[level-membership-for-pediatrics-category]

CHAPTER 7 Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula

Step 3: Operative Steps

Anesthetic Induction

♦ If the anesthesiologist attempts to place the endotracheal tube past the fistula, care must be taken to avoid a right mainstem intubation, which can cause problems when the right-sided chest is insufflated and the right lung is collapsed.

♦ There is usually no need for bronchial blockers or other techniques to perform single lung ventilation.

♦ The same issues of anesthetic induction for open repair of esophageal atresia with tracheoesophageal fistula apply for thoracoscopic repair.

Positioning

♦ The patient is placed in a nearly prone position.

♦ Position the patient for success! You will have a much greater chance of completing the operation thoracoscopically if the patient is positioned for a thoracoscopic procedure, not for conversion.

Port Positioning

♦ The ports are positioned to facilitate dissection and suturing (Fig. 7-1).

♦ The “baseball diamond” should be maintained.

♦ Be careful positioning the most cephalad port site so that the patient’s arm does not interfere with mobility.

Figure 7-1

Establishment of Pneumothorax

♦ The chest is accessed first through the planned camera port site with a Veres needle (Fig. 7-2)

♦ Initial insufflation is with 3 to 4 mm Hg of pressure using CO₂.

Figure 7-2

Trocar Placement

♦ Generally, 3.5-mm trocars are used.

♦ A 5-mm trocar may be used for the cephalad (surgeon’s right hand) port.

Dividing the Azygos Vein

♦ The vein can be dissected and divided.

♦ Hook cautery is usually sufficient (Fig. 7-3).

♦ Impedance feedback bipolar cautery or ultrasonic energy (such as the Ligasure, Valleylab, Boulder, CO) may also be used with less collateral damage (although this requires a 5-mm port).

♦ Clips are not recommended because they can dislodge or entangle sutures during the anastomosis.

Figure 7-3

Dissecting the Fistula

♦ The fistula is identified by following the distal esophagus up to the trachea (Fig. 7-4).

♦ The distal esophagus can be identified by watching for respiratory variations.

♦ Care should be taken to identify and preserve the vagus nerve.

Figure 7-4

Dividing and Ligating the Fistula (Fig. 7-5)

♦ The fistula can be “test clamped” to make sure you have the correct structure.

♦ The fistula can be sutured or clipped. There have been reports of tracheal migration of metal clips. I prefer to use plastic clips or suture (Fig. 7-6).

Figure 7-5

Figure 7-6

Mobilization of Upper Pouch

♦ The upper pouch is mobilized while anesthesia places gentle pressure on a tube in the pouch. This maneuver is used to determine whether there is adequate length to complete the anastomosis.

♦ The pouch can be mobilized off the trachea if necessary.

♦ An adequate enterotomy is made at the end of the pouch (Fig. 7-7). This often entails removing the tip of the pouch. There is a tendency to make an enterotomy that is too small if no tissue is removed, which may lead to stricture.

Figure 7-7

Anastomosis

♦ Care must be taken to ensure that you have mucosa in each bite.

♦ Three back wall (medial wall) sutures are placed with the knots inside the lumen.

Each suture is tied after it is placed (Fig. 7-8).

If there is tension, two sutures can be placed with “slip knots.” The sutures are then alternately cinched down.

♦ Two corner sutures are placed with the knots outside the lumen.

♦ A small feeding tube is then passed transnasally or transorally by anesthesia through the anastomosis into the stomach (Fig. 7-9).

♦ The anterior (lateral wall) sutures are placed (usually three or four) with the knots tied outside the lumen (Fig. 7-10).

♦ The anastomosis is inspected and any additional sutures are placed as needed.

A chest tube is placed (Fig. 7-11).

Skin is closed with Steri-strips or glue.

Figure 7-8

Figure 7-9

Figure 7-10

Figure 7-11

[/level-membership-for-pediatrics-category][not-level-membership-for-pediatrics-category]

CHAPTER 7 Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula

Step 3: Operative Steps

Anesthetic Induction

♦ If the anesthesiologist attempts to place the endotracheal tube past the fistula, care must be taken to avoid a right mainstem intubation, which can cause problems when the right-sided chest is insufflated and the right lung is collapsed.

♦ There is usually no need for bronchial blockers or other techniques to perform single lung ventilation.

♦ The same issues of anesthetic induction for open repair of esophageal atresia with tracheoesophageal fistula apply for thoracoscopic repair.

Positioning

♦ The patient is placed in a nearly prone position.

♦ Position the patient for success! You will have a much greater chance of completing the operation thoracoscopically if the patient is positioned for a thoracoscopic procedure, not for conversion.

Port Positioning

♦ The ports are positioned to facilitate dissection and suturing (Fig. 7-1).

♦ The “baseball diamond” should be maintained.

♦ Be careful positioning the most cephalad port site so that the patient’s arm does not interfere with mobility.

Figure 7-1

Establishment of Pneumothorax

♦ The chest is accessed first through the planned camera port site with a Veres needle (Fig. 7-2)

♦ Initial insufflation is with 3 to 4 mm Hg of pressure using CO₂.

Figure 7-2

Buy Membership for Pediatrics Category to continue reading. Learn more here

[/not-level-membership-for-pediatrics-category]

Atlas of Pediatric Surgical Techniques A Volume in the Surgical