THORACOSCOPIC DIVISION OF A VASCULAR RING

Thank you for giving us the opportunity to present our video. This video will discuss a thoracoscopic division of a vascular ring in a patient with a right-sided aortic arch. Our patient is a twelve-year-old male who presented with a several month history of worsening dysphagia. He underwent a CT chest and an echocardiogram that showed a right-sided aortic arch with an aberrant subclavian artery off a diverticulum of commoral and a ligamentum arteriosum. It was unclear from the CT scan if there is still a patent vessel here or not, so it was treated as though it were patent. This drawing shows the patient's approximate anatomy and the location of the ligament. Arteriosum can be seen here. Because of his symptoms, he was taken to the OR for a thoracoscopic resection of his vascular ring. Prior to starting the procedure, a proximal and distal pulse oximeter were placed on the hand and on the foot, and the patient also had a proximal and distal blood pressure cuff. The procedure was performed with single lung ventilation through a right main stem intubation. He was positioned with the left side up to 40 degrees, and the procedure is performed with three ports, a 4 millimeter camera port just posterior to the tip of the scapula, and 3 and 5 millimeter working ports anterior and posterior to the camera port. The procedure was first started by opening the pleura overlying the ligamentum arteriosum using a 3 millimeter vessel sealer. The ligamentum arteriosum was mobilized using blunt dissection and the bipolar energy device being on the constant lookout for the recurrent laryngeal nerve. We continue our careful dissection towards the ligamentum arteriosum using blunt dissection and the bipolar vessel sealer. We have now identified the ligamentum arteriosum, and the vagus and the recurrent laryngeal nerve can be seen here in relation to it. We now attempt to get around the ligamentum arteriosum first by using our bipolar energy device in Maryland before switching to our right angle clamp. We were able to get around the ligamentum arteriosum with a right angle clamped bluntly with the assistance of our hook dissector. After dissecting out the ligamentum arteriosum prior to dividing it, a test clamp was performed, and this was to ensure that there was no change in the blood pressure or pulse oximeter in the proximal and distal locations. After performing the test clamp over the ligamentum arteriosum, a 20 silk suture is placed around it, and this is to assist with stapling it off. The ligamentum arteriosum is then divided using a 5 millimeter stapler. After the division of the ligamentum arteriosum, the surrounding fibrous tissue was then resected to ensure the relief of the anatomic obstruction of the trachea and esophagus. We used a combination of our bipolar energy device as well as scissors to get through this fibrous tissue. The vagus and the recurrent laryngeal nerve can again be seen here. We complete our dissection and the lung is reinflated and we decided to not leave a chest tube. The patient tolerated the procedure well and was discharged home on post-op day one. On two-week follow-up, the patient was completely asymptomatic without any further episodes of dysphagia. Thank you and I'll be happy to take any questions.