# Laparoscopic Neonatal and Abdominal Surgery — GCMD Library living collection

Updated: n/a · 23 episodes · 161 cited statements

## Episodes
### Intestinal atresia, malrotation and duplication
- [Laparoscopic Jejunal Atresia Repair - Technique](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748) — video · 5:55 · [machine version](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748.md)
- [Technique: Laparoscopic Repair of Duodenal Atresia, Ladd's Procedure, and...](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761) — video · 15:01 · [machine version](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761.md)
- [Lap DA Stapled 1.5 Kg](https://qa.library.globalcastmd.com/watch/lap-da-stapled-1-5-kg-11930) — video · [machine version](https://qa.library.globalcastmd.com/watch/lap-da-stapled-1-5-kg-11930.md)
- [Malrotation Infant](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940) — video · 9:22 · [machine version](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940.md)
- [Malrotation and Volvulus with Trinity](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941) — video · 8:02 · [machine version](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941.md)
- [Laparoscopic Intestinal Duplication Cyst Repair - Technique](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750) — video · 4:58 · [machine version](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750.md)

### Hirschsprung disease and anorectal malformation
- [Technique: Laparoscopic Assisted Pull-through for Hirschsprung's Disease](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760) — video · 10:48 · [machine version](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760.md)
- [Technique: Laparoscopic-Assisted Pull-through for Imperforate Anus](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762) — video · 15:14 · [machine version](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762.md)

### Appendectomy
- [Technique: Laparoscopic Appendectomy (Two incision)](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-appendectomy-757) — video · [machine version](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-appendectomy-757.md)
- [Mini lap appy](https://qa.library.globalcastmd.com/watch/mini-lap-appy-11943) — video · 4:50 · [machine version](https://qa.library.globalcastmd.com/watch/mini-lap-appy-11943.md)
- [Narrated Dipes appy](https://qa.library.globalcastmd.com/watch/narrated-dipes-appy-11946) — video · 3:23 · [machine version](https://qa.library.globalcastmd.com/watch/narrated-dipes-appy-11946.md)
- [Retrograde appy](https://qa.library.globalcastmd.com/watch/retrograde-appy-11958) — video · [machine version](https://qa.library.globalcastmd.com/watch/retrograde-appy-11958.md)

### Bowel resection and anastomosis
- [Trinity Ileal resection w narration](https://qa.library.globalcastmd.com/watch/trinity-ileal-resection-w-narration-11976) — video · 10:50 · [machine version](https://qa.library.globalcastmd.com/watch/trinity-ileal-resection-w-narration-11976.md)
- [NEC small bowel stricture](https://qa.library.globalcastmd.com/watch/nec-small-bowel-stricture-11945) — video · 7:47 · [machine version](https://qa.library.globalcastmd.com/watch/nec-small-bowel-stricture-11945.md)
- [open bowel anast stapled](https://qa.library.globalcastmd.com/watch/open-bowel-anast-stapled-11991) — video · [machine version](https://qa.library.globalcastmd.com/watch/open-bowel-anast-stapled-11991.md)
- [open bowel anast](https://qa.library.globalcastmd.com/watch/open-bowel-anast-11992) — video · [machine version](https://qa.library.globalcastmd.com/watch/open-bowel-anast-11992.md)

### Solid organs, biliary, vascular and tumors
- [Liver Bx JRS](https://qa.library.globalcastmd.com/watch/liver-bx-jrs-11934) — video · [machine version](https://qa.library.globalcastmd.com/watch/liver-bx-jrs-11934.md)
- [Narrated R Adrenal Coolseal](https://qa.library.globalcastmd.com/watch/narrated-r-adrenal-coolseal-11947) — video · 8:34 · [machine version](https://qa.library.globalcastmd.com/watch/narrated-r-adrenal-coolseal-11947.md)
- [Neuroblastoma Paracaval](https://qa.library.globalcastmd.com/watch/neuroblastoma-paracaval-11948) — video · [machine version](https://qa.library.globalcastmd.com/watch/neuroblastoma-paracaval-11948.md)
- [MALS with Trinity](https://qa.library.globalcastmd.com/watch/mals-with-trinity-11938) — video · 7:09 · [machine version](https://qa.library.globalcastmd.com/watch/mals-with-trinity-11938.md)

### Hernia, continence procedures and small-access surgery
- [RIH CK needle](https://qa.library.globalcastmd.com/watch/rih-ck-needle-11952) — video · [machine version](https://qa.library.globalcastmd.com/watch/rih-ck-needle-11952.md)
- [Robotic hernia repair](https://qa.library.globalcastmd.com/video/11960) — article · [machine version](https://qa.library.globalcastmd.com/video/11960.md)
- [Malone & Mitrofanoff NCH](https://qa.library.globalcastmd.com/watch/malone-mitrofanoff-nch-11939) — video · 5:13 · [machine version](https://qa.library.globalcastmd.com/watch/malone-mitrofanoff-nch-11939.md)

## Chapters
- [0:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=0) Patient positioning and port placement (Ep 7)
- [1:15](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=75) Laparoscopic mesenteric dissection to pelvic floor (Ep 7)
- [4:35](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=275) Timing of surgery and completion of laparoscopic phase (Ep 7)
- [5:10](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=310) Transanal dissection and mucosal plane development (Ep 7)
- [7:46](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=466) Muscular cuff division and colon mobilization (Ep 7)
- [8:57](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=537) Coloanal anastomosis and postoperative course (Ep 7)
- [0:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=0) Patient positioning, trocar placement, and initial mesenteric mobilization technique (Ep 8)
- [2:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=120) Fistula dissection and division at bladder neck level (Ep 8)
- [6:09](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=369) Completion of laparoscopic mobilization (Ep 8)
- [7:29](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=449) Perineal dissection and pull-through using nerve stimulation guidance (Ep 8)
- [11:10](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=670) Anastomosis creation and presacral fixation (Ep 8)
- [0:00](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=0) Case presentation and initial findings (Ep 5)
- [0:59](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=59) Division of Ladd's bands and reduction of volvulus (Ep 5)
- [4:29](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=269) Complete bowel run and mesenteric base widening (Ep 5)
- [6:49](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=409) Final bowel run and appendectomy (Ep 5)
- [0:00](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=0) Case presentation and room setup (Ep 4)
- [0:47](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=47) Initial dissection and proximal duodenal mobilization (Ep 4)
- [2:56](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=176) Division of Ladd bands and colonic mobilization (Ep 4)
- [5:18](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=318) Posterior duodenal mobilization and straightening (Ep 4)
- [7:31](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=451) Bowel derotation (Ep 4)
- [8:46](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=526) Appendectomy and final positioning (Ep 4)
- [0:00](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=0) Case presentation and patient positioning (Ep 1)
- [1:30](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=90) Port placement and initial exploration (Ep 1)
- [3:00](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=180) Bowel examination and apple peel defect confirmation (Ep 1)
- [4:00](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=240) Resection of dilated proximal segment (Ep 1)
- [5:00](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=300) Anastomosis creation and procedure completion (Ep 1)
- [0:00](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=0) Case presentation and initial exploration (Ep 6)
- [1:30](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=90) Bowel division and mesenteric dissection (Ep 6)
- [3:00](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=180) Anastomosis creation and closure (Ep 6)
- [4:30](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=270) Specimen extraction and outcomes (Ep 6)
- [0:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=0) Room Setup, Port Placement, and Initial Exposure (Ep 2)
- [3:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=180) Takedown of Ladd's Bands and Bowel Derotation (Ep 2)
- [6:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=360) Duodenoduodenostomy: Enterotomies and Anastomosis (Ep 2)
- [12:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=720) Resection of Meckel's Diverticulum and Appendix (Ep 2)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- The key to mesenteric dissection is staying exactly adjacent to the colon wall to prevent injury to surrounding structures. (clinical) [Ep 7 · 1:21](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=81)
- Because all heat and energy remains between the jaws of the sealer, there is no danger in injuring surrounding structures by brushing aside them with the sealer. (clinical) [Ep 7 · 1:32](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=92)
- Small perforating vessels are grasped, sealed, and then pulled down off the rectal wall during circumferential dissection. (clinical) [Ep 7 · 1:48](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=108)
- Dissection at the peritoneal reflection uses the same technique of grasping the peritoneal reflection and small perforating vessels and pulling them down off the colon. (clinical) [Ep 7 · 2:10](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=130)
- The 3 millimeter sealer allows dissection of vessels and mobilization of tissue around the colon without risk of pass-pointing, unlike the 3 millimeter hook which was previously the preferred mode of dissection. (clinical) [Ep 7 · 2:32](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=152)
- Using the 3 mm sealer eliminates the need for instrument changes with the right hand throughout the case. (clinical) [Ep 7 · 2:55](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=175)
- Carrying the laparoscopic dissection down to the pelvic floor limits the amount of transanal dissection necessary and decreases the risk of injury to the external sphincter. (clinical) [Ep 7 · 3:24](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=204)
- Because there is no energy spread from the tips of the 3 mm sealer, it is safe for the instrument to be adjacent to the bladder, vagina, prostate, and other surrounding structures. (clinical) [Ep 7 · 3:42](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=222)
- Energy being only between the jaws of the instrument diminishes the risk of injury to the ureters, vas deferens, and other vital structures. (clinical) [Ep 7 · 4:05](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=245)
- The preferred timing is to perform this operation in the newborn period prior to discharge to home, though it is acceptable if the child tolerates rectal irrigations to let them grow. (opinion) [Ep 7 · 4:35](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=275)
