THORACOSCOPIC AORTOPEXY FOR SEVERE TRACHEOMALACIA

We present an 8 month old male who was born of pure esophageal atresia who has never been able to wean from oxygen. He suffered from a respiratory coat event requiring intubation at about 8 months of age. Bronchoscopy at that time showed near complete airway collapse. Therefore, aortopexy was indicated. A 5 millimeter port was placed in the anterior axillary line about the level of the nipple, and 23 millimeter ports were placed above and below this. The pleura overlying the thymus was divided, and the left lobe of the thymus was bluntly dissected from the surrounding tissues. This blunt dissection continued circumferentially all the while maintaining visualization and protection of the phrenic nerve. After the left lobe of the thymus was completely free, it was removed from the chest. The aortic arch and pericardium were then bluntly freed from the surrounding tissues. Here you can see excellent visualization of the pericardium and aortic arch. A 22 gauge needle was then passed through the sternum. To help gauge where these suture needles should be passed through the sternum into the chest, then a 30 braided ethylene suture on a V5 needle was passed through the sternum into the chest. More length of the suture was brought into the chest as well. The pericardium and aorta were lifted, demonstrating upward movement of the mediastinal structures. The first suture was placed through the adventitia of the superior aspect of the arch of the aorta. Pulling up on the suture shows that it was an adequate bite of the adventitia, allowing for elevation of the mediastinal structures. Next came the arduous task of feeding the needle back up through the sternum. This turned out to be very difficult and took multiple attempts to get the needle in the right direction up through the sternum. Finally, the tip of the needle was able to be grasped, and the suture was pulled out of the chest through the sternum. Pulling up on the suture demonstrated elevation of the mediastinal structures. The next suture was passed in through the sternum, more easily this time. This suture then encompassed the adventitia of the proximal ascending aorta. As bringing the needle back up through the sternum provided to be very difficult, another method was attempted. An 18 gauge needle with a monofilament suture fed as a loop through the needle was in place through the sternum. The blue monofilament suture then acted as a lasso to grab the green aortic suture and bring that back up through the sternum. Again this demonstrates the mediastinum being elevated when pulling up on the suture. The next suture was again passed through the sternum and was placed through the superior aspect of the pericardium. The 18 gauge needle and blue monofilament suture were then again used to lasso the greenerydopexy suture. Here you can now see all three erodopexy sutures in place. A flexible bronchoscopy was then performed, and copious thick secretions were then encountered in the trachea. These were suctioned, and the bronchoscopy was then performed again. There still remains some movement to the airway at this point. Even after the aerotopexy sutures were tied down completely postoperatively, he did very well and was extubated the next day. Over the next week, his oxygen was completely weaned off. A bronchoscopy the next week demonstrated no residual airway collapse. He remains off all oxygen and essentially symptom free in follow up.