QUAD #2 Thoracoscopic Tracheopexy with Dr. Aaron Garrison

Hi, I'm Em Goddy from Cincinnati Children's Hospital Medical Center, and last year in October 2022, Cincinnati Children's hosted the Quad conference, which was a combination of four conferences. The International Organization for Esophageal atresia, the Aerodigestive Society conference, the Cincinnati Children's Airway Course, and the Cincinnati Children's Pediatric Dysphagia Series. And today we're going to review thochoscopic turchyopexy, an orthopexy for Turcheomalacysia with Doctor Erin Garrison. Several years ago, our approach was that comers with tracheomalacia would undergo orthopexy. However, in the last 4 to 5 years, it's becoming standard practice to determine which patients will respond best to the tracheopexy versus orthopexy. But first, let's hear why it's important to repair tracheomalacia. I think some of us who are peat surgery trained were told initially that tracheomalacia is something that kids will grow out of and will get better and as data has shown recently that there's no long term consequences for soiling into the lungs and having chronic lung lung aspiration and over time that really is detrimental. Knowing which kid will benefit from a tracheopexy or an orthopexy is a little more challenging. So how do we determine which procedure is best for each patient? Preoperative dynamic reconstruction studies gives us a lot of information. This is inspiratory and expiratory films from a patient we were evaluating for an aortopexy, and this is the same airway with expiration. You really see what you need to see with the dynamic studies. Part of the workup is making sure that there is space. The anteriorly suspend the aorta so that you actually can make the trachea diameter larger. So we always look for the thymus and make sure that there is enough tissue to remove to be able to bring the trachea up anteriorly. Preoperative bronchoscopy gives the surgical team an idea of internal anatomy, which can assist in classifying the degree of tracheomalacia prior to surgical intervention. You can really see how the member. His trachea bulges posteriorly. Our classification system is in evolution, and trying to describe what is mild or severe or moderate is a little bit challenging. Now that we determined which procedure that patient needs, let's talk about the advantages and disadvantages of a minimally invasive turchoscopic approach as opposed to an open approach. The benefits of minimally invasive to me, the biggest one is that visualization and exposure. Disadvantages, it takes longer to learn. It's more uncomfortable to learn, and your anesthesia colleagues sometimes are a little bit, uh, hesitant to allow cases to go on a little bit longer, especially the throscopic cases. Historically there were concerns that longer cases can lead to metabolic derangements, causing the patients become more acidotic. Is that still the case? What exactly are the concerns of the anesthesia team? This is a paper out of anesthesiology that looked at open thoracoscopic and then converted patients and just looked at blood gasses and metabolic derangements during the surgery, and there's really no difference whenever they checked the gasses. Same thing when they looked at blood pressure with acidosis and hypoxia. Next, positioning the patient. When using a tchoscopic approach, correct positioning is the key to success. It's best to use gravity to your advantage as it aids in retracting the lungs and your truck replacement. If you're working in the anterior mediastinum, this is how we position the babies with the arm up and a bump underneath so that you have access to the axilla and anteriorly. Positioning is set and trochcards are placed, the surgeon can begin the procedure. Here. Doctor Garrison describes his approach to aortopexy. We're gonna briefly touch on aortopexy. The goal is to spin the aorta. Our first step is taking out the thymus, finding the aortanomic junction, and then identifying the arch of the aorta, which is here. Next is opening the pericardium, and this is really the key point, finding the area at the pericardial adventitial junction to suspend. If you go up too high, then you're doing a pericardioexy and it isn't quite as successful or durable. Passing suture transternally is preferred with this approach, though it can be technically difficult. And for trachiopexy, a posterior approach via semiprone position is preferred. Here, you need to create a pneumothorax by putting the virus off of the tip of the scapula, which helps collapse the lung for trochar placement. When operating here, triangulating your hands gives the best visualization and working space. The, the goal of the posterior tracheopexy is taking that anterior spinal ligament and fixing it to the posterior membranous trachea, and that area of floppy membrane is distal to that dilated pouch usually. When available, a multidisciplinary team which includes a pulmonologist can allow for internal visualization via bronchoscopy. This technique is primarily used in non-esophageal atresia patients. We can make an indent on the posterior wall of the trachea, and they can see it pop up on their bronchoscopy and help us. This is a patient who we are talking about doing that tracheopexy at the time of EA repair, and you can really see the trachea here just bulging with ventilation. That proximal pouches hidden up there. The next step is to determine the best location to place sutures and where the esophagus will lie once the PEXI is completed. And trying to figure out where is that esophagus going to go as you Py the posterior wall of the trachea to that anterior spinal ligament. It usually takes about 2 or 3 sutures, leaving enough space for that esophagus to come through. And I do like using the knot pusher in the tension suture. I think is helpful. It's important to create enough tension in the suture to ensure that Pi is secure. And this is the part that I think is honestly the, the hardest. Getting that suture to roll through the anterior spinal ligament is actually pretty, pretty challenging. And our approach changes if it's for a patient without oesophageal atresia or an esophagus in continuity. This time, the first step is to dissect around the esophagus using a vessel loop for retraction is a helpful technique. And there are times where we've put the esophagus to the left of the trachea, and there are times where we put the esophagus to the right of the trachea. I always worry a little bit about dysphagia, but honestly, it's not something that I've, I've seen a ton of. Using pre and post-operative bronchoscopy allows the surgeon to see the improvement prior to case completion. You can see how much intrusion on the posterior trachea there is at the beginning of the case and then afterwards at different levels, it looks much better. In summary, both aortopexy and tracheopexy are beneficial to patients suffering from tracheomalacia. It's important to obtain preoperative dynamic studies to determine which procedure is best suited for each patient. In this video, we've briefly reviewed both procedures through a minimally invasive teroscopic approach and are excited to see future data regarding best practices for determining who can benefit from these procedures and standardization of the approach. Thank you for watching this video. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Globalcast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.