# Mediastinum, Great Vessels and Diaphragm — GCMD Library living collection

Updated: n/a · 12 episodes · 11 cited statements

## Episodes
### Patent ductus and vascular rings
- [PDA ligation by Dr. Steven Rothenberg](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714) — video · 6:24 · [machine version](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714.md)
- [Stapled double arch](https://qa.library.globalcastmd.com/watch/stapled-double-arch-11964) — video · [machine version](https://qa.library.globalcastmd.com/watch/stapled-double-arch-11964.md)
- [Vascular ring handout](https://qa.library.globalcastmd.com/video/11980) — article · [machine version](https://qa.library.globalcastmd.com/video/11980.md)

### Mediastinal masses and thymus
- [Thoracoscopic Thymectomy](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399) — video · 4:20 · [machine version](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399.md)
- [mediastinal masses 2014](https://qa.library.globalcastmd.com/video/11989) — article · [machine version](https://qa.library.globalcastmd.com/video/11989.md)

### Thoracic duct and diaphragm
- [Thoracic Duct](https://qa.library.globalcastmd.com/watch/thoracic-duct-11973) — video · [machine version](https://qa.library.globalcastmd.com/watch/thoracic-duct-11973.md)
- [thoracoscopic thoracic duct ligation presentation. MIS w video. 1.15](https://qa.library.globalcastmd.com/video/11998) — article · [machine version](https://qa.library.globalcastmd.com/video/11998.md)
- [Thoracoscopic Diaphragmatic Plication](https://qa.library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974) — video · 4:40 · [machine version](https://qa.library.globalcastmd.com/watch/thoracoscopic-diaphragmatic-plication-11974.md)
- [plication narrated](https://qa.library.globalcastmd.com/watch/plication-narrated-11994) — video · 6:01 · [machine version](https://qa.library.globalcastmd.com/watch/plication-narrated-11994.md)

### Access and incisions
- [Thoracoscopy](https://qa.library.globalcastmd.com/video/11975) — article · [machine version](https://qa.library.globalcastmd.com/video/11975.md)
- [thoracotomy incisions](https://qa.library.globalcastmd.com/video/11999) — article · [machine version](https://qa.library.globalcastmd.com/video/11999.md)

