Esophageal atresia without tracheoesophageal fistula: thoracoscopic repair

This is the case of a 3-month-old girl presenting with a type I esophageal atresia without tracheoesophageal fistula. A wide gap is separating the two esophageal pouches. The girl was fed by a gastrostomy until now. The surgical procedure is begun with the closure and the freeing of the gastrostomy.

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Esophageal atresia without tracheoesophageal fistula: thoracoscopic repair

Authors

Abstract

This is the case of a 3-month-old girl presenting with a type I esophageal atresia without tracheoesophageal fistula. A wide gap is separating the two esophageal pouches. The girl was fed by a gastrostomy until now. The surgical procedure is begun with the closure and the freeing of the gastrostomy.

Mots-clés

Esophageal atresia, thoracoscopic repair, tracheoesophageal fistula

Type de vidéo

Vidéo chirurgicale

Durée

03'40''

Publication

2011-11

Popularité

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E-publication

WeBSurg.com, Nov 2011;11(11).
URL: http://www.websurg.com/doi-vd01en3481.htm

Esophageal atresia without tracheoesophageal fistula: thoracoscopic repair

1. Clinical case 00'07''

This is the case of a 3-month-old girl presenting with a type I esophageal atresia without tracheoesophageal fistula. A wide gap is separating the two esophageal pouches. The girl was fed by a gastrostomy until now. The surgical procedure is initiated with the closure and the freeing of the gastrostomy.

2. Patient and trocar position 00'33''

The child is then placed in a left lateral decubitus position for a right thoracoscopy. Three ports have been placed, one under the axilla, the second one (optical port) under the tip of the scapula, and the third one in a triangulation on the mid-axillary line. A 2mm needle introduced under the axilla helps to retract the lung. The tip of the proximal esophageal pouch is at the level of the azygos vein. The preaortic lymphatic cistern of Pecquet is identified at the level of the hiatal orifice.

3. Lower esophageal pouch dissection 01'09''

Once the vagus nerve has been followed cranially to caudally, the lower esophageal pouch is reached. It will be easily mobilized without any electrocautery, only using dissection by means of the scissors’ tip.

4. Gastric mobilization 01'24''

Here, the hiatal orifice is visible and the stomach is pulled up. It will get back to its normal position into the abdomen at the end of the procedure. Once the gastric mobilization has been completed, the lower esophageal pouch is stabilized using a transparietal stitch.

5. