Thoracoscopic Repair of Esophageal Atresia with Distal Tracheo-esophageal...

This video will demonstrate the repair of an esophageal atresia with distal tracheoesophageal fistula in the term male newborn. The patient is placed in the left lateral decubers position with the arm extended and restrained in a roll under the left axilla. Division of the azygous vein typically leads the surgeon to the fistula site. The vein is dissected by opening pleural windows with blunt dissection and cautery above and below its transverse segment. A good distance away from its last tributary. Here, the vein is divided with an energy device. However, it can also be simply coagulated, or double clipped and divided. Next, the fistula site is located and bluntly dissected. The magnification allows for excellent delineation of the trachea and esophagus. Once the fistula is well dissected, it is ligated with a suture ligature, flushed with a trachea, but not divided. This prevents the distal esophagus from retracting. The proximal esophageal stump is then dissected from the mediastinum, asking the anesthesiologist to push on the naso esophageal tube aids in the dissection. This dissection should be performed with great care, as the esophagus is often quite adherent to the trachea and may even share a common wall. A combination of sharp and blunt dissection is used. The dissection can be continued to the thoracic inlet, resulting in excellent mobilization of the proximal esophagus. The surgeon then returns to the site of the ligated fistula and divides the fistula a few millimeters distal to the ligature to liberate the distal esophagus. Following division, the fistula ligature should be tested with 25 to 30 centimeters water positive pressure ventilation. The blind end of the proximal esophagus is then divided to visualize the lumen. The back wall anastomosis is completed first, using interrupted 40 or 50 absorbable sutures. In this case, extracorporeal knot tying was used, as the two ends came together nicely with minimal tension. The process is continued, placing the sutures 2 to 3 millimeters apart. 5 to 6 sutures usually suffice to complete the posterior wall anastomosis. The nasoesophageal tube is advanced to protect the posterior wall prior to starting the anterior wall anastomosis. It is important to take full thickness bites of healthy esophageal wall and mucosa with each suture. Fewer sutures are usually required for the anterior wall anastomosis. The nasoesophageal tube is removed following completion of the anastomosis. In this case, a chest tube was placed. However, this is no longer routinely used.