- With current technology, the operation is considered extremely safe in the newborn period. (opinion) [Ep 7 · 4:45](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=285)
- For the transanal dissection, traction stitches are placed inside the anus just proximal to the dentate line and then out to the skin, slightly inverting the anus so the dentate line can be clearly visualized. (clinical) [Ep 7 · 5:13](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=313)
- Between 4 to 8 sutures are used to evert the anus. (clinical) [Ep 7 · 5:38](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=338)
- A mucosal incision is made with hand cautery 2 to 3 millimeters proximal to the dentate line and crypt. (clinical) [Ep 7 · 5:53](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=353)
- The key to the transanal portion is that it should all take place externally to the anus. (clinical) [Ep 7 · 6:28](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=388)
- The laparoscopic dissection down to the pelvic floor allows the transanal dissection to be carried out outside of the anus, so no retractors are ever placed within the external sphincter which may cause these muscles to be damaged. (clinical) [Ep 7 · 6:36](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=396)
- Sharp dissection is preferred to mobilize the submucosal space, although blunt dissection can also be used. (opinion) [Ep 7 · 7:05](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=425)
- Performing the dissection external to the anus protects the external sphincter muscles and improves the chance of good continence. (clinical) [Ep 7 · 7:31](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=451)
- The colon is divided 5 to 6 centimeters above the biopsy site, which is 5 centimeters above the obvious transition zone. (clinical) [Ep 7 · 8:57](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=537)
- The coloanal anastomosis is performed with 12 to 16 sutures total, placing 3 to 4 additional sutures in each quadrant after the initial 4 quadrant stay sutures. (clinical) [Ep 7 · 9:19](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=559)
- Vicryl suture is used for the anastomosis in newborns. (clinical) [Ep 7 · 9:44](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=584)
- This operation took 70 minutes. (clinical) [Ep 7 · 9:57](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=597)
- The child was left without a nasogastric tube and started stooling the morning following surgery. (clinical) [Ep 7 · 10:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=600)
- The patient was started on feeds less than 24 hours after the procedure. (clinical) [Ep 7 · 10:07](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=607)
- The anastomosis is calibrated with a 12 Hegar dilator at the end of the procedure. (clinical) [Ep 7 · 10:36](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=636)
- Gauze packing is placed in the anus at the end of the procedure. (clinical) [Ep 7 · 10:45](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=645)
- The patient is placed transversely on the table with the surgeon standing at the head for laparoscopic pull-through for high imperforate anus. (clinical) [Ep 8 · 0:05](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=5)
- Three trocars are used: one umbilical for the scope, and 3mm and 5mm trocars in the right and left mid-quadrants just below the umbilicus. (clinical) [Ep 8 · 0:10](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=10)
- The mesenteric mobilization technique uses fine dissection just on the serosa of the bowel wall, with small vessels individually isolated, grasped with the sealer, sealed, and retracted away from the bowel. (clinical) [Ep 8 · 0:32](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=32)
- This vessel sealing technique is safer than using electrocautery in the pelvic area, which could spread to surrounding structures causing injury to the vas deferens, bladder, ureter, and other structures. (clinical) [Ep 8 · 0:50](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=50)
- Electrocautery could also damage surrounding nerves in the pelvic dissection. (clinical) [Ep 8 · 1:10](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=70)
- The 3mm sealer allows fine dissection completely around the circumference of the bowel with very limited heat spread. (clinical) [Ep 8 · 1:13](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=73)
- Using the sealer in the right hand allows the surgeon to dissect with both hands, providing traction with the left hand and doing fine dissection with the right. (clinical) [Ep 8 · 1:25](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=85)
- In this case, the rectourethral fistula is a high fistula at the level of the bladder neck. (clinical) [Ep 8 · 2:04](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=124)
- There is no bleeding during the dissection because each of the vessels is sealed before being divided. (clinical) [Ep 8 · 2:26](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=146)
- The posterior dissection goes quite quickly down to the level of the pelvic floor. (clinical) [Ep 8 · 2:40](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=160)
- The most difficult portion of the dissection is always anteriorly where the fistula comes up into the bladder, requiring careful technique to prevent injury to the prostate, seminal vesicles, or vas deferens. (clinical) [Ep 8 · 2:49](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=169)
- A hitch stitch is placed through the anterior abdominal wall down to the peritoneal reflection to retract the bladder up out of the way, exposing the anterior rectum more completely. (clinical) [Ep 8 · 3:12](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=192)
