Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula

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CHAPTER 7 Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula

Mark L. Wulkan

Step 1: Surgical Anatomy

♦ The fistula usually lies in proximity to the azygos vein.
♦ A moderately stiff tube should be placed through the mouth into the upper pouch to facilitate identification.
♦ Placement in the semiprone position greatly facilitates the operation by allowing the lung to drop away from the operative field (the posterior mediastinum).

Step 2: Preoperative Considerations

♦ Consideration should be given to reserving the thoracoscopic technique for patients who weigh more than 2000 g and are clinically stable until you become comfortable with the technique.
♦ Fistula ligation alone can be undertaken thoracoscopically.

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.
image

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.
image

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.
image

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.
image

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).
image

Figure 7-5

image

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.
image

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.

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

image A chest tube is placed (Fig. 7-11).
image Skin is closed with Steri-strips or glue.

image

Figure 7-8

image

Figure 7-9

image

Figure 7-10

image

Figure 7-11

Step 4: Postoperative Care

♦ Postoperative care is the same as that after open procedures.
♦ Feeding is begun through the transanastomotic feeding tube on postoperative day 1.
♦ An esophagram is obtained between postoperative days 5 and 7.
♦ Transoral feeding is begun after a negative esophagram and the chest tube is removed.

Step 5: Pearls and Pitfalls

♦ Don’t be afraid to place the patient nearly prone: position the patient for success, not conversion.
♦ Secure the trocars at the skin site with a suture.
♦ Minimize tension at the anastomosis by adequate mobilization.

Bibliography

Holcomb GW, Rothenberg SS, Bak K, et al. Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula: a multi-institutional analysis. Ann Surg. 2005;242(3):422-428. discussion 428-430

Rothenberg SS. Thoracoscopic repair of esophageal atresia and tracheo-esophageal fistula. Semin Pediatr Surg. 2005;14(1):2-7.

van der Zee D, Bax NMA. Thoracoscopic repair of esophageal atresia with distal fistula. Surg Endosc. 2003;17(7):1065-1067.

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