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Uh Greetings from East London. Um And thank you for joining uh our Zoom academic meeting of the Department of pediatric Surgery today uh Today, uh I'm really again, pleased and honored to welcome uh Doctor Rasha, um who is going to talk about thoracoscopy in Children. And Doctor Rasi Shah is not new to our, our Zoom academic meetings. In fact, he's quite well known and he has already contributed uh in the last two or three years uh to these um Zoom invited lectures. Doctor Shah is head of the Department of Surgery at the SRC Children's Hospital in Mumbai. And he has been pioneer in minimal access pediatric surgery. He was the first pediatric surgeon to start minimal access surgery in India. And he actually revolutionized the surgical care of Children in India and subsequently other countries as well. And he also has interest in pediatric oncosurgery and pediatric urology. And my association with DSA goes back to uh uh uh years between 1987 and 1990 when we were corear together, I was a registrar in pediatric surgery and he was rotating registrar from general surgery. But even in those days, I learned a lot from uh doctor Shah just by uh being involved in patient care with him. He was first in the Bombay University for the MC H the exit exam for pediatric surgery. He has been past president and honorary secretary of the Indian Association of Pediatric Surgeons and Pediatric Endoscopic Society of India. He is the current editor in chief of the Indian Journal of pediatric Surgery. Quite a distinguished achievement. He has delivered many guest lectures, articles in peer reviewed journals and presentations and as a faculty participation in many years, conferences and workshops. He I think he's, he will agree that his biggest achievement actually is establishing an Institute of medical and minimal access surgery training center in Mumbai. Originally, it was called CAS now, I think it is called IMA. And that institute has trained literally thousands of surgeons from all different faculties, but most of them pediatric surgeons, not only from India, but also from South Africa like me, he also has a dedicated youtube channel on pediatric minimal inva invasive or minimal access surgery, which is very well received. And he has a US patent on a laparoscopic device. So his contribution um to pediatric surgery and minimal invasive surgery is really massive. But I think another most important thing is as I call him a fly by is he likes to teach and he likes to share his knowledge, experience wisdoms and pulse of wisdom with anybody who is willing to listen. So I said I'm really happy. I will stop sharing now and many colleagues are very keen to listen to your talk. And the ones which you can easily recognize are Doctor Hans Raj Man, senior pediatric surgeon from Peterburg, who has also been faculty at your institute. And then there are pediatric surgeons in private practice, state practice from South Africa from uh I can certainly recognize from West Indies and I'm sure some other African countries so please it by you can start your talk. Thank you. Yeah, thank you for very nice introduction. Uh The uh there is little bit correction in the sense, the Institute of uh minimal access and medical uh uh training was found by Doctor Laria. I took care of the pediatric section and we, we had uh organized many uh training courses. Um, uh we trained more than 400 surgeons during uh 2013 to 2020. After that, it went, uh the courses, number of courses have dropped significantly after the COVID started. Uh, so that is the only correction apart from that. Uh, I mean, I love teaching. That is what I would agree with me and uh, uh let's start with the talk. So, Thoracoscopic pediatric surgery, it is a vast topic. We actually have three day course, uh running from morning, 9 to 5 and uh, uh we can complete badly during that time. So what we are going to do is uh, brush up on some of the things and uh go into little depth in some of the conditions. But uh each and every condition will take at least 45 minutes to one hour. If you want to uh discuss more or less thoroughly, it takes time. But what we will do whatever the important I thought I put down together and uh we will see some of the videos and what uh said that uh there are quite a few videos which are there on youtube. So you can log on any time and see them. Uh we will see a few of them today. So, indications of minimal excess thoracoscopic pediatric surgery. So, if we go back, historically, we started with Pima and Pima surgery was started not uh recently, not in last 2030 years, but uh long back, uh it was started to look into the thorax in case of Pima. And uh uh so it is something which pediatric surgeon used to do long back. Uh So prima is one of the condition debridement decortication both can be done then lung lymph node and pleural biopsies can be done wherever it is indicated. Diaphragmatic hernia, that has become one of the common indication whether it is posterior, lateral, anterior, lateral or anterior diaphragmatic hernia, all can be taken care, eventration of diaphragm, which can be either congenital or required following cardiac surgery. So we have a very thriving cardiac surgery department. And uh we got opportunity to do I think, uh five acquired diaphragm, acquired eventration of diaphragm. Uh Basically these patients uh ha have uh some cardiac surgery and following which they don't come out of the ventilator because of uh uh uh eventration of diaphragm. So in then we go in and fix the diaphragm and they can be extubated and build off the ventilation and extubated early. So that is in a required, uh, not uh, not done earlier, but after the uh closely associated with pediatric cardiac surgeons, once in a while, we will get the opportunity to do that. Then the cyst mediational and lung cyst all can be done using minimal access technique, the fistula with esophageal atresia, it can be done ICSC ically and once you get the hang of it, it is better than doing open. Of course, the number or incident in a corporate setting of this particular anomaly has uh decreased significantly over the last uh 30 years because of in internatal scan and medical termination of pregnancy. And I think that is across the world though everyone knows that if it is an isolated, the fistula with esophageal atresia without any cardiac and normally without any other problem, then the survival is very good. But somehow uh because the pediatric surgeons are not involved in decision making, many of these kids get terminated today, then recurrent fistula after the surgery for esophages with PF can be tackled uh thoracoscopically. Uh but I have not done any of this, I have done a couple of them open. I have done few of them uh using endoscopically bronchoscopic procedure. And uh uh last two patients, we