- The anterior dissection can be difficult as the tissue planes can be very dense and difficult to differentiate between the rectum and surrounding structures. (clinical) [Ep 8 · 3:26](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=206)
- The colon tapers relatively quickly as it enters down into the bladder neck in high fistulas. (clinical) [Ep 8 · 4:06](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=246)
- Most of the rectourethral fistulas dealt with in this procedure are closer to the level of the prostate rather than at the bladder neck. (epidemiological) [Ep 8 · 4:19](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=259)
- The fistula is taken using a 5mm stapler, with the best angle achieved by placing the stapler through the left-hand port in this case. (clinical) [Ep 8 · 5:05](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=305)
- Whether the left or right hand port is upsized to 5mm for the stapler depends on the particular anatomy of the child. (clinical) [Ep 8 · 5:22](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=322)
- The fistula is taken almost completely flush with the bladder neck to prevent any residual fistula and eliminate the chance of a diverticulum. (clinical) [Ep 8 · 5:32](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=332)
- In most cases, it is not necessary to mobilize the rectosigmoid much above the pelvic reflection. (clinical) [Ep 8 · 6:09](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=369)
- The dissection stays relatively close to the bowel wall to prevent devascularization of the colon and injury to surrounding structures. (clinical) [Ep 8 · 6:26](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=386)
- The vessel sealing and tearing technique prevents the need for changing to scissors to cut tissue and prevents the heat spread seen with monopolar hook cautery. (clinical) [Ep 8 · 7:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=420)
- The baby's feet and legs are prepped at the beginning of the procedure and retracted up toward the baby's head to expose the area of the external sphincter for the perineal portion. (clinical) [Ep 8 · 7:29](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=449)
- A nerve stimulator is used to identify the center of the external sphincter, which is marked just over 1 centimeter from a reference point. (clinical) [Ep 8 · 7:45](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=465)
- A skin incision is made in the center of the sphincter, and needle-tip cautery is used to gently divide the tissues in the midline. (clinical) [Ep 8 · 7:54](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=474)
- The nerve stimulator is used throughout the perineal dissection to ensure the dissection does not wander off to the right or left and stays in the center as close as possible. (clinical) [Ep 8 · 8:19](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=499)
- After dissecting through skin and subcutaneous tissue down to the sphincter level, blunt dissection is performed right in the center of the sphincter to preserve the circular fibers as much as possible. (clinical) [Ep 8 · 8:34](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=514)
- A Veress needle is inserted through the center of the external sphincter and into the center of the pelvic floor under direct laparoscopic visualization. (clinical) [Ep 8 · 8:53](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=533)
- It is important to visualize the tip of the Veress needle coming through the levator complex under laparoscopy, as it is possible to injure the urethra or bladder if not careful. (clinical) [Ep 8 · 9:07](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=547)
- A sheath is inserted over the Veress needle, and a series of serially expandable trocars are used to go from 5mm up to 10mm to create the anal canal. (clinical) [Ep 8 · 9:24](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=564)
- A Babcock clamp is passed through the 10mm trocar and used to grasp the rectum; because of the staple line, there is no spillage during this portion of the procedure. (clinical) [Ep 8 · 9:47](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=587)
- Care should be taken to ensure the orientation of the bowel is correct and that it does not get twisted or the mesentery kinked during pull-through. (clinical) [Ep 8 · 10:10](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=610)
- Occasionally there is too much tension during pull-through and more mobilization needs to be done, which can be achieved relatively easily laparoscopically. (clinical) [Ep 8 · 10:45](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=645)
- The staple line is resected from the exteriorized bowel end, and stay sutures are placed to give better exposure. (clinical) [Ep 8 · 11:18](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=678)
- A series of 4-0 interrupted absorbable sutures are used to create the neo-anus, going full-thickness through the colon and then through the skin. (clinical) [Ep 8 · 11:35](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=695)
- Because the patient has a diverting colostomy, it is only necessary to place about 12 to 16 sutures, as the anastomosis does not need to be airtight and should not be made ischemic. (clinical) [Ep 8 · 11:53](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=713)
- Anal calibration and dilations are started at approximately 2 weeks postoperatively and are often only necessary for a few weeks. (clinical) [Ep 8 · 12:57](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=777)
- Two to three stitches are placed in each quadrant after the four corner sutures are placed for the anastomosis. (clinical) [Ep 8 · 13:22](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=802)
- Once the anastomosis is complete, the anus already retracts somewhat, creating a more normal-appearing skin line and external column. (clinical) [Ep 8 · 13:59](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=839)
