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QUAD #10 Pt.2: Surgical Technique for Thoracoscopic Repair of Tracheoesophageal Fistula (TEF) with Dr. Steve Rothenberg
With Dr. Steven Rothenberg · hosted by Dr. Em Gootee
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Single lung ventilation is not required for thoracoscopic TEF repair; CO2 insufflation is used to collapse the lung.
All babies will desaturate when initially insufflating the chest and collapsing the lung, but almost all recover.
Patient positioning was modified from left lateral decubitus to 60-degree prone tilt because the lung would get in the way in lateral position.
Initially making only a slit in the upper pouch (rather than complete amputation) resulted in a higher stricture rate.
The upper pouch is now completely amputated except in cases of really long gaps.
A single layer anastomosis of 4-0 or 5-0 PDS is used (Vicryl or other sutures are also acceptable).
Thoracoscopic visualization of the fistula entering the trachea is much better than with open surgery.
A simple clip is used most of the time to ligate the fistula; suture ligation is used if the patient is under 2 kilograms.
The degree of magnification and visualization during upper pouch mobilization cannot be achieved through a thoracotomy to this degree.
The fistula is no longer divided immediately after ligation; it is kept intact until ready to place sutures to avoid losing it and having to chase it down.
The lower fistula is mobilized as far as necessary, but the hiatus is never breached because doing so creates a giant hiatal hernia with its own set of issues.
The entire thoracoscopic TEF repair operation is performed in a 2 square centimeter space.
A chest drain is left in selected cases but almost never anymore, unless there is concern about the anastomosis or in cases of really long gaps with significant tension.
Transanastomotic tubes are no longer left in place because they have been shown to result in a higher stricture rate.
A contrast study is obtained on day four postoperatively, and feeds are started if everything is okay.
Thoracoscopic TEF repair results in nearly no scars, no chest wall deformity, and no scoliosis.
There has been no mortality directly related to TEF repair at Rocky Mountain Hospital, though some patients have died of comorbidities.
Recurrent TEF can be repaired thoracoscopically, though these are tough operations requiring thorough understanding of the anatomy.
For thoracoscopic TEF repair, the surgeon should stand at the patient's front to view in line directly at the fistula for better visualization and ergonomics.
Three ports are used for thoracoscopic TEF repair with the scope placed more posterior behind the tip of the scapula to look down into the posterior mediastinum.
The azygos vein is divided to avoid inadvertently sticking a needle in it during suturing, though it can be left alone if preferred.
Mobilizing the upper pouch is the key part of the operation where all the length is gained.
Full thickness bites are very important for the anastomosis, with posterior row knots placed intraluminally.
An OG tube is slid down across the gap during the anterior row to ensure the lumen is not closed, but is now removed rather than left in place.
At Rocky Mountain Hospital, the leak rate for thoracoscopic TEF repair is about 3%, representing significant leaks that altered treatment but none requiring reoperation.
There has been just one recurrent fistula in the Rocky Mountain Hospital series.
The stricture rate is about 16%, defined as requiring dilation even one time.
About 25% of patients undergo fundoplication because of reflux, with a relatively low aortopexy rate.
For recurrent TEF repair, perpendicular visualization allows better viewing of the area, enabling dissection of the trachea off the esophagus, suturing of the recurrent fistula, and placement of a pleural patch between them.