could achieve the success by endoscopic glue. Uh We will not go into details of that. The lobectomy can be done uh using uh this technique. So we will see at the end uh one of the video and we'll discuss a little bit about that. It can be congenital, acquired aqui becomes a little difficult because of the infection and bronchi cases. Uh if there are recurrent uh episodes of infection, then uh there may be a lot of reasons and it may not be easy, but of course, it can be done. Uh Thoracoscopically, esophageal stricture stenosis can be tickled, sympathectomy for hyperhidrosis. Again, that is one of the common indication in middle age. But somehow in Bombay, I have not seen any patient who needs sympathectomy uh or they are not being referred to us. One of the two thymectomy can be done for my gravis or for the tumor. Again, one of my colleague has done a few of them, but I have not got any opportunity to do that. So whenever you are uh planning for uh uh thoracoscopic surgery, we cannot consider anything as a minor surgery and just go in, you have to be prepared that it can become advanced at any point and uh you should be mentally ready to tackle them. So e even debridement, decortication in all this stage, it is relatively much easier and it can be done by anyone. Uh even the newcomer. But if it is chronic thick pill, it is not easy. If there is lung necrosis, again, it becomes difficult. Uh If the lymph node is subcarinal, it's not again easy approach wise. But once you are doing it regularly, thoracoscopic surgery, one can tickle that lung biopsy in a small kid with bilateral lung disease, again, is not easy. In the sense, the patient can desaturate any time. Diaphragmatic hernia. If there is a large defect, then putting a mesh and repairing it becomes uh advanced surgery. If the cyst is sharing a common wall with the trachea, esophagus and trachea, if they are sharing the common wall, again, it will become difficult, the fistula recur uh with. So if it is longer or recurrence, again, they are difficult, surgeries, lobectomy per se, it is difficult. So all these surgeries, whenever you are planning, you have to be ready that if you did, you will uh uh do needful. So what all can be done? So you, if you think that you are getting into the problem, then convert it into open surgery. And, and it means that you will always take consent for an open surgery, always have an open trolley read. Uh uh you know, you should be able to go in immediately if there is a torrential reading. And uh if you are not able to control that uh within minutes, the kid can die. Uh And if you are getting into the problem, if you know that anybody is available around you, you know, if, if next to a cardiac surgeon is there or anyone else general surgeon, you can call for the help, always be mentally prepared that basic surgery can become advanced. Uh How will you prepare yourself for thoracoscopic surgery? You need to have anatomical understanding of thorax, including lung fissures, vascular Anoma, uh anatomy, bronchial anatomy. Uh When I started doing all these surgeries, often I will go, you know, when this is about 25 years back, I will go into the diabetes, read the anatomy, uh read the principles uh even for open surgery. So these are not easy for uh anyone to start with. So, uh your anatomy has to be very clear. Once you do it often, once you're done 1520 then it is easier for you to understand how the things will be. And you can uh operate particularly when it comes to lobectomy. The basic surgeries like uh hyma, maybe you are right on stages. But uh when you are doing lobectomy, uh then you, you need to know the anatomy. Then working in cardiothoracic department during residency, certainly will help you for doing all these thoracic surgeries for endoscopic surgeries, dissection of uh chest or lungs in lab. Again, that helps. So when we started courses at uh or I today, uh, we dissected multiple times lungs so that we get used to how is the lungs in the animal as well as, uh, it, it gave us, uh some more confidence uh to carry out the surgeries. Sly, you have to have the anesthetic who are well experienced because many of these advanced surgeries like lobectomy will need single lung ventilation. If you are operating on time, they will need replacement of blood. Uh, and they have to be equipped and they need to know when to give or they may give it. All patients have access to advanced equipment. Again, that is very important. We'll see a few of the slides of the equipment, bipolar vs device. So all these, if you have, then the surgery relatively becomes easier. The anatomically, you need to understand uh how is the bronchial anatomy? And uh when you are doing bronchoscopy, you will have uh and on view. Uh So you need to know that particularly the right menstruate bronchus is acute and left menstruum bronchus is obtuse the length of right menstruum, bronchus is less than the left menstruate bronchus. So if you have to put any balloon catheter, if you put on the right side, it can slip into the trachea or it can go distally and block the upper lobe. So right side becomes a little difficult for putting a balloon catheter to occlude the lumen. So if you are going to put left side, it is much easier so that we need to remember. Uh So in disclaimers, these are the slides which are taken from internet or photographs from internet. So there are some photographs from the internet for educational purpose. Now, uh selective ventilation can be done by multiple ways. The few techniques which have been routinely used includes double lumen tubes, also known as endobronchial tubes, which can be right and left. So as I told you, we should prefer left because the left menstruum bronchus is longer. So something like this. So there are two lumens. One can occlude the left menstruate bronchus, the other can occlude the trachea. So one has to use this when you want to give single lung ventilation, you can use fogarty balloon catheter. So you put a regular endotracheal tube and you put a fogarty balloon on the side on which you want the uh lung to collapse or the side ipsilateral side where you are going to operate. Now, all these techniques are not easy. Now, the double lumen or endobronchial tube you can't use in a child who is less than 789 years old or weight of less than 25 kg, you may not be able to use them. So then you have to use either fogarty balloon or simple endotracheal tube. If we put foty balloon catheter, as I told you, the balloon can slip out or it can go distally or in and in both cases, it can, may not work. So many of us will do just simple endotracheal intubation along with you give CO2 in circulation at low pressure. We generally keep the pressure of five centimeter of water and flow of 1 L per minute, but it can be increased as long as the anesthetics are fine with the CO2 level and