Neonatal Open Repair of Esophageal Atresia & Tracheo-esophageal Fistula EA_TEF. Dr Tamer Ashraf

Hello and welcome. This video shows open repair of oesophageal atresia with distal tracheoesophageal fistula in a 3 day old baby. The approach is through a right trachotomy. The extrathoracic muscles that will be encountered are the serratus anterior muscle anteriorly and the latissimus dorsi muscle posteriorly. A curvy linear incision is centered 1 centimeter below the tip of the scapula. The first muscle to come in view is the latissimus dorsi muscle which is lifted up and incised by diathermy. This reveals the scapula and the serratus anterior muscle attached to it. The serratus anterior is elevated and dissected from the chest wall to allow its retraction. Now the rip spaces are counted, and the force space is chosen for axis. The intercostal muscles are gently divided layer by layer with care not to injure the underlying pleura. Then the pleura is gently separated off the chest wall using a moist peanut. The dissection is advanced posteriorly toward the posterior mediastinum until the arch of the azyous vein is cleared off. That brings the mediastinal structures in view with the trachea anteriorly, the proximal retic esophagus just behind it at a variable level, and the distal esophagus connected to its back by a fistula, most commonly at the level of the arch of the azygus. Dissection starts around the distal esophagus just below the arch of the azygu, that is here now divided. The esophagus is identified by the vagal nerve branches running on its surface and by its distention with inspiration. A vessel loop is passed around it to facilitate further dissection and to minimize traumatic grasping. Dissection is advanced upwards till the junction with the trachea. Then the fistula is transfixed and ligated using a 40 absorbable suture, then divided. Identification of the proximal pouch is facilitated by moving the NG tube. Anate suture is placed at its lowermost part to help in traction during dissection. Careful dissection between the trachea and the esophagus is done with sharp and blunt dissection with great care not to injure the trachea. Here a thick connection is present between the trachea and the proximal esophagus and therefore ligated for fear of the presence of a proximal fistula. Mobilization is advanced as high as possible, toward the thoracic inlet and into the neck. A stay suture is placed in the lower esophagus to facilitate its handling. Now the gap is successfully minimized in order to lower the tension on the anastomosis. The proximal pouch is cut open horizontally at its most dependent part. The first few sutures are placed in the posterior wall from inside the lumen, using 50 absorbable sutures on a rounded tip needle. The distal esophagus is split anteriorly to help making a wider anastomosis. After a few stitches, an 8 French nasogastric tube is passed through the anastomosis all the way down into the stomach. Now the rest of the sutures are placed from the outside over the tube. The anastomosis is now completed and this was the contrast study on the 5th postoperative day. An intercostal tube is inserted and tucked to the chest wall away from the anastomosis. Ribs are approximated with pericostal absorpal sutures. Then the latissimus dorsi muscle is sutured using 40 continuous absorbable sutures. The subcutaneous tissue is approximated with inverted sutures, and finally, the skin is closed with subcuticular sutures. Thank you for watching.