Right radial art line. Positioned with a roll under the rib cage and left arm above head with securing tape. Slightly rolled anteriorly. Strapped at the hip to the table. Soft roll between legs. Mark spine, nipple, scapular tip. Feel the rib spaces to note how horizontal or oblique they are, as neonates tend to have more horizontal spaces.

Incision starting laterally extending posteriorly, straight line; not too close to the scapular tip.

For muscle-cutting, open the fascia between trapezius and latissimus. Identify the latissimus running from the broad lower thoracic ribs to the humerus. Place forceps under lat.dorsi and come out anteriorly isolating the muscle bundle and transecting it cleanly. Avoid cutting the serratus. Can cut part of the trapezius posteriorly to enlarge the incision. Score the periosteum on the rib to create a flap of intercostal muscle. Stop the lungs and enter the pleural cavity, opening it widely with forceps to protect the lung.

Place the retractor with the handle anteriorly. A couple of small wet mastoids and malleable to retract the lung anteriorly to visualise the anatomy of the arch and descending aorta.

Open the pleura over the aorta and extend it towards the subclavian and the descending aorta. Place a silastic loop on the subclavian and the descending aorta to retract them posteriorly. Dissect the mediastinal pleura anteriorly, identifying the duct, arch and nerve – use DB, curved ratchetless. Place stays on the pleura taking the nerve on the pleura, and a small gauze to retract the lung. Transfix the duct proximally and distally with 6 or 7-0 prolene.

Divide the duct and keep the proximal suture on a stay, cutting the other suture. Complete mobilisation including to the intercostal arteries and the brachiocephalic trunk. If need be, transfix/ligate an intercostal artery in the way. Test the mobility of the vessels, test the clamps, 6-0 needle prolene ready.

Clamp distally, and clamp proximally. Cut obliquely distal to the subclavian. Excise the ductal tissue. Forward cutting Potts to cut the arch more on the anterior aspect (so the suture line is more easily accessible). May or may not need a counter-incision distally. Adjust the distal clamp as necessary to get a tension-free anastomosis. Ask assistant to bring the clamps together if possible.

Start just at or above the corner. Outside-in on the left (DAo) with the other end on a shod. Inside out on the right (arch). Bring the needle under the suture to avoid tangling while continuing to suture on the posterior line. Minimise handling of the edges of the aorta with forceps. Parachute after the first 2-3 bites, with clamps taking the tension. Complete the posterior line as forehand shots and and place on a shod. Take the other end and start outside-in on the right (arch), inside-out on the left (DAo). Complete the anterior suture line as forehand shots. Warn the anaesthetist about removing clamps soon. Ensure follows are tight and tie.

When removing distal clamp (left hand) hold the DAo with forceps (right hand) to avoid excess tension. Remove the proximal clamp. Pack with a swab, and complete haemostasis of the suture line.

Place drain (tunnelled). Close the mediastinal pleura (+-). Close the thoracotomy. Monitor for recurrent larygneal injury and chylothorax.