RIGHT THORACOSCOPIC REPAIR OF AN H-TYPE TRACHEOESOPHAGEAL FISTULA

Thank you for giving us the opportunity to present our video. This video will discuss a right thoracoscopic repair of an H-type tracheoesophageal fistula. Our patient is a 3 month old female with severe combined immunodeficiency and suspected CHARGE syndrome who presented with difficulty swallowing and possible aspiration. She underwent a swallow study that showed evidence of aspiration as well as reflux. A bronchoscopy was then performed that showed an H-type TEF in the lower neck. H-type TEFs are very rare and represent about 4% of all TEFs, just like in our patients, they're usually diagnosed later in infancy when the patient presents with difficulty swallowing, aspiration, and recurrent pneumonias. After the diagnosis of the TEF, she was taken to the OR for a right thoracoscopic repair of her H-type TEF. The patient was placed in the left lateral decubitus position, and the procedure was performed using 3 ports, a camera port behind the tip of the scapula at approximately the 4th intercostal space, a working port directly below the camera port, and another one anterior to it at the mid-axillary line. Upon entering the chest, we first identified the ziggu vein and the trachea. The parietal pleura at the groove of the esophagus and the trachea then opened up using a combination of blunt dissection and a bipolar energy device. The right vagus nerve can be seen here. We continue carefully dissecting between the groove of the esophagus and trachea, working towards the approximate location of the fistula. We have now identified the tracheoesophageal fistula. We now work to mobilize the TE fistula posteriorly, continuing to use our bipolar energy device as well as a right angle clamp. We continue to work posteriorly as well as superiorly trying to mobilize the TE fistula using blunt dissection. Once we have come circumferentially around the fistula, we use a 5 millimeter stapler to transect it. There was still some residual tissue left which we were able to transect by again using a 5 millimeter stapler and then scissors. A pleural flap was then placed between the staple lines to help avoid a recurrent fistula. The parietal pleura was then sutured closed over the esophagus and the trachea. The patient tolerated the procedure well. She had a swallow study on post-op day 2 that was negative for a leak, and she was started on feeds. Advantages to a thoracoscopic H-type TEF repair are direct and magnified visualization between the esophagus and the trachea. It allows us to see the vagus nerve and avoid injury to the recurrent laryngeal nerve, and it also avoids a neck incision. Thank you and I'll be happy to take any questions.