O2 level or saturation level. The pediatric flexible pediatric bronchoscope will help you in placement of the fogarty balloon or for that matter, even the single lumen tubes. So, uh this will be of your uh health pediatric uh bronchoscope. Even the cr can, can guide you whether the tube is on right side, left side or in the er so either bronchoscope or cm should be able to help you in proper placement of the balloon. Now, uh the what happens when we give single lung ventilation is physiologically just remember two things without going into the details of all this as a surgeon. Many things are like uh I mean, if we give time, we will understand, but it's not uh very essential. It is more for the anesthetist and others. So what happens is a decrease in the oxygenation when we give single lung ventilation. Along with that, there is slow rise in PC two, it slowly increases. Now, if it goes beyond the level, then anesthetist will not be happy and uh how we tackle that. So we either have uh increased frequency of ventilation. That is one and second, if needed, discontinue the procedure or in circulation for a few minutes and resume, particularly when you are doing all these surgeries in newborn. Then the problem of uh elimination of PCO two will come up. Uh If it is beyond 5060 level, then the anesthetic are not comfortable continuing uh the procedure. So you may stop. Now in some of the procedure, even after discontinuing of ation, you will be able to continue with the procedure particularly if you are operating on diaphragmatic. If you have put a few sutures, then you will be able to continue the procedure without in circulation. So, uh that is uh important to know. Now, you need to know the anatomy. As I told you so many of these diagrams which you have on the internet, they are busy and you need to see through. Uh I do have the application of the anatom anatomy which I see whenever II want to refresh my uh general knowledge about the anatomy of any area in the uh body. So these are some of the diagrams. So you may go through as and when required, then you need to know the, well, how is the diaphragm if you are particularly going to operate on diaphragmatic hernia? So you just need to remember that the diaphragmatic blood uh now supplies from C THREE to C five, right? Phrenic now runs posterior to the subclavian vein as it enters the thorax and anterior to brachiocephalic trunk. It crosses the right lung anteriorly and leaves the thorax by passing through the vena cava hiatus at the level of T eight, left ph nerve passes over the pericardium uh of the left ventricle and pierces diaphragm separately. Now, the pain is always to disorder. Now, this is in general. Now, if you see this diaphragm, this is the attachment of the diaphragm origin or insertion, whatever you want to call from L2 to L4, right cross, left cross, then as you go anteriorly, the attachment will go from T 12 to T six. So at the level of ZID, it is T six and all these costal cartilages and everywhere there will be attachment of the diaphragm and the hiatus is that uh IV cat eight esophagus at T 10 and T eight T 12. This is general knowledge if you have it will help you while doing some of these surgeries. Now, equipment continuing on that. Uh All of us knows that our regular equipment is straight and in the chest, everything is cold. So if we have anything cold, then the, we can easily access the area which otherwise we may not be able to uh put uh we have a straight instrument. However, it is this all shape equipment though it is available hand instruments. I don't think many people have it and even those who have it, they are not comfortable using it. So I am not sure whether they are still available in the market or not. But at one point uh uh this was manufactured by car stores and marketed. Uh This is, yeah, but the important thing is if you are going to do thoracoscopic surgery, uh particularly if you are going to do lung resection, then bipolar vessel sealing device is one of the equipment. If you have, then the life becomes much easier and simpler. And even in that, if you have something like this, Maryland like shape, it is much easier to dissect and control small blood vessels using uh this even the larger blood vessels can be controlled using uh uh bipolar vessel sealing device. Similarly, the equipment, the envelope clips. So these are the clips which gets logged. They are not the simple clips. So if you want to use clips, I would advocate, please use this only thing uh is that the size of the clip, even if you are using five millimeter clip applier, it will not go through the five millimeter TRCA, you will have to put it through 78 millimeter trer. Uh And uh the important thing is once it is sleep, it is unlikely to sleep, the regular uh regular sleep can sleep and it can give torrential bleeding. Now, as I told you, if anything B or roticulator instrument, if you have, you will be happy. So even uh reticulated uh envelope clips are available today in market. We still don't have it. We, we will try and get it. Uh uh They are, I think man manufactured and marketed in UK, similarly endos endo loops. All these helps uh in carrying out these advanced surgeries. Now, the ports are like this without the valve, you can have port. Uh These are the sorry disposable ports. These are reusable. We use our regular laparoscopy ports to carry out uh thoracoscopic surgery. So these are not essential, but if you have it, it may be worth what you see is, the length is less. And this serration will fix the trocar, which otherwise we fix it with the suture and uh uh finger glove on the trocar. So instead of that, this will remain like that, of course, uh these are size but you can get even smaller size. Now, again, the stapler, if you have handy, it will help you in some of the difficult situationss, particularly if you want to control the vessels or uh you want to do lung biopsy or uh uh uh to control the bronchus, the staplers are the good thing to have. Now, many, if you have your, uh, if you are working in a children's hospital, then many times you don't have staplers and you may have to order, uh, before the surgery depending upon what you are doing. Now, like laparoscopy, even in thcy, Ergonomics plays a major role uh to carry out the surgeries. And, uh, as I told you told, you always have a guard on Procar and fix it with the skin. Idea is lungs should not expand against your telescope. So if there is any air leak around the trocar, then lung expands and you can't proceed with the surgery. So this is like a religion. And we tell all our uh uh students to carry out this for all surgeries, use of gravity, triangular site of lesion distance from the lesion anterior now, and this is very important anteriorly. This space is larger than posterior surface of the chest. It means that if you want to introduce