- Hitch stitches are placed in the colon, attaching the distal or mid-rectum to the presacral fascia to help prevent prolapse later on. (clinical) [Ep 8 · 14:17](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=857)
- Usually two presacral fixation stitches, one on each side, are sufficient to prevent prolapse. (clinical) [Ep 8 · 14:36](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=876)
- The key to this operation is to operate in front of the camera and run the bowel in front of the camera instead of chasing the bowel around the abdomen, which prevents disorientation and allows the surgeon to keep a clear view. (opinion) [Ep 5 · 2:52](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=172)
- It is critical that the bowel be completely run from the duodenojejunal junction all the way to the ileocecal valve to ensure that all bands have been released. (opinion) [Ep 5 · 4:00](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=240)
- The key to this operation is making sure that the mesentery has been broadly widened to prevent a twist in the future. (opinion) [Ep 5 · 6:29](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=389)
- One should be able to see the superior mesenteric artery and vein coming straight down into the middle of the abdomen with no twists or obstruction. (opinion) [Ep 5 · 6:39](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=399)
- The 3 millimeter sealer can be used to safely grasp the bowel and act as a forceps which is atraumatic to the bowel. (clinical) [Ep 4 · 1:00](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=60)
- The first portion of the duodenum is extremely dilated. (clinical) [Ep 4 · 1:22](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=82)
- Dense adhesions to the proximal duodenum can be safely taken down using the sealer by dissecting them off the bowel and then sealing and gently tearing them off the surface of the duodenum. (clinical) [Ep 4 · 1:33](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=93)
- Because of the minimal energy spread of the sealer, it is very safe to dissect in this fashion. (clinical) [Ep 4 · 1:51](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=111)
- The bowel can be grasped immediately after the sealer is activated without any evidence of any heat injury to the bowel. (clinical) [Ep 4 · 1:58](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=118)
- The sealer is found to be much more useful than using a hook, which had significant energy spread and also could not be used to grasp the bowel. (opinion) [Ep 4 · 2:10](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=130)
- As is common in these cases, the duodenum goes towards the retroperitoneum, and this is the most difficult part to mobilize. (clinical) [Ep 4 · 3:13](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=193)
- Adhesions between the transverse colon and the duodenum, some of which are consistent with Ladd bands, can be extremely thick and dense and difficult to take down. (clinical) [Ep 4 · 3:35](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=215)
- Complete mobilization of the transverse and proximal or ascending colon is necessary because of the posterior attachments. (clinical) [Ep 4 · 4:08](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=248)
- The minimal energy spread from the sealer allows this device to be used in close proximity to the small bowel without any risk of injury to it. (clinical) [Ep 4 · 5:19](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=319)
- Ladd bands can traverse across the duodenum causing proximal obstruction. (clinical) [Ep 4 · 5:35](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=335)
- The posterior retroperitoneal attachment of the duodenum cannot be reached until the Ladd bands have been completely divided. (clinical) [Ep 4 · 7:01](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=421)
- The bowel is run from proximal to distal to completely derotate the bowel and eliminate the risk of volvulus in the future. (clinical) [Ep 4 · 6:50](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=410)
- The sealer can act as an atraumatic bowel grasper during bowel running, though the jaws are not quite as large as the 3 millimeter bowel grasper. (clinical) [Ep 4 · 7:39](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=459)
- The sealer is used during bowel running because other bands are often encountered, and this allows immediate sealing and division. (clinical) [Ep 4 · 7:56](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=476)
- Enlarged lymph nodes in the mesentery and the chylous appearance within the bowel show evidence of chronic mild obstruction. (clinical) [Ep 4 · 8:29](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=509)
- At the completion of the Ladd procedure, all of the colon is on the left and the small bowel is on the right. (clinical) [Ep 4 · 8:56](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=536)
- In a small infant with a small appendix, the appendix can be brought out through the right trocar site and amputated extracorporeally. (clinical) [Ep 4 · 9:06](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=546)
- A newborn with prenatal diagnosis of bowel obstruction was found to have jejunal atresia on upper GI study (clinical) [Ep 1 · 0:00](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=0)
- The surgeon stands at the baby's feet with the cameraman on the baby's right and the scrub tech on the patient's left for this procedure (clinical) [Ep 1 · 0:30](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=30)
- A 3-port technique was used with a 4 mm 30-degree scope for visualization and two 3 mm ports for dissection (clinical) [Ep 1 · 0:50](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=50)
