Answer to Quiz #1: What is the surgery (surgeries) shown in this image?

Answer:
Components of the surgery shown in the image are the following:
1) Classic/Unidirectional Glenn anastamosis (SVC - distal RPA connection)
2) RA connected to proximal RPA stump.
3) PA band or PA ligation
4) Two biological valve: one between IVC and RA, other between RA and RPA. This was supposed to ensure that RA contractility - thought to be important as a pump for pulmonary circulation - can be transmitted only forward, into pulmonary circulation.
5) ? Right atrial appendage anastamosed to RVOT (Not sure if this was part of original Fontan operation - published in 1971.

As we know, much of this operation has changed since 1971. But, the concept remains the only solution for children with single ventricle.

Differences between 1971 Classic Fontan and the figure in WJPCHS are the following:

1) In Classic Fontan, a pulmonary homograft valve was placed inside the native IVC-RA junction (In 2012 image, it appears the there is interpositioning of a piece of homograft. This would entail disconnecting IVC from RA and then, placing this homograft.

2) In Classic Fontan, an aortic homograft was sutured to the proximal stump of RPA first. Then, the other end of the aortic homograft was sutured to RA appendage. (In 2012 image, RA appendage seems to remain undisturbed. the aortic homograft is sutured on to top of the right atrial wall.

(Picture of "Classic" Fontan operation is from Fontan, F. & Baudet, E. Surgical Repair of Tricuspid Atresia. Thorax 1971;26:240-248)