## Chapters
- [0:02](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=2) Patient positioning, port placement, and initial thymic exposure (Ep 5)
- [0:49](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=49) Mobilization of the left upper pole of the thymus (Ep 5)
- [1:43](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=103) Identification and division of the thymic vein (Ep 5)
- [2:49](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=169) Medial dissection and removal of residual thymic tissue (Ep 5)
- [3:53](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=233) Specimen removal and postoperative course (Ep 5)
- [0:02](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=2) Patient positioning and port placement for thoracoscopic PDA ligation (Ep 1)
- [2:00](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=120) Pleural dissection and identification of the ductus arteriosus (Ep 1)
- [4:00](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=240) Mobilization of the ductus and preparation for clip placement (Ep 1)
- [5:00](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=300) Test clamping and clip application (Ep 1)
- [5:30](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=330) Lung biopsy for interstitial lung disease evaluation (Ep 1)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Thoracoscopic PDA ligation can be performed in a 2 kg infant using a modified prone position with the left side elevated approximately 30 degrees — Steven Rothenberg (clinical) [Ep 1 · 0:02](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=2)
- Simple insufflation to collapse the lung is sufficient for thoracoscopic PDA ligation; single lung ventilation is not required, although it can be carried out in larger patients — Steven Rothenberg (clinical) [Ep 1 · 1:00](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=60)
- It is important not to use monopolar cautery at the level of the ductus because of the risk of injuring the recurrent laryngeal nerve — Steven Rothenberg (clinical) [Ep 1 · 2:00](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=120)
- Creating a pleural flap over the mid portion of the aorta is helpful to safely retract the vagus and recurrent laryngeal nerves out of the way during PDA dissection — Steven Rothenberg (clinical) [Ep 1 · 3:00](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=180)
- Gentle spreading with the 3 millimeter vessel sealer is an excellent way to get adequate mobilization of the ductus — Steven Rothenberg (clinical) [Ep 1 · 4:00](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=240)
- It is generally recommended to spread in the direction of the ductus to eliminate the risk of tearing the ductus — Steven Rothenberg (clinical) [Ep 1 · 4:30](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=270)
- Test clamping of the ductus should be performed with a distal pulse oximeter present on the foot to ensure the correct structure is being occluded — Steven Rothenberg (clinical) [Ep 1 · 5:00](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=300)
- It is very important to have proximal and distal monitoring during PDA ligation — Steven Rothenberg (clinical) [Ep 1 · 5:15](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=315)
- It is important to deploy the clip into the clip applier before placing it onto the duct, as deploying the clip while already around the duct can force the tissue away — Steven Rothenberg (clinical) [Ep 1 · 5:20](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=320)
- A 5 millimeter stapler fits appropriately for lung biopsy in a 2 kg infant — Steven Rothenberg (clinical) [Ep 1 · 6:00](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=360)
- Care must be taken to ensure the tissue is far enough in the stapler to make sure the staple line will reach across the entire line of the resected specimen during lung biopsy — Steven Rothenberg (clinical) [Ep 1 · 6:10](https://qa.library.globalcastmd.com/watch/pda-ligation-by-dr-steven-rothenberg-6714?t=370)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- The procedure is performed in a seven-year-old patient with myasthenia gravis. — The host summarizing a resource [Ep 5 · 0:02](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=2)
- Patient positioning is modified supine with the left side elevated 30 degrees. — The host summarizing a resource [Ep 5 · 0:07](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=7)
- 3-5 millimeter ports are used for the procedure. — The host summarizing a resource [Ep 5 · 0:14](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=14)
- Upon entering the chest, the thymic gland is easily visualized with its surrounding fat pad. — The host summarizing a resource [Ep 5 · 0:17](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=17)
- Blunt dissection is used to dissect the thymus off the pericardium. — The host summarizing a resource [Ep 5 · 0:24](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=24)
- The phrenic nerve and its surrounding vessels are visible at the lower end of the field. — The host summarizing a resource [Ep 5 · 0:29](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=29)
- Great care must be taken to ensure that the phrenic nerve is not damaged during the dissection. — The host summarizing a resource [Ep 5 · 0:33](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=33)
- Any dissection using cautery or sharp dissection should be well medial to the phrenic nerve. — The host summarizing a resource [Ep 5 · 0:40](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=40)
- The pleura overlying the anterior of the thymus and extending up into the neck is divided, giving access to the left upper pole of the thymus. — The host summarizing a resource [Ep 5 · 0:49](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=49)
- The majority of the mobilization is done bluntly to avoid injury to surrounding structures. — The host summarizing a resource [Ep 5 · 1:01](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=61)
- Blunt dissection allows easy access up into the thoracic inlet and well above the sternal notch. — The host summarizing a resource [Ep 5 · 1:07](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=67)
- Mild gentle traction downward on the left lower pole of the thymus allows exposure of the upper pole. — The host summarizing a resource [Ep 5 · 1:15](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=75)
- A lateral division is safely performed, ensuring complete resection of the upper pole of the thymus while preserving the phrenic nerve. — The host summarizing a resource [Ep 5 · 1:22](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=82)
- The innominate vein and the thymic vein, which drains directly into the innominate, are identified during dissection. — The host summarizing a resource [Ep 5 · 1:43](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=103)
- The thymic vein comes off the back wall of the thymus near the isthmus of the thymus. — The host summarizing a resource [Ep 5 · 1:55](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=115)
- The thymic vein is sealed and divided using a ligature device. — The host summarizing a resource [Ep 5 · 2:07](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=127)
- There are a number of other small perforating arteries and veins, but none are of significant size and usually can be taken easily using the ligature device. — The host summarizing a resource [Ep 5 · 2:19](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=139)
- The thymus gland is pulled into the left chest, thereby pulling over the majority of the right lobe of the thymus. — The host summarizing a resource [Ep 5 · 2:52](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=172)
- After the thymic gland is divided, a careful inspection of the mediastinum is made to ensure that no thymic tissue is left. — The host summarizing a resource [Ep 5 · 3:08](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=188)
- The right lung is herniating over with its pleura intact. — The host summarizing a resource [Ep 5 · 3:16](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=196)
- Tissue that could be residual thymic gland is identified, and although it is not clear that this is exactly thymic tissue, it must be excised to ensure a complete thymectomy. — The host summarizing a resource [Ep 5 · 3:22](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=202)
- Continual gradual traction into the left chest allows for safe dissection without injury to the phrenic nerve. — The host summarizing a resource [Ep 5 · 3:38](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=218)
- Any residual fat extending up into the thoracic inlet should be removed. — The host summarizing a resource [Ep 5 · 3:48](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=228)
- The lower port is changed for a 10 millimeter trocar, and the thymus is placed in an endobag and brought out through the wound. — The host summarizing a resource [Ep 5 · 3:53](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=233)
- Final inspection of the thoracic inlet and suprasternal area shows no residual gland. — The host summarizing a resource [Ep 5 · 4:03](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=243)
- The patient had an uncomplicated course and was discharged on the 2nd postoperative day. — The host summarizing a resource [Ep 5 · 4:13](https://qa.library.globalcastmd.com/watch/thoracoscopic-thymectomy-399?t=253)

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