QUAD #2 Thoracoscopic Tracheopexy with Dr. Aaron Garrison

Hi, I'm M. Guorry from Cincinnati Children's Hospital Medical Center. And last year, in October 2022, Cincinnati Children's hosted the QUAD conference, which was a combination of four conferences. The International Organization for Esophageal Atresia, the Aero Digestive Society conference, the Cincinnati Children's Airway course, and the Cincinnati Children's pediatric dysphagia series. And today, we're going to review thoracoscopic tracheopexy and aortopexy for tracheomalacia with Dr. Aaron Garrison. Several years ago, our approach was that come with tracheomalacia would undergo aortopexy. However, in the last four to five years, it's becoming standard practice to determine which patients will respond best to the tracheopexy versus aortopexy. But first, let's hear why it's important to repair tracheomalacia. I think some of us who are ped surgery trained were told initially that tracheomalacia is something that kids will grow out of and will get better. And as data has shown recently that there's now long-term consequences for swelling into the lungs and having chronic lung lung aspiration and over time that really is detrimental. Knowing which kid will benefit from a tracheopexy or an aortopexy is a little more challenging. So how do we determine which procedure is best for each patient? Preoperative dynamic reconstruction studies gives us a lot of information. This is inspiratory and expiratory films from a patient we were evaluating for an aortopexy, and this is the same airway with expiration. You really see what you need to see with the dynamic studies. Part of the workup is making sure that there is space to anteriorly suspend the aorta so that you actually can make the trachea diameter larger. So we always look for the thymus and make sure that there is enough tissue to remove to be able to bring the trachea up anteriorly. Preoperative bronchoscopy gives the surgical team an idea of internal anatomy, which can assist in classifying the degree of tracheomalacia prior to surgical intervention. You can really see how the membranous trachea bulges posteriorly. Our classification system is in evolution and trying to describe what is mild or severe or moderate is a little bit challenging. Now that we determine which procedure that patient needs, let's talk about the advantages and disadvantages of a minimally invasive thoracoscopic approach as opposed to an open approach. The benefits of minimally invasive, to me, the biggest one is that visualization and exposure. Disadvantages takes longer to learn, it's more uncomfortable to learn, and your anesthesia colleagues sometimes are a little bit hesitant to allow cases to go on a little bit longer, especially the thoracoscopic cases. Historically, there were concerns that longer cases can lead to metabolic derangements causing the patients become more acidotic. Is that still the case? What exactly are the concerns of the anesthesia team? This is a paper out of anesthesiology that looked at open thoracoscopic and then converted patients and just looked at blood gases and metabolic derangements during the surgery and there's really no difference whenever they checked the gases. Same thing when they looked at blood pressures with acidosis and hypoxia. Next, positioning the patient. When using a thoracoscopic approach, correct positioning is the key to success. It's best to use gravity to your advantage as it aids in retracting the lungs and your trocar placement. If you're working in the anterior mediastinum, this is how we position the babies with the arm up and a bump underneath so that you have access to the axilla and anteriorly. Positioning is set and trocars are placed. The surgeon can begin the procedure. Here Dr. Garrison describes his approach to aortopexy. We're going to briefly touch on aortopexy. The goal is to spend the first step is taking out the thymus finding the aortanomic junction and then identifying the arch of the aorta, which is here. Next is opening the pericardium. And this is really the key point, finding the area at the pericardial adventitial junction to suspend. If you go up too high, then you're doing a pericardiopy and it isn't quite as successful or durable. Thing suture transsternally is preferred with this approach, though it can be technically difficult. And for tracheopexy, a posterior approach via semi- prone position is preferred. Here you need to create a pneumothorax by putting the varies off of the tip of the scapula, which helps collapse the lung for trocar placement. When operating here, triangulating your hands gives the best visualization and working space. The the goal of the posterior tracheopexy is taking that anterior spinal ligament and fixing it to the posterior membranous trachea. And that area of floppy membrane is distal to that dilated pouch usually. When available, a multi-disciplinary team, which includes a pulmonologist, can allow for internal visualization via bronchoscopy. This technique is primarily used in non esophageal atresia patients. We can make an indent on the posterior wall of the trachea and they can see it pop up on their bronchoscopy and help us guide them. This is a patient who we are talking about doing that tracheopexy at the time of EA repair and you can really see the trachea here just bulging with ventilation. That proximal pouch is hidden up there. The next step is to determine the best location to place sutures and where the esophagus will lie once the pexy is completed. And trying to figure out where is that esophagus going to go as you pexy the posterior wall of the trachea to that anterior spinal ligament. It usually takes about two or three sutures. Leaving enough space for that esophagus to come through. And then I do like using the knot pusher and a tension suture, I think it is helpful. It's important to create enough tension in the suture to ensure that pexy is secure. And this is a part that I think is honestly the the hardest getting that suture to roll through the anterior spinal ligament is actually pretty pretty challenging. And our approach changes if it's for a patient without esophageal atresia or an esophagus in continuity. This time the first step is to dissect around the esophagus. Using a vessel loop for retraction is a helpful technique. And there are times where we've put the esophagus to the left of the trachea and there are times where we put the esophagus to the right of the trachea. I always worry a little bit about dysphagia, but honestly it's not something that I've I've seen a ton of. Using pre and post-operative bronchoscopy allows the surgeon to see the improvement prior to case completion. You can see how much intrusion on the posterior trachea there is at the beginning of the case and then afterwards at different levels, it looks much better. In summary, both aortopexy and tracheopexy are beneficial to patients suffering from tracheomalacia. It's important to obtain pre-operative dynamic studies to determine which procedure is best suited for each patient. In this video, we briefly reviewed both procedures through a minimally invasive thoracoscopic approach and are excited to see future data regarding best practices for determining who can benefit from these procedures and standardization of the approach. Thank you for watching this video. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Global Cast MD, along with Cincinnati Children's Hospital. Sharing knowledge to improve child health around the globe.