Evaluation of a Novel Bony Landmark-Based Method for Teaching Percutaneous Insertion of Subclavian Venous Catheters in Pediatric Patients

  • Zhiyang Jace Lin
  • York Tien Lee
  • Joyce Horng Yiing Chua
  • Rachel Wang
  • Vanessa Lee
  • Sue Mei Cheah
  • Seyed Ehsan Saffari
  • Joyce Ching Mei Lam
  • Amos Hong Pheng LohEmail author
Original Scientific Report



Surgical trainees performing subclavian vein (SCV) cannulation often incorrectly perceive needle trajectory and anatomical relations. As surface landmark-based methods derived from adult surgical practice may be less effective in younger patients, we developed and evaluated a novel bony landmark-based method for teaching SCV cannulation for central venous access device (CVAD) placement in children.


Over 2 sequential 3-year periods, pediatric surgical trainees were taught infraclavicular SCV cannulation via surface- and bony-landmark approaches, respectively. We prospectively recorded patient, surgeon and operative details on all Hickman line and port-a-cath insertions placed by trainees as the first surgeon via percutaneous infraclavicular SCV puncture and compared procedural outcomes and complications across both periods.


Of 271 cases included in the study, trainees performed 52 (50.5%) and 92 (54.8%) procedures in the first and second periods, respectively. Patients in both periods did not differ by gender, disease, CVAD device, or prior CVAD, chemotherapy or infection status. In the second (bony landmark) period, although patients were younger (6.0 vs. 8.7 years, P = 0.003) mean procedural duration was shorter (42.5 vs. 58.3 min, P < 0.001). Also, cannulation attempts and complication rates did not differ significantly between study periods (P = 0.257 and 1.0, respectively).


With the bony landmark approach, trainees could perform the procedures faster despite operating on younger patients, without impacting complication rates and cannulation attempts. Bony landmarks may better approximate SCV position across a range of ages, thus improving the consistency of SCV cannulation in CVAD placements in children.



We thank Dr Evan Lim, DVM, MSc (Medical Art); Ms. Germaine Liew and Ms. Jillian Teo, Singapore Childhood Cancer Registry; Ms. Tan Sheng Hui, VIVA-KKH Paediatric Brain and Solid Tumor Program; Ms. Candy Choo, Department of Paediatric Surgery, KK Hospital.


This work was supported by the VIVA Foundation for Children with Cancer (AHP Loh), and Children’s Cancer Foundation.


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Copyright information

© Société Internationale de Chirurgie 2019

Authors and Affiliations

  • Zhiyang Jace Lin
    • 1
  • York Tien Lee
    • 2
  • Joyce Horng Yiing Chua
    • 3
  • Rachel Wang
    • 4
  • Vanessa Lee
    • 4
  • Sue Mei Cheah
    • 5
  • Seyed Ehsan Saffari
    • 6
  • Joyce Ching Mei Lam
    • 7
  • Amos Hong Pheng Loh
    • 2
    Email author
  1. 1.Flinders University School of MedicineFlinders UniversityAdelaideAustralia
  2. 2.Department of Paediatric SurgeryKK Women’s and Children’s HospitalSingaporeSingapore
  3. 3.Children’s CentreRaffles HospitalSingaporeSingapore
  4. 4.Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
  5. 5.Department of Paediatric MedicineKK Women’s and Children’s HospitalSingaporeSingapore
  6. 6.Centre for Quantitative MedicineDuke-NUS Medical SchoolSingaporeSingapore
  7. 7.Department of Paediatric Subspecialties Haematology Oncology ServiceKK Women’s and Children’s HospitalSingaporeSingapore

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