any large instrument like sta like helo clip, if you introduce from the anterior part of the chest, it is much easier than posterior removal of specimens. Similarly, you can carry out from the anterior port. Uh Yeah. So if you have to think about ergonomics, this is one of the examples you can see there is a small neuroblastoma. This was a 10 month old boy who came with ops Myoclonus. And then the only investigation was to find found to have a neuroblastoma at the level of T 10 to T 12. Uh And uh yeah, this is do scan, you can see the lesion there. So then when you are planning to take it out thoracoscopically, you need to understand three dimensional anatomy. So we mark out the vertebrae, then we marked out this is D 10 to D 12 level and the tumor or neuroblastoma will be lying somewhere here. Now, if it is here, where should I put my first port for the camera? Whether I should put here here here. If you go too far, then lung will come in your way. Uh Because in a 10 month old, the selective ventilation is going to be difficult. So we will have to use the CO2 in circulation. Uh And if there is a leakage, then lung will come on heart failure and then the the working ports will be 34 centimeter away from the primary port so that we have adequate triangulation. At the same time, we want to have some distance from the lesion. If you have 789 centimeter from the lesion, the distance it would be good for carrying out this surgery. If there is a semi prone position that will help uh uh exposing the area of interest. So something like that, we will be standing here and the monitor will be somewhere there. So in each and every patient, you have to think three dimensionally when you are going to put your ports, whether it is laparoscopy, thoracoscopy, any other surgery, we will discuss some of the conditions which are common. So acute, uh whether to do now what is acute, thin uh let's see the video also simultaneously. So there is a thin exudative pus this stage last typically for 34 days. We used to read that it is for seven days. But today we say three or four days, you know, after that, the local population starts developing, the pulse becomes very thick. Um So I if they come early, 1 may try aspiration. And if you are happy with that, that you got rid of everything, you might not do anything but most of the time you need D insertion or you can do or thoracoscopy. Now, in general, our experiences in any stage, if you do thoracoscopy, the results are better than uh uh uh doing conservative management with ICD, the results are better in the sense, the ICD requirement is for 2 to 3 days. The fever settles down in 2 to 3 days provided you are giving proper antibiotics. So like this, this is early second stage or uh you know, if there was not that, that much of thick fibrinopurulent material, then you can say it is uh stage one. but here the fibrinopurulent material is there. So you will call it as it uh uh uh early stage two. Now, what we are saying is we are inserting the open instrument. Now, this open instrument should be large blade if it is and it should be gentle curve. So we can hold the big chunk of this uh equip uh this stuff and take it out. Now, what we like to have at the end is the fissures, we should be able to see uh we should be able to see the cardiophrenic post phrenic angle and most of the stuff if we are taken out, we are happy, we cannot take out each and every fibrilla material, the lung is expanding. Well, this is what I like to see. And then you put the ICD under vision and come out. So that's the ICD. Now, the subacute stage in this stage, there is acute exudate uh or fibrinopurulent material. So if we do sonography, there will be loculations. And in this stage, if you put ICD, that is not going to work and we need to mechanically get rid of this thick fibrinopurulent material. The illness is uh if you go into the history, it will be more than 5 to 7 days. Best thing is to do thoracoscopy and most of the time we can uh get away with just two trocars with one, we introduce camera depending upon age. We can use either five or 10 scope uh 30 degree scope we use called open instrument as I told you earlier. And in between, you can change the scope and instrument site. Generally, we put it in uh uh mid Axillary line. Third intercostal space is 1/4 incision and sixth intercostal space is another I stand anteriorly uh of the patient because most of the collection is posteriorly, the monitor is usually posteriorly. Now there will be stuff or fibrinopurulent material even anteriorly. So if you have a monitor anteriorly placed the second monitor, you can go behind and then do this part, then it becomes easy. So you can see this is, I think this is the uh cardiophrenic angle or costophrenic angle, one of the angle which uh has been clear. So once you clear everything, then then you uh put the ICD and come out and whenever the drainage has stopped, you come out. And the last is chronic empyema. So in chronic emp earlier, we thought that we will not be able to do it thoracoscopically. Today, we say if we can get the space to work, we can do it. So uh in this, we will need three ports, one for camera and two working ports. Uh We may just take the incisions, multiple incisions on the thick pill using hook. And once you do that, then you try and dissect between the pill and the lung and then take out the pill as much as possible. As I told you at the end, what you want to see is the expansion of the lung. If the lung is not expanded, then you need to do more. If you are not comfortable thoracoscopically, you may do open, but the lung expansion is mandatory. Uh uh Yeah, sorry. Uh Now, if, if uh of course, you have to remember, you don't want to go into the pal area where the PLT vessels will be there in the mediastinal area where again, the major vessels and heart will be around. So you have to be careful. I have opened the diaphragm in my, I think third or fourth case and this is the early stage and then we converted into open and repair the diaphragm. But you have to be careful. As I told you, the diaphragmatic attachment. If you, if you uh are uh uh if you use a lot of force on diaphragm to take out the pill, diaphragm will get, uh that is one way of injuring diaphragm. The second is you can open even in the center because it's all errant and you have to be careful whatever you are doing. Um As I told you, end point is the lung expansion. Now, the lung necrosis when it is present, then the surgery becomes difficult. Uh Then if you are doing a thoracoscopically, first point is we have to identify whether it is localized, this little bit area of the lung is bad or the entire lobe is affected. If it is small area, then 1 may go ahead with the pride. If the entire lobe is affected, then the lobectomy is required and I am not comfortable doing it sical and I will I