- The left mid-quadrant port was later changed to a 5 mm port for the stapler (clinical) [Ep 1 · 1:10](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=70)
- The Veress needle is inserted below the umbilicus to avoid injury to the umbilical vessels and prevent CO2 embolism (clinical) [Ep 1 · 1:20](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=80)
- There was a complete gap between the proximal jejunum and the distal bowel, with visualization of appendix and cecum suggesting an apple peel defect (clinical) [Ep 1 · 2:00](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=120)
- The bowel was run from proximal to distal to ensure there were no other areas of obstruction or kinking (clinical) [Ep 1 · 2:30](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=150)
- Running the bowel distally confirmed an apple peel defect, as the bowel could be seen twisting around the mesentery (clinical) [Ep 1 · 2:50](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=170)
- Because there was no evidence of a kink or significant obstruction, the mesentery was not further manipulated (clinical) [Ep 1 · 3:10](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=190)
- A decision was made to remove the proximal dilated segment in the hopes of improving bowel motility following surgery, because it was relatively short and significantly dilated (clinical) [Ep 1 · 3:40](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=220)
- The mesentery is taken down using a 3 mm bipolar vessel sealer, with vessels clamped, sealed, and then teased off the mesenteric border of the bowel (clinical) [Ep 1 · 4:10](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=250)
- The dissection was carried back almost to the ligament of Treitz and encompassed approximately 10 cm length of bowel (clinical) [Ep 1 · 4:30](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=270)
- A 5 mm endoscopic stapler was used to divide the bowel, laying down 4 rows of staples and dividing between them (clinical) [Ep 1 · 4:50](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=290)
- Two applications of the stapler were required because the bowel was so dilated, with a diameter of almost 4 cm (clinical) [Ep 1 · 5:10](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=310)
- The distal jejunal segment was anastomosed to the proximal dilated segment in an end-to-side fashion (clinical) [Ep 1 · 5:30](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=330)
- An enterotomy was made in the proximal dilated bowel using a 3 mm hook cautery and then decompressed with a 3 mm sucker (clinical) [Ep 1 · 5:45](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=345)
- A similar enterotomy was made in the distal jejunal segment and slightly dilated to allow access of the stapler (clinical) [Ep 1 · 6:00](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=360)
- The anastomosis was approximately 2.5 cm in length (clinical) [Ep 1 · 6:15](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=375)
- The resultant enterotomy was closed with a running absorbable suture (clinical) [Ep 1 · 6:25](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=385)
- Previous to having the stapler, an end-to-end anastomosis would have been performed with multiple interrupted or running sutures (clinical) [Ep 1 · 6:35](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=395)
- After completion of the enterotomy, there was no evidence of significant mesenteric defect or any gap in the anatomy (clinical) [Ep 1 · 6:50](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=410)
- The procedure took 80 minutes and was tolerated well by the infant (clinical) [Ep 1 · 7:05](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=425)
- The patient had diminishing NG aspirates over the next week (clinical) [Ep 1 · 7:20](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=440)
- An upper GI obtained one week postoperatively showed a widely patent anastomosis (clinical) [Ep 1 · 5:55](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=355)
- The resected specimen measured 10 cm (clinical) [Ep 1 · 5:55](https://qa.library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-748?t=355)
- A full-term infant with a prenatally diagnosed abdominal cyst underwent ultrasound which confirmed the presence of a duplication cyst. (clinical) [Ep 6 · 0:00](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=0)
- At 3 weeks of age, the patient underwent laparoscopic exploration. (clinical) [Ep 6 · 0:20](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=20)
- The surgeon is positioned at the patient's feet for this procedure. (clinical) [Ep 6 · 0:30](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=30)
- 3 ports were used with ports in the right and left mid quadrant used for the manipulation and resection. (clinical) [Ep 6 · 0:40](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=40)
- The initial maneuver was to elevate the transverse colon in order to run the bowel. (clinical) [Ep 6 · 0:50](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=50)
- The intestinal duplication cyst appeared to be mid-jejunal. (clinical) [Ep 6 · 1:00](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=60)
- The left mid quadrant port was upsized to a 5 millimeter port to allow for placement of the endoscopic stapler. (clinical) [Ep 6 · 1:50](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=110)
- A single load of the stapler was used to divide the bowel both on the proximal and then on the distal end. (clinical) [Ep 6 · 2:05](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=125)
- This allowed for division of the bowel without any intraabdominal contamination from the bowel contents. (clinical) [Ep 6 · 2:20](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=140)
