Hemidiaphragm paresis results in significant morbidity after repair of congenital heart defects. Early diagnosis and plication result in timely extubation. The plicated diaphragm demonstrates return of function that may improve over time. This is the first study to numerically quantitate the degree of diaphragm recovery.

Introduction Super-morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) present unique technical challenges. In our experience the ease of the operation and the operative time seem to be more dependent on body habitus than body mass index (BMI). We hypothesized that the distance between the xyphoid process and the umbilicus (the XU distance) correlated with surgical difficulty and described an original modification of trocar placement based on this measurement to improve the ease of the operation. Methods Seven hundred and seventy-four patients underwent LRYGB, and the XU distance was measured in a subset of 38 patients midway through the experience. The need for additional trocars was assessed intraoperatively and the relationship between the XU distance and the need for extra trocars was subsequently analyzed. A standardized approach for trocar placement was implemented in the second half of our series. The operative time was compared between the standardized and nonstandardized groups.Results Fifty percent of the patients required a five-trocar technique. Median XU distance in this group was 21.4 cm (range 17-25 cm). In the remaining 19 patients additional trocars were added; median XU distance was 27.3 cm (range 24-33 cm). From the 774 patients included in the study period, the operative time for the first 322 patients who were completed with a nonstandardized trocar approach was significantly longer than the subsequent 452 cases in which the standardized trocar approach was used (210 versus 173 min, p \ 0.001).Conclusions We define XU distance as the key element in determining the choice of trocar placement. When XU distance is less then 25 cm, the basic approach should be used and if it is greater than 25 cm, the advanced trocar approach is recommended. This standardized technique leads to decreased operative time and improved ease of operation.Keywords Morbid obesity Á Laparoscopic gastric bypass Á Trocar placement Á Surgical treatment of obesity Á Ergonomics in laparoscopy Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a technically demanding procedure with a learning curve of approximately 100 cases [1,2]. Patients with a very high body mass index (BMI) present unique challenges.In our experience ease of the operation, and consequently operative time, seemed to be more dependent on body habitus than BMI alone. Patients with significant central obesity (apple-shaped) were surgically more challenging and had a prolonged operative time compared to pear-shaped patients, independent of their BMI.We noted that the distance between the xiphoid process (X) and the umbilicus (U), which we defined as the XU distance, was significantly greater in patients with marked

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Vascular surgeons of all backgrounds play an important role in providing high quality vascular surgical care in their communities. In America, with our diverse population and communities, patients presenting with vascular disease are very common and could pattern the community demographic. Often faced with the challenges of community hospital politics and demand, the vascular surgical workforce has continued to be active members in their communities, focusing on their strengths to lead vascular surgery healthcare in an environment of high patient demand. Having a varied vascular surgery workforce provides all patients afflicted by vascular disease a comfortable opportunity for compassionate and empathic vascular care. This is a significant strength of vascular care when diversity, equity, and inclusion are supported by the leadership.

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