Collection
Mediastinum, Great Vessels and Diaphragm
Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
Content of this collection
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, PDA ligation by Dr. Steven Rothenberg · 1:00
PDA ligation by Dr. Steven Rothenberg
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This is a thoracoscopic PDA ligation in a 2kg baby by Dr. Steven Rothenberg
video6:24 · Jun 2023
IPEG 2020 TOP ABSTRACT: Thoracoscopic Division of a Double Aortic Arch Vascular Ring Anomaly
video2:44 · Nov 2020Private
Vascular ring handout
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Surgical content by Dr. Steve Rothenberg — Thoracic Surgery
article · May 2026
Thoracoscopic Thymectomy
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Dr. Steve Rothenberg explains the detailed steps of thoracoscopic thymectomy.
video4:20 · Sep 2018
mediastinal masses 2014
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Surgical content by Dr. Steve Rothenberg — Thoracic Surgery
article · May 2026
thoracoscopic thoracic duct ligation presentation. MIS w video. 1.15
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Surgical content by Dr. Steve Rothenberg — Thoracic Surgery
article · May 2026
Thoracoscopic Diaphragmatic Plication
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Surgical content by Dr. Steve Rothenberg — Thoracic Surgery
video4:40 · May 2026
thoracotomy incisions
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Surgical content by Dr. Steve Rothenberg — Thoracic Surgery
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Featured picks for families are being prepared — the summaries above are written for you.
Thoracoscopic PDA ligation is feasible in extremely low birth weight infants (≥2 kg) using a modified prone position with 30-degree left-side elevation and simple insufflation without single-lung ventilation, though the latter remains an option in larger patients [e6714-c1, e6714-c2]. The critical technical challenge is recurrent laryngeal nerve protection: monopolar cautery must be avoided at the ductal level, and creation of a pleural flap over the mid-aorta facilitates safe retraction of the vagus and recurrent laryngeal nerves [e6714-c3, e6714-c4]. Dissection technique centers on gentle spreading with a 3 mm vessel sealer in the direction of the ductus to prevent inadvertent tearing [e6714-c5, e6714-c6]. Proximal and distal monitoring—including test clamping with a foot pulse oximeter—is mandatory to confirm correct structure identification before definitive occlusion [e6714-c7, e6714-c8]. Clip deployment requires pre-loading into the applier to avoid tissue displacement . Concurrent lung biopsy is achievable with a 5 mm stapler, provided tissue is adequately advanced to ensure complete staple-line apposition [e6714-c10, e6714-c11].
- Thoracoscopic PDA ligation is safe in infants ≥2 kg using modified prone positioning and simple insufflation without mandatory single-lung ventilation.
- Recurrent laryngeal nerve injury is prevented by avoiding monopolar cautery at the ductus and using a pleural flap to retract the vagus nerve.
- Gentle spreading with a 3 mm vessel sealer in the ductal direction minimizes risk of inadvertent ductal tear during dissection.
- Test clamping with distal pulse oximetry and dual-site monitoring confirms correct structure identification before permanent occlusion.
- Pre-load clips into the applier and ensure adequate tissue advancement in the stapler to avoid deployment complications during ligation and biopsy.
For patients & families
When a baby is born with a patent ductus arteriosus (PDA)—a blood vessel that should close after birth but remains open—doctors sometimes need to close it surgically. Surgeons can now perform this procedure using a minimally invasive approach called thoracoscopy, even in very small babies weighing as little as 2 kilograms (about 4.4 pounds). The baby is positioned carefully on their side, and the surgeon uses small instruments and a camera to work inside the chest. The lung doesn't need to be completely deflated; gentle pressure is enough to create working space. During the operation, the surgical team takes great care to protect the recurrent laryngeal nerve, which controls the vocal cords, by avoiding certain types of energy devices and gently moving the nerve out of the way with a protective tissue flap. The ductus is carefully freed using spreading motions rather than cutting, always working in the direction of the vessel to avoid tearing. Before closing the ductus permanently, doctors test their work by temporarily blocking it while monitoring oxygen levels in the baby's foot to confirm they're working on the correct structure. The vessel is then closed with clips or sealed permanently.
When a baby is born with a patent ductus arteriosus (PDA)—a blood vessel that should close after birth but remains open—doctors sometimes need to close it surgically. Surgeons can now perform this procedure using a minimally invasive approach called thoracoscopy, even in very small babies weighing as little as 2 kilograms (about 4.4 pounds). The baby is positioned carefully on their side, and the surgeon uses small instruments and a camera to work inside the chest. The lung doesn't need to be completely deflated; gentle pressure is enough to create working space. During the operation, the surgical team takes great care to protect the recurrent laryngeal nerve, which controls the vocal cords, by avoiding certain types of energy devices and gently moving the nerve out of the way with a protective tissue flap. The ductus is carefully freed using spreading motions rather than cutting, always working in the direction of the vessel to avoid tearing. Before closing the ductus permanently, doctors test their work by temporarily blocking it while monitoring oxygen levels in the baby's foot to confirm they're working on the correct structure. The vessel is then closed with clips or sealed permanently.
Expert statements from the recordings in this collection.
PDA ligation by Dr. Steven Rothenberg
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 Rothenberg0:02
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 Rothenberg1:00
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 Rothenberg2:00
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 Rothenberg3:00
Gentle spreading with the 3 millimeter vessel sealer is an excellent way to get adequate mobilization of the ductus
Steven Rothenberg4:00
It is generally recommended to spread in the direction of the ductus to eliminate the risk of tearing the ductus
Steven Rothenberg4:30
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 Rothenberg5:00
It is very important to have proximal and distal monitoring during PDA ligation
Steven Rothenberg5:15
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 Rothenberg5:20
A 5 millimeter stapler fits appropriately for lung biopsy in a 2 kg infant
Steven Rothenberg6:00
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 Rothenberg6:10
Thoracoscopic Thymectomy
The procedure is performed in a seven-year-old patient with myasthenia gravis.
Patient positioning is modified supine with the left side elevated 30 degrees.
3-5 millimeter ports are used for the procedure.
Upon entering the chest, the thymic gland is easily visualized with its surrounding fat pad.
Blunt dissection is used to dissect the thymus off the pericardium.
The phrenic nerve and its surrounding vessels are visible at the lower end of the field.
Great care must be taken to ensure that the phrenic nerve is not damaged during the dissection.
Any dissection using cautery or sharp dissection should be well medial to the phrenic nerve.
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 majority of the mobilization is done bluntly to avoid injury to surrounding structures.
Blunt dissection allows easy access up into the thoracic inlet and well above the sternal notch.
Mild gentle traction downward on the left lower pole of the thymus allows exposure of the upper pole.
A lateral division is safely performed, ensuring complete resection of the upper pole of the thymus while preserving the phrenic nerve.
The innominate vein and the thymic vein, which drains directly into the innominate, are identified during dissection.
The thymic vein comes off the back wall of the thymus near the isthmus of the thymus.
The thymic vein is sealed and divided using a ligature device.
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 thymus gland is pulled into the left chest, thereby pulling over the majority of the right lobe of the thymus.
After the thymic gland is divided, a careful inspection of the mediastinum is made to ensure that no thymic tissue is left.