- The 3 millimeter vessel sealer was used to seal the mesentery and then it was stripped off the cyst in the bowel without any bleeding or other issues. (clinical) [Ep 6 · 2:35](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=155)
- For vessels of this size, this maneuver is extremely efficient as it allows for rapid sealing and division of the mesentery without the repeated placement of endoscopic scissors. (opinion) [Ep 6 · 2:55](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=175)
- A 3-0 Prolene stitch was placed through the anterior abdominal wall and then placed through first the distal limb and then the proximal limb of the bowel to align the two segments for the side to side anastomosis. (clinical) [Ep 6 · 3:30](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=210)
- A Vicryl suture is placed intracorporeally to align the proximal segments of the two pieces of bowel to facilitate the side to side anastomosis. (clinical) [Ep 6 · 4:00](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=240)
- Two enterotomies were then made side by side in each limb of the bowel to allow for placement of the 5 millimeter stapler. (clinical) [Ep 6 · 4:15](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=255)
- A side to side anastomosis was completed with a single application of the stapler. (clinical) [Ep 6 · 4:30](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=270)
- The resultant enterotomy was then closed with a running 4-0 Vicryl suture. (clinical) [Ep 6 · 4:45](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=285)
- This was a very fast and efficient way of closing the small enterotomy. (opinion) [Ep 6 · 4:55](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=295)
- The surgeon can follow himself, keeping adequate tension on the running suture line to prevent any gaps. (clinical) [Ep 6 · 5:05](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=305)
- A small specimen bag was placed into the abdomen, which was the thumb of a #8 glove. (clinical) [Ep 6 · 5:35](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=335)
- The cyst was decompressed using cautery and suction to allow the bowel to fit in the specimen bag. (clinical) [Ep 6 · 5:50](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=350)
- The specimen was brought out through the left mid quadrant trocar site. (clinical) [Ep 6 · 6:05](https://qa.library.globalcastmd.com/watch/laparoscopic-intestinal-duplication-cyst-repair-technique-750?t=365)
- The patient is a 1 day old infant who had a prenatal diagnosis of duodenal atresia (clinical) [Ep 2 · 0:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=0)
- Room setup places baby at foot of table with surgeon standing at baby's legs for most ergonomic position (clinical) [Ep 2 · 0:30](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=30)
- Port placement: 4mm scope in umbilicus, 3mm port in left mid quadrant, 3mm stab wound in right mid quadrant, triangulated towards right upper quadrant (clinical) [Ep 2 · 1:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=60)
- The 3 millimeter sealer is an excellent dissecting device and can be used in safe energy in close approximation to both the gallbladder and the small bowel (opinion) [Ep 2 · 1:30](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=90)
- A transabdominal stitch (30 Prolene on RB1 needle) placed through anterior abdominal wall in right upper quadrant retracts gallbladder superiorly for greater exposure (clinical) [Ep 2 · 2:30](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=150)
- The child has malrotation with complete duodenal atresia (clinical) [Ep 2 · 3:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=180)
- The sealer is an excellent instrument for grasping and manipulating the bowel in an atraumatic fashion (opinion) [Ep 2 · 3:30](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=210)
- A Meckel's diverticulum was found in the distal ileum during the procedure (clinical) [Ep 2 · 4:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=240)
- All small bowel is placed on patient's right and large bowel on patient's left during Ladd's procedure (clinical) [Ep 2 · 4:30](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=270)
- Widening the mesenteric base should diminish the chance of volvulus in the future (clinical) [Ep 2 · 5:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=300)
- Transverse enterotomy is made at the most dependent portion of the dilated proximal segment (clinical) [Ep 2 · 5:30](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=330)
- The distal segment enterotomy is longitudinal (clinical) [Ep 2 · 6:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=360)
- There is increased smoke and debris from using electrocautery compared to the 3mm sealer (clinical) [Ep 2 · 6:30](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=390)
- A transabdominal stitch aligns the two sides of bowel to perform the side-to-side anastomosis and makes it quite easy (clinical) [Ep 2 · 7:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=420)
- Pre-cut Vicryl suture approximately 10 to 12 centimeters in length is used to run the back row of the anastomosis (clinical) [Ep 2 · 7:30](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=450)
- In some cases the distal duodenal segment is more fixed to the retroperitoneum making this part of the procedure more difficult, but the same technique is used with excellent result (clinical) [Ep 2 · 8:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=480)
- This portion of the anastomosis can be done in an interrupted fashion, but a running suture works extremely well and is more efficient (opinion) [Ep 2 · 9:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=540)
- The entire procedure took approximately 50 minutes (clinical) [Ep 2 · 9:30](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=570)
