
21.6
Contraindications
1. Isolated symptomatic patent ductus arteriosus (PDA) after failure of indomethacin treatment. 2. PDA with contraindications to medical therapy. 3. Asymptomatic PDA in older infants with the aim of preventing infective endocarditis.
1. High-pressure open PDA. 2. PDA associated with other congenital heart defects requiring surgery. 3. Prematurity or small size (relative contraindication). 4. Inability to withstand lung retraction.
21.7
21.8
Preoperative Considerations
Technical Notes
1. Care should be taken to ensure that the clip is in the clip applicator because the empty applicator can act as a pair of scissors if the clip has fallen out. 2. Normothermia and proper attention to ventilation are imperative, especially in neonatal patients. 3. For PDA repair in the infant, either an operating room or a portable operating room in the neonatal intensive care unit may be sufficient to perform the procedure.
1. Single-lung ventilation or carbon dioxide insufflation is not used routinely. A fourth incision anteriorly may be required for additional retraction of the lung to increase visibility. 2. The vagus and recurrent laryngeal nerves should be handled with extreme care and manipulation avoided if possible 3. Two clips are preferred. Inappropriate clip application could cause injury to the recurrent laryngeal nerve or the ductus wall. 4. Chest drain is not necessary; if placed it could be removed once the pleural cavity has been evacuated.
21.9
21.10 Thoracoscopic Closure of a Patent Ductus Arteriosus
Procedure Variations
1. Bimanual dissection is feasible. However, this usually requires a fourth incision. 2. In the presence of a large ductus, ligation may be preferred prior to clip application. 3. Monitoring the left laryngeal nerve is feasible and advocated. 4. In older children, transesophageal echocardio graphy can be utilized to demonstrate the complete interruption of ductal flow in real time during the procedure.
Please see Figs. 1–6.
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Chapter 21 Closure of a Patent Ductus Arteriosus
Figure 21.1
The posterior pleura overlying the aorta is incised with an electrocautery hook from the base of the left subclavian artery toward the ductus arteriosus
Figure 21.3
The upper and lower margins of the duct are dissected free, but no attempt is made to circumvent the ductus
Figure 21.2
The medial pleural leaf is retracted with nerve hooks and separated from the aorta using blunt dissection and electrocautery
Figure 21.4
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