QUAD #10 Pt.3: Advantages of Thoracoscopic Repair of Esophageal Atresia with Dr. Steve Rothenberg

Open surgery for TEF creates some of the tracheomalacia that patients develop because surgeons crank on the trachea during dissection.

Residual esophageal pouches after open fistula ligation are more common than recognized, occurring when the fistula is ligated below the proper level.

Thoracoscopic repair allows elevation of the esophagus and direct visualization of where the fistula enters the membranous portion of the trachea.

Thoracoscopic dissection of residual esophageal pouches can be performed using a stapler.

According to Dr. Rothenberg, the key to achieving anastomosis in long-gap cases is gaining length through extensive upper pouch mobilization.

Thoracoscopic technique allows dissection all the way up to the posterior oropharynx under direct vision.

At Rocky Mountain Hospital for Children, they have never been unable to achieve primary repair of a type C fistula.

The staged repair technique involves gastrostomy tube placement, allowing growth for 3-8 weeks with bolus feeds to toughen up the lower pouch, obtaining a gap study, then performing thoracoscopic repair.

Extensive upper pouch mobilization can bring down a pouch that initially was at the thoracic inlet, allowing anastomosis in the lower third of the chest even with a six vertebral body gap.

Operative time for long-gap repairs ranges from 50 minutes to a little over 2 hours.

Documented anastomotic leaks after thoracoscopic repair were all treated successfully with conservative therapy.

All H-type fistulas are located in the same place, at the thoracic inlet.

Thoracoscopic approach to H-type fistulas allows direct visualization of the vagus and recurrent laryngeal nerves, potentially avoiding injury better than neck dissection.

Thoracoscopic approach avoids cranking on the trachea and retracting it out of the way, allowing dissection under direct vision.

A stapler can be used to divide H-type fistulas thoracoscopically, with tissue interposition placed between the divided ends.