Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula

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

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Jun 18, 2016 | Posted by in PEDIATRICS | Comments Off on Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula

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