QUAD #10 Pt.2: Surgical Technique for Thoracoscopic Repair of Tracheoesophageal Fistula (TEF) with Dr. Steve Rothenberg

Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi, I'm M. Gody 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 hear from Dr. C. Rothenberg, a pioneer in pediatric surgery, and chief of pediatric surgery at the Rocky Mountain Hospital for Children. In our previous video, he told us the history of toroscopic repair of esophageal atresia and tracheoesophageal fistula. So, don't forget to check it out if you haven't seen it yet. And today, we'll hear from him on surgical technique for these toroscopic repairs. Let's start with anesthesia. Anesthesia and basically, you don't need single lung ventilation. We just use CO2 to collapse the lung. We will see some increase in N tidal CO2. All the babies will desaturate when you initially insufflate their chest and collapse their lung, but almost all of them recover. There are some little tricks you can use to do it. So it's actually quite feasible, even though it seems daunting. This is what a thoracoscopic TF repair looks like, as opposed to when you do an open TF repair, where for the surgeons in the room stand at the patient's back. I should be standing at the patient's front, that I could view in line directly at the fistula, so I could see it better and work in line with the camera and it was more ergonomic and I also had more space to work. And Dr. Rothenberg adds that in these cases, his assistant needed to be directly next to them working, holding the camera, working in line, looking at the monitor, and that is the key. I started out doing these in a left lateral decubitus position, but quickly learned that the lung would get in the way and so we modified this and put the patient more prone. So when he tilted the patient down about 60 degrees, it gets everything out of the way. In this position, they use gravity to retract the lung. And then, they do all these with three ports, so they have to have adequate access. And then I put the scope more posterior behind the tip of the scapula, so I'm actually looking down in the posterior medium. This is what the setup looks like. This was the initial trocar placements. We learned from Dr. Rothenberg that the steps of the surgical repair are the same. I tend to divide the aus just to get it out of the way, but a lot of people don't. I think it's fine either way. You ligate the fistula, mobilize the upper pouch, excise the tip of the pouch. Initially, when they did this, he would just make a slit in the upper pouch because he was worried about losing length and getting the two ends together. And I realized, I think we had a higher structure rate because of that. So now we completely amputate it except for in really long gaps. And then we use a single layer anastomosis of 4 or 50 PDS. You can also use Vryl or whatever you want. So, this is what it looks like today. That's the aus vein. Dr. Rothenberg divides the vein so that he doesn't inadvertently stick a needle in it later on when suturing. But he mentioned that if a surgeon would not like to divide it, they can leave it alone. And next, Dr. Rothenberg divides the fistula. I want you to see here is the visualization you get. This is so much better than when you do open surgery and you can see we can see right where the fistula is going into the to tra. This is actually a trifurcation fistula. And I showed this one because that means the gap is longer. Here, the fistula is coming in right at the bifurcation of the carina. I most of the time will just use a simple clip to ligate it. I can suture ligate it if they're under 2 kilos. And then, this is the key part, mobilizing the upper pouch. This is where you get all your length. And the view again is exceptional. According to Dr. Rothenberg, this is something you cannot see through an opentomy to this degree of the magnification in this well. I used to divide the fistula right away after I ligated it, but then I realized I was losing it. I'd have to go down and chase it. And now, he doesn't divide the fistula until he's ready to place the sutures. I mobilize the lower fistula as far as necessary, but I never breach the hiatus because all you do is create a giant hiatal hernia, which has its own set of issues. And then they do an end-to-end anastomosis. It is very important to have full thickness. The posterior row of the knots are intra luminal. And then we slide an OG tube down, put it across the gap, and then put in the front row to make sure that we don't close the lumen. I used to leave an OG tube in place, I now remove it, I don't leave them in anymore. And this is the hard part of this operation. Learning to suture in this tiny little space. You do this whole operation in a 2 square cm space. And so that's the skill set that you have to develop. This is an operation that is transferable with the right skill set and I think it makes a significant difference. Dr. Rothenberg states that he leaves a chest drain in selected cases, but almost never anymore. Unless he's really worried about the anastomosis or in a case of a really long gap where there's a lot of tension. I don't leave a transanastomotic tube anymore because it's been shown that there's a higher structure rate. I still get a contrast study on day four and then we feed them, and then we start the feeds after if everything's okay. And this is the cosmetic result. These kids have nearly no scars. They have no chest wall deformity and they have no scoliosis. So assuming that you can achieve the same results with thescopic approach is an open, I think that we owe it to our patients to do this. Here we see the results of the procedures that they performed at Rocky Mountain Hospital that Dr. Rothenberg's been involved with. We have a leak rate of about 3%. That's a significant leak rate, meaning that we did something altered our treatment, but none that we've had to reoperate on. They had just one recurrent fistula and about 16% stricture rate. And to me, if you have to dilate them one time, that's a structure. About 25% get fundations because of their reflux and relatively low ortopexy rate. And luckily, they had no mortality related directly to the TF repair. Although they have had patients who have died of comorbidities. And here, Dr. Rothenberg touches on recurrent TF repair. I had a number of recurrent TFs referred that we've had to go after and it can be done. They're tough operations and you have have to really understand the anatomy. Again. Here we can see how he's able to look at the esophagus and the trachea at a right angle directly across perpendicular. Perpendicular. So I can actually see the area much better and I'm able to dissect the trachea off the esophagus here and you can see that there's the recurrent fistula and then we sutured this and then took down a plural patch and put it between them. So it is possible to approach things this way. In conclusion, we review the innovative technique of toroscopic repair for tracheoesophageal fistula. This minimally invasive approach offers enhanced visualization, less postoperative complications, and improved cosmetic results. Key advancements include optimal patient positioning, precise surgical steps, and refined anastomosis methods, leading to significant improvements in patient outcomes. Thanks 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.