think do it open. We have not done many like this, but uh we have done, I think two or three lobectomies where the entire lung entire lobe was bad. Now move you plan debridement, whether it is copy or whether you are doing open that you have to remember, tissues are extremely friable and likely to bleed profusely. And before the debridement is started, keep blood ready in the operating room. And from the anesthetic you, they may start the blood because these kids are sick. Uh always check open control is ready. If there is a head may remain prolonged if you have done it. Sical shortening of brain may be considered if lung expansion is good. But in uh if you do uh shortening or if you remove and if the child develops a recurrence of pneumothorax, best thing is to go in and take care of it uh by open surgery or whatever thoracoscopically. Now, the lung biopsy is another condition which uh can be done. Now, if the child has bilateral disease, then we prefer the right side because it has two fissures and multiple angles. The stapler is handy. If you have multiple lesions, then it becomes easier. If it is single reason, even then one can do it uh to it. I mean using staplers. So here is a video which will show you the stapler. But if you are going to use stapler, always remember, whatever is the cartridge size length, you need at least 23 centimeter beyond that, that leg. So most of the time we end up taking out the trocar and putting the stapler directly and then you have to be fast so that you can do the procedure. Because if it is bilateral disease, the kidney can desaturate. If you are reticulated stapler, it becomes easier. One can use endoloop technique also and preferably v endo loop and two loops should be placed. If, if it is metas in in postcancer patient, if there is any nodule, then one needs to identify histopathologically whether it is metastatic or inflammatory. So the biopsy is mandatory. If the lesion is on surface, we will be able to s see it on thoracoscopically. If it is a death, then one can inject patient's blood under ct guidance near the nodule on the surface and then one can do it. Thoracoscopically confirm on frozen section, whether the nodule has come out or not, if it has come out fine, otherwise do it open. So if the nodule is deep, this is what one can do. Now again, this is just to tell you again that if, if you are going to put large instrument like stapler amlo clip use anterior side or anterior port because the space is larger. Now, diaphragmatic hernia, the steps includes the head, high position, increase the pressure. Sorry. So how the uh these are the steps reduction of the content? This is done by giving a eye position, increase the pressure gradually from 56789, 1011, you can slowly increase. And along with that, you put your rest of the instrument, the blunt grasper and gently push it into the uh abdominal side. If there is desaturation, wait for a couple of minutes and then restart. Cause the anesthetic are comfortable. Uh One can do a small laparotomy and reduce the content to repair the diaphragm. Put the back the uh uh uh b into the abdomen and close the abdominal wall. If suturing is under tension, then use sliding or tumble. Not technique, one can use extracorporeal suturing or knotting techniques also always reduce the pressure of CO2 in circulation, especially your suturing on the lateral aspect because otherwise the sutures will not be tight enough, they will be loose. So reduce the pressure. What pressure you have increased at the time of reduction of content should be decreased at the time of the uh suturing of the diaphragm. The first couple of suture, you may leave the pressure high but then decrease it me should be handy in case if you need to do reinforcement. Uh I am fortunate enough that uh we probably don't have very bad patients and uh defects and we are able to close all our defect primarily. Uh If there is deficient diaphragm, this is what we do unplug the diaphragm where it is attached, but make sure you don't detach it. So you have to be gentle use of rib and not the intercostal space. More common with the anterior lateral defect, use of mesh can be done suturing always the ages when you are suturing so that you know, you are not taking any structure from the abdominal side, 20 polyester or bone suture. This is what we use in general, but you can use silk. Also, you can use any other nonedible suture. So these are a couple of videos which I'll show you. Yeah. So uh this is the right side. We have the newborn with anterior lateral defect. So this is anterior, this is lateral part. So anterior lateral defect on the left side, you have the diaphragm. Uh this was a 10 month old girl uh who had a very large defect and we were not sure whether we will be able to do it or not. Now, this is, you know, that's the esophagus that aorta always remember. So we said, let's try. So uh we, we, we started first suture, you know, midway and then continued. Fortunately, we could close it on the right side. You will see the how is the tumble knot. So first note, you put a regular suture, then you put another note and then you slide it now the uh short side and then continue. Now this is an you, you separate it out a little bit so that you get little more diaphragm to close it and you want to separate from the, from the uh chest wall so that some part of the peritoneum should be lying along with all the lining over the muscles. If the muscles are completely ba then it may not work. So that was the first suture which has been placed. So again, you will see the tumble no or sliding note, watch carefully on the left side, this is how we do it. Now, this is 201. So it is relatively easy to slide. If you use 4050, then they are not easy to slide. Now all the this media sutures will come easily. Now, yeah, they will come easily only will be a little difficult on the later side. So we will take it along with the cage. And as I told you remember to decrease the CO2 in circulation pressure, even if you stop it, it will be all right at this point. So that is the suture which will come, we will use uh uh loop suture to pull out the suture and then tie it as the diaphragm raises, rises, then it comes closer on the right side. Also, you can see how we are using the loop suture to pull out the stitch and the knot will be tied in a subcutaneous area. So I'll show you one more small video clip. This is how you have to decide about diaphragm can visualize it. This is patient is in later position. This will be the posterior later defect like this. So how we are going to put your ports again? Remember that after putting your first port, always see the defect, whether it is anterior posterior where, where you will put your 2nd and 3rd port. Because if it is anterior de defect, this anterior port will come very close to the zip and then the suturing