The next step is to identify the tracheoesophageal fistula, which can usually be found entering the membranous portion of the trachea superior to the carina (this area is usually delineated by the azygos vein ) (Fig. 13.2). Mobilization of the azygos vein with division may be accomplished by the following: hook electrocautery, bipolar sealing device, or 5-mm clips. The vein may be preserved if desired, with a suggestion that it might improve the vascularity of the area and decrease the esophageal anastomotic leak rate. The lower esophageal segment is identified and followed to its insertion point on the trachea. The fistula can be either suture ligated or ligated using endoclips. The vagus nerve should be identified to prevent injury. Identification of the upper segment is facilitated by asking the anesthesiologist to place gentle pressure on the naso-esophageal tube. The overlying pleura is then opened. Though not typically required, placement of a stay suture on the lowest aspect of the upper esophageal segment into the NGT may aid in retraction during dissection. Blunt/sharp dissection along the plane between the esophagus and trachea extending into the thoracic inlet completes the mobilization of the upper pouch. An opening and resection of the most distal upper pouch is made to create a wide anastomosis to prevent future stricture formation. The resulting opening may be dilated with the Maryland dissector to improve visualization of the mucosa. The NGT may be advanced to decompress the stomach after the anastomosis is established. The anastomosis is completed using 4-0 or 5-0 absorbable sutures on a small tapered needle in an interrupted manner. (A slipknot approach may be taken with initial approximation. With the second suture, the tension can be increased to gradually bring the ends together under shared tension.) Alternatively, a traction suture through the chest wall may be used to suspend the two ends of the esophagus to facilitate suturing. The back wall is completed first typically with four interrupted sutures and knots placed intraluminally (Fig. 13.3). Care should be taken to guarantee full-thickness bites that include the mucosa. The nasogastric tube can be used as a guide to suture the anterior wall and prevent inadvertent inclusion of the back wall in the anterior repair. The anterior wall is completed with an additional four interrupted sutures. Under magnification there may appear to be small tears. These tears are usually not clinically relevant but if there is concern, fibrin glue or a pleural patch may be used to bolster the anastomosis. The final step is placement of a chest tube via the lower of the three port sites to facilitate drainage postoperatively.