The first view upon entering the thoracic cavity consists of the thymus, heart, and the great vessels. It is important to identify the left phrenic nerve prior to dissection of the pleura (Fig. 8.2a). The nerve can be identified by its posterior course along the pericardium. Next, the left lobe of the thymus overlies the pericardium. The left lobe of the thymus is mobilized and pushed toward the right side of the chest to expose the pericardium (Fig. 8.2b). It is safe to hold the thymus up toward the sternum to allow traction for hook cautery or a 3-mm sealing device to divide the attachments off the pericardium. This will ensure that the dissection will not injure the underlying pericardium or its contents. Once the thymus is mobilized, the pericardium is opened using laparoscopic scissors starting from the aortic root and extending cephalad (Fig. 8.2c). Again, care must be taken to preserve the phrenic nerve.

Once the pericardium is adequately opened to reveal the aorta, aortopexy sutures can now be placed. The goal is to approximate the anterior wall of the aorta to the posterior surface of the sternum (Fig. 8.2d). We use a permanent 3-0 polypropylene suture instead of a braided suture to avoid sawing of the aortic wall when elevating the aorta off the trachea; however, vicryl sutures are also used. There are several important points to consider before placement of sutures. The first stitch can inadvertently be placed too close to the aortic valve and coronary arteries. It is also important to ensure that the aorta is not twisted along its long axis [2]. Since the patient is on a 15-degree right tilt, we ensure the sutures on the aorta are at the most anterior portion. Lastly, all sutures are placed through the tunica media of the aorta (partial thickness); sutures through the lumen of the aorta may cause bleeding. A partially straightened needle is passed through a stab incision in the skin. This needle is then grasped with a standard laparoscopic needle holder. The first stitch is placed distal to the takeoff of the aortic root. The needle is then passed back through the sternum without tying. Securing the aorta to the parasternal tissue has been described but we need to consider the proximity of the left internal mammary vessels as they can be easily injured. A total of 3–8 stitches may be needed to provide adequate traction. We use intraoperative rigid bronchoscopy to guide the number of stitches. The pericardium can also be incorporated into each stitch to act as a pledget [15]. Once the appropriate number of sutures are placed, they are concurrently given traction to approximate the aortic wall to the sternum. A bronchoscope is then inserted to ensure the tracheomalacia is relieved (Fig. 8.3). The sutures are then tied down subcutaneously and ensuring that no aortic twisting has taken place. At the end of the procedure, pneumothorax is evacuated under direct visualization to ensure the left lung inflates adequately. Unless there is an unacceptable amount of bleeding, we do not recommend the routine use of a chest tube. Incisions are closed with 5-0 sutures or simply sealed with surgical glue [17].