becomes very difficult. So here you see, there is a diaphragm is completely deficient anteriorly. So entire diaphragm, we had sutured with the rib cage. And always remember, you need to suture with the ribs and not with the intercostal muscles. If you do with the intercostal muscle, there is a risk of recurrence. So this is how the loop suture will be used to pull out the thread. Now, some of the defect where the the defect means uh there was complete defect and we had to suture with the ribcage. We put all the sutures using this technique. There was no intracorporate suturing required. All sutures were done uh using loop technique and all sutures were tied in a subcutaneous area. So ergonomically, I will have the patient head very close to the end of the table. I will be, if it is posterior lateral defect, I will be standing anteriorly near here. If many times it is anterior lateral defect, then my position will go there. This is for the left side of the diaphragmatic hernia. So if it is posterior lateral defect monitor is here. If it is an inter lateral defect, the monitor can come here. So always be prepared to change your position, of course, as well as position of monitor depending upon what you are going to find inside because ultimately, you want to be comfortable so that you can do a better procedure. Yeah, if it is MG as we do it laparoscopically, we will not go into details of that. Uh You'll see one video of the fistula. So this patient you can say you can, this is the axillary uh azygous vein which has been uh bipolar and then divided. Now you can see you are directly on the fistula that is the beauty of uh thoracoscopy. Uh and the way in which you can see you can't have this view even when you are using magnifying glue, that's the vagus. Now, you can see very nicely vagus. Now, you can see the upper pouch once you put the catheter in little. So yeah, the anesthetic are pushing the catheter. You can see nicely uh upper pouch. Then we are putting a, a suture or loop to elevate. That's that you can see nicely the junction of the fistula junction of the lower pouch of the esophagus with the trachea. This is 50 P suture. You can do transfixation. You need to have adequate experience of suturing in a small space. If you have that, then you can do it thoracoscopically, it takes extra time, not only particularly in the initial uh experience, it may take extra time, 2.5, 3 hours. But as your experience increases, you can complete the procedure in uh uh 1 to 1.5 hour. Yeah. Then you speculate the lower pouch of the esophagus. You can use 5060 PD. You can use tri whatever you are comfortable with. So this was a stitch was placed and we could dissect the esophagus right up to the neck and you have to be careful like what we call uh uh sharing wall with the trachea. So use the sharp dissection in the lower part, the upper part will come out very easily using blood uh dissection. So you dissect it out and then may, you can go right up to the neck as I told you. And the view what you get in Cortico is beautiful and then you start uh suturing. So that is the opening which has been done in the upper pouch and then you can start anastomosis. So we had used 50 PDA S to suture that these videos are there on youtube. So you can see it. I just fast forwarding it and then you put the ICD and come out. So what is the advantage? Thoracoscopically? It is transpleural, it takes extra time. The visualization is better, you control the fistula is the first step. If you are doing open surgery, it can be transpleural, extrapleural, it is operating time is relatively less there is adequate visualization. The incision is the first step and control of the fistula is later. The problem with open surgery in uh TF and even in other surgeries include shoulder elevation, chest deformity, abduction, limited spine deformities, breast deformities, all these. So this is what has been reported in one of the paper probably it is much less than this, at least today with whatever refinement, but it is still there. So if you are doing any surgery, thoracoscopically, you can avoid all this. So if you are doing it thoracoscopically, you decrease the chances of a musculoskeletal sequela, superior visualization of anatomy, easy to identify fistula, full ligation we'll discuss about lobectomy uh in next 1012 minutes and then uh we'll call it a day. So as I told you, you have to have anatomical knowledge, you have to have equipment including bipolar vessel, sitting device clips, staplers, surgeon stands anteriorly and monitor this posteriorly towards the face. Fourth insertion. Like you have to imagine the right uh lower photograph, the fissure is going to be oblique like this. That is a horizontal fissure. This is on the right side, right, upper lobe, middle lobe, lower lobe, you are going to work in the fissure. So your port has to be somewhere here in posterior exit line or uh uh mid axillary line in the 4th 5th intercostal space uh or maybe even lower down and then two more ports so that you have adequate visualization of the hilum fissure. And that is how we are going to work. We are going to work anterior to posterior. So we will skip some of these slides and let's see. Yeah, this is one of the uh right uh upper lobe CPAP. I'll show you video of that. So just imaging again, five minutes because there are lots of questions. So we'll need to uh OK those questions and I Yeah. Yeah. OK. Yeah. So this is uh uh the port side, we'll just see the video, I think a little bit of that. So we have, so you, you are, this is like chest wall, if you have to see, you know, thoracoscopically, this is the right upper lobe and you can see that is the phrenic nerve on the IVC uh so beautifully, you can see, I uh not, this is OK when I the nerve was just behind that. Now, you can see there's the right upper lobe and this is the middle lobe and you need to develop the fissure. So if, if, if you have bipolar vessel sealing device, you can, you can develop the fissure and continue dissection towards the high number. So that dissection is being carried out. Now, if you are lucky, then the fissure is completely developed, then the procedure becomes easy. Now, here you we are dissecting. Now, the hilar area, you can see these are the pulmonary veins, there will be pulmonary artery also. So you have to carefully dissect. Now, this instrument is beautiful where you can dissect, uh it's a blunt tip, so you are less likely to damage. So after the fissure is completely developed, you can see all each and every structure well. Now we were not comfortable to completely rely on bipolar vessel sealing device. So after dissection, we use envelope clip to take care of all these vessels. So that's the pulmonary vein which is being dissected. So that's the pulmonary vein which is under dissection. That was the pulmonary artery, which