VATS H-Type Fistula Repair - Technique

This video shows a thochoscopic repair of an H-type fistula in a 3-month-old infant. The infant, who had multiple medical issues, had recurrent aspiration in an upper GI which showed an H fistula. Here you see a bronchoscopy demonstrating that fistula. There were 2 attempts at endoluminal ablation. For this thoracoscopic approach, the patient was placed in a modified lateral decubitus position with the patient rolled prone. Of approximately 45 degrees, three ports were used, a 4 and 2 3s. 13 later advanced to a 5. Here you see the fistula again at rigid bronchoscopy at the beginning of the procedure. A 4 millimeter 30 degree lens was used for the procedure and was placed behind the tip of the scapula. The procedure is started up in the apex, and the 3 millimeter vessel sealer is used for dissection and to open the pleura up in the apex. Careful dissection is used to identify the esophagus and the trachea. Gradually, a plane is developed between the esophagus and the trachea below the level of the fistula. This is an important maneuver in helping safely separate the two before the very adherent area between the two structures is encountered. In this particular case, we did not put a catheter across the H-type fistula as we felt confident we would identify it, but occasionally this can be helpful. The section is continued inferiorly. And a small bridge of tissue which initially was thought to be the fistula but later was clearly just adherent connective tissue was divided. In this case, a 3 millimeter hook cautery was used to pull on the fibers and separate them around away from critical structures. With the area of the fistula encountered, dissection was carried out above the fistula so that a retro fistula plane could be developed. Using the 3 millimeter Maryland and later a 5 millimeter hook. An instrument was passed around behind the fistula. Taking care to not injure the esophagus or the membranous portion of the fistula. Where you can see. The right angle hook, right angle instrument being passed behind the fistula. The tips are visualized, and then a 20 silk is passed around the fistula to help with retraction. Previously, we have divided the fistula. And then oversewn the two ends. In this case, the child was large enough, and now with the availability of a 5 millimeter stapler, a decision was made to use this to divide the fistula. Care was taken to make sure that the recurrent laryngeal nerve and other important structures were not within the field of dissection. The lower The port, which was in the posterior axillary line was enlarged to a 5. And the 5 millimeter stapler was inserted. And the 20 silk was used to help retract the fistula to allow for insertion of the stapler. The silk was then removed and a single application of the 5 millimeter stapler was used. This divided the fistula, placing two rows of staples on either side. And there was no evidence of any. Incomplete division or other issues. A portion of apical fat was then taken and sewn down to cover the esophageal end of the staple line to help separate the two staple lines to try and prevent recurrent fiscralization. With this portion of the procedure completed. The pleura was closed. Over the Divided fistula in case there was a leak so that it would remain contained. Here you see the closed fora. The lung was re-expanded, and no chest tube was left. Here you see the patient 2 weeks postoperatively and the fistula at 3 months.