- The patient was a 2.8 kg child (clinical) [Ep 2 · 10:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=600)
- About 10% of patients who undergo laparoscopic repair of duodenal atresia have malrotation (epidemiological) [Ep 2 · 10:30](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=630)
- A nasogastric tube is left to suction for approximately 3 to 4 days; in most cases feeds are started by the 5th day (clinical) [Ep 2 · 11:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=660)
- This child started eating on the 5th postoperative day and was on full feeds by the 8th postoperative day (clinical) [Ep 2 · 11:30](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=690)
- The base of the Meckel's could adequately be divided without compromising the lumen of the bowel, so decision was made to remove it using 5mm stapler (clinical) [Ep 2 · 12:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=720)
- The 3mm port in left quadrant was changed to 5mm port to allow insertion of endoscopic stapler (clinical) [Ep 2 · 12:30](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=750)
- The base of the Meckel's was crushed with an atraumatic clamp before stapler was applied (clinical) [Ep 2 · 13:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=780)
- Because of the malrotation, the appendix was also removed (clinical) [Ep 2 · 13:30](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=810)
- The child was discharged to home on the 10th postoperative day (clinical) [Ep 2 · 14:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-repair-of-duodenal-atresia-ladd-s-procedure-and-761?t=840)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- The JRS 3 millimeter sealer is used as the primary mode of dissection for laparoscopic-assisted pull-through in Hirschsprung's disease. — The host summarizing the discussion [Ep 7 · 0:00](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=0)
- The patient was a newborn weighing 3.2 kg. — The host summarizing the discussion [Ep 7 · 0:32](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=32)
- A super umbilical ring incision is used for small newborns to place the Veress needle and 4 mm trocar, with care taken to avoid the umbilical vein by placing the trocar just to the left of midline. — The host summarizing the discussion [Ep 7 · 0:36](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=36)
- A full thickness biopsy is obtained from the muscular wall approximately 5 centimeters above the transition zone between the distal sigmoid and rectum. — The host summarizing the discussion [Ep 7 · 0:53](https://qa.library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=53)
- A 12-year-old female presented with a three-month history of intermittent pain and weight loss with acute worsening of symptoms. — The host summarizing a resource [Ep 5 · 0:08](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=8)
- CT scan showed evidence of midgut volvulus. — The host summarizing a resource [Ep 5 · 0:15](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=15)
- Patient was positioned in dorsal lithotomy position with surgeon positioned between patient's legs. — The host summarizing a resource [Ep 5 · 0:18](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=18)
- 5 millimeter ports were used for the procedure. — The host summarizing a resource [Ep 5 · 0:29](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=29)
- Upon entering abdomen, there was clear disorientation of the bowel with an internal hernia and complete twist of the bowel. — The host summarizing a resource [Ep 5 · 0:36](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=36)
- The anatomy was confusing because of 360-degree twist of the bowel as well as the internal hernia. — The host summarizing a resource [Ep 5 · 2:38](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=158)
- The superior mesenteric vessels were engorged because they had been twisted. — The host summarizing a resource [Ep 5 · 3:13](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=193)
- Running the bowel from proximal to distal places all the small bowel on the patient's right and the colon on the patient's left. — The host summarizing a resource [Ep 5 · 7:11](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=431)
- Using a 5mm stapler for appendix division allows keeping all ports at 5mm and not upsizing to a 12mm port for a larger stapler. — The host summarizing a resource [Ep 5 · 7:37](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=457)
- The operation took approximately 90 minutes and the patient did well. — The host summarizing a resource [Ep 5 · 7:58](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=478)
- The infant presented with repetitive bilious vomiting. — The host summarizing the discussion [Ep 4 · 0:00](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=0)
- An upper GI series showed a redundant duodenum which did not cross the midline. — The host summarizing the discussion [Ep 4 · 0:09](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=9)
- The surgeon is positioned at the end of the table with the baby brought down to the foot of the table to allow the surgeon to be in line with the foregut. — The host summarizing the discussion [Ep 4 · 0:16](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=16)
- A 4 or 5 millimeter port is placed in the umbilicus, and right and left hand operating ports are placed either side of the umbilicus. — The host summarizing the discussion [Ep 4 · 0:28](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=28)
- In a small infant, the right hand port is placed above the umbilicus so that the right hand does not conflict with the scope. — The host summarizing the discussion [Ep 4 · 0:36](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=36)

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