has been dissected. And if you loop it like this, then it becomes easier to put the clip, hemlock clip. So that is the the envelope lip has been placed, that locking will make sure that it does not sleep. So you can continue dissecting and take care, taking care of the vessels. Yeah. So at the end, the bronchus, you can either uh uh staple or you can put the helo clip in this particular patient. We had put the amlo clip, we go towards the end, all the vessels were clipped and then divided using the bipolar vessel sealing device. Even at the end, there will be some vessels along the bronchus. And you have to be careful, you have to control them. Uh If uh we, we had to convert one patient because it was bleeding torren and we did not take the all possible instrument. It was in a government hospital. So uh you, you have to be careful. That is what I'm trying to say that for a little bit uh one vessel you end up opening up which you feel feel bad. So that's the bronchus which has been uh double ECL and uh uh we are done with it. Uh Tumors can be done. I will not go into the details of that. We have done large ganglioneuromas, neuroblastomas, multiple of them, mediational cysts can be done so anything and all surgeries can be done. II went through something which was not very common because uh or advanced surgery uh into little more death. Uh If complication and troubleshooting will include bleeding where you can suck and control, you can put gauze so that you can give a pressure. You can use bipolar forces, veiling device clips and low staplers. But most important thing is keep open to ready and convert to open surgery. Air leak can be controlled using sutures or staplers. But if there is a leak, always put two intercostal drains. Thank you very much. If, if I can take care of questions, if anybody is going to ask, then it may be easier. Um Yeah. Ros Thank you very much. We exceeded the normal time of presentation, but it was going so nice and so interesting. So I didn't interrupt you. Um Yeah, I think few things you have repeatedly told all of us is that knowledge of anatomy is mandatory. Experience of open surgery is mandatory and you need to be prepared for all eventualities and you should have very small ego or no ego. And if things are not going well and there is trouble immediately, you must convert. So I think those well taken, there are at least half a dozen questions. Um And the first we'll start with one after other doctor Mansour Nasa who is joining from Ashkan, his first question is can three millimeter castors, Robie Bipolar substitute three millimeter Boulder Sealer. Uh We have used bipolar forceps. Uh But uh I think uh the vessel sealer are a little better than just plain bipolar. Uh We, we don't have three millimeter uh vessel sealer. So we end up using five millimeter. Uh But if you have access to three millimeter vessel sealer, I think that would be the best. If you don't have, then you can use three millimeter bipolar. But on a smaller vessel, you can't use on it on a larger vessel. OK? I think he also has uh one more question related to esophageal atresia repair divide or not divide a weight. So my take is by dividing. If my life is becoming simpler, then I will divide it. I don't think it affects the results in any way. Like some of the papers may have uh described better results by not dividing. Uh It does not make sense to me, but there are a lot of people they don't divide and they carry out the surgery. So I think it is up to you what you like, you do it. But uh I like to divide the one in open and I continue doing that in uh thoracoscopy. Mm II fully agree with you. Then the next question is from doctor A mu how long can we wait for air leaks to subside before deciding to go again. I believe he's talking about uh emp emp. Yeah. So my take is if the lung is expanded, I will give a trial of 8 to 10 days. Uh And then I will claim ICD. If the lung remains expanded, I will take it out or shorten the ICD. Yeah, most of the time it will work if the lung remains expanded. But there is uh the last patient which we did about a month back in that child, there was recurrence of collection of air. We had to go in and take care of that. So uh when we went in, of course, II went in with open surgery because there were a lot of adds also. And uh so usually if you are going to wait with, I think you have to give 8 to 10 days minimum for adds to develop between visceral and parietal pleura. So when you shorten the drain or when you remove the drain, it will the air will not get collected between the two. I think I'm clear. No, no, you made it perfectly clear. You see the next question is from doctor NM consultant in our department. Would you advise using a clip to ligate the tracheo fal fistula? I mean, I have not done it, but certainly a lot of people are doing it. But in general, what is the trend today is not to use clip in any surgeries? Because there are problem with the clip migration. So even adults, I think they are saying today, if you can ligate any structure, whether it is cystic duct, artery, whatever it is, it is better than putting a clip. So uh you can do it. I mean, a lot of people are doing it. So there is no reason not to do it. But if you can suture, I think that is better. I think that's very sound advice. Then the next question again is about esophageal atresia. How important is it to live nasogastric tube? And ICD? I think so. So we put it in all you can give your advice. Yeah, we put it in all uh I did not uh discuss about that, but we did put it in. We, we do put in all patients. OK? And we start feeding after a couple of days through metric you. Yes. Yes. We also do the same. Um That's the same practice. I think what you do in open surgery, you practice it. Yeah. Yeah. Surgery. Then another question is, what do you do in a fused fissure? I think it's probably talking about lobectomy. Yeah. Yeah. So I, II mean, we use the bipolar vessels in there and uh control that and divide it. A lot of people will dissect right near the high LM and then fire the stapler uh to open up the fissure completely. So these are the two options which we have. Yeah. Uh I think the last question uh is probably uh self-explanatory, but you can answer Doctor Patkar from Mumbai, what is the criteria intraoperative to decide it's long gap? And how would you proceed then? So, I mean, if it is under tension, if it is not coming closer, there are no obvious criteria uh like uh vertebral spaces or you put it uh any uh ruler or there's nothing like that. It is more subjective. If you think it is not coming close enough, then it is a longer Resia and you, you take care uh as you wish. Yeah. No, that, that's wonderful. Th thank you. Um uh invite uh any comments from doctor uh Hans man who also who um most of us in South Africa know, he's a senior consultant, pediatric surgeon in Pieter Maritzburg in Kwazulu, Natal. He does uh thoracoscopic surgery and he is also a faculty in Amas Institute in Mumbai. So Hansi uh thanks uh Malin and uh thanks uh Rai for giving us this insightful lecture. And I must say he's uh definitely one of my mentors that stimulated me to uh you know, uh proceed and expand the minimal access surgery in South Africa. And uh so we are following a lot of these principles so routinely doing our esophageal atresias and C DHS uh thoracoscopically and uh using the similar sort of uh principles uh just to, to add that, uh you know, with the regards to the vessel sealing, we're also following uh a two step sort of procedure with the uh vessel sealing and uh clipping or, or suturing. Uh In addition, and we've had one experience where during a lobectomy, the hemo clip actually fell off while we were doing the lobectomy. And uh therefore, we do encourage that. And uh I must say, uh you know, uh has encouraged me. So uh to the extent that we developed our own uh uh laparoscopic suturing course in Ter Maritzburg. And uh we, we focusing only on suturing and that definitely has uh expanded the practice, uh you know, within the province and uh uh uh throughout South Africa where we could actually teach more uh uh students and trainees and uh allow them to do more operations um using minimal access surgery. And thank you. Thanks for your time and teaching us. Thank you. I think what said uh suturing, I think that is the crux. If you know suturing in a small space, you can do anything and everything in pediatric surgery. No, ve ve very sound advice. I think I see you need to, um you need to arrange a workshop and you need to invite uh doctor Shah to visit South Africa. I don't think he has visited our country. Not yet. Yeah. So, so before I retired in the next three years, I will ask for very quick comments from two consultants from outside our department. And then finally, um uh my senior consultant in my department. Uh I see Doctor Shaman Harilal is here. He is a consultant, pediatric surgeon in private practice in Cape Town. So Shama a anything different? Have you people tried at all? Do you know what happens in Cape Town? In, in state hospitals? Hi. Um uh Thank you so much. Thank you so much. Uh We, we really appreciate all the input and um like uh um doctor man said, uh all the mentorship that you've given us to us while we were developing in, in P Maritzburg and we're still getting, he gets muted. He's muted. Yeah. Yeah, you, you got muted. Some again muted. You need to unmute yourself. Yeah. Yeah. Cut off. So load shedding. Um Yeah. Um In, in terms of Cape Town, um I've managed to do the first uh thoracoscopic esop atresia in the province here um a little earlier in the year. Um Sorry, uh at the end of last year. Um So that was the first one that was done here. Um And I think one of the, and the first uh total um um uh colectomy as well for a kidney with advanced uh IBD. Uh So hopefully uh with uh continued um presence in the province, uh we can sort of expand the minimal access um aspects of, of surgery here as well. Excellent. Well, then I think due to shortage of time, I'll ask final comments from Doctor Yashoda manic chan who is a senior senior consultant pediatric surgeon in our department. Ya. Uh Thanks pro and thank you, Doctor Shah. That was a really uh informative, really beautiful presentation with the videos. Uh such good practical advice. I just have a question about a recurrent uh tracheoesophageal fistula in a 1 to 2 year old after an open um Thoraco thoracotomy repair as a neonate. Would you attempt a thoracoscopic approach to close that fistula? And if you have any um tips about an endoscopic approach as well, it would be the previous. So, yeah, see endoscopically, we have done uh four of them. First two, actually, I was learning, it did not work in 3rd and 4th, we knew exactly what is to be done and we could uh tickle it. Uh uh we can, we can we got the results uh successful results. So the crux here is you have to have double lumen tube to inject uh the two solutions so that they meet right near the fistula. So what we do there is a video on youtube. You can go and see first thing we will put a tube uh endotracheal. Uh I mean, you put a scope, we use a cystoscope or nephroscope or whatever the scope. And with the scope cystoscope, you have that working channel through that you put a bug or try the fistula, then you take out the bug and put a double lumen tube, either it goes not to, but you can call it as a catheter, it is fine, maybe a couple of range in size, uh, either through the scope or by the side of the scope. If the scope does not take it and then go right near the fistula opening, inject both the solution when you are injecting, keep the child. Uh, I mean, the ventilation should be stopped, there should be apnea. You have to inform the anesthetist inject, wait for a minute, then go distally with your scope and start ventilation gently allow the uh this uh solution to solidify. And then then you can have successful results of endoscopy. Uh As far as the uh the thoracoscopy is concerned, I don't have any personal experience but a lot of people are doing it successfully. Ok. Thank you so much. Yeah, that was very helpful. Thank you. Um I think uh we are ready to conclude. So maybe your final, final uh message before uh we conclude the meeting today. Yeah, II wanted to ask how common is in your country. Um Maybe you should talk, I'll talk to you. Uh Well, we we're not actually managing the empyemas because the cardiothoracic surgeon, the cardiothoracic surgeon does even in the pediatric age group. Uh But yeah, I think after trauma and you know, like uh infected empyema is the most common. I'm not sure about how common it is. I think it, yeah, but a decent amount. Ok, fine. So, uh anyway, it was wonderful to give this particular talk and uh looking forward to uh mean, I do attend the, the whatever program you people arrange uh because many of them are quite informative. So thank you for the invitation and looking forward to participate in future. Thank you. Uh Thank you. Thank you all for joining uh lots of people attending from all over the world, which actually is an honor for us. And exactly in a month's time on the second Tuesday of June, we are expecting to have a nice talk uh uh from another friend of ours who works in Mumbai, Doctor Santhosh Karar, a senior pediatric surgeon who has done a lot of work on spina bifida and uh and uh that type of problems. So he will be talking about spina bifida. What does pediatric surgeon need to know? Uh So thank you all. I will convert the recording and late today or tomorrow morning, it will be available on my youtube channel for those who want to uh visit it again or those who couldn't attend. So thank you for attending. We'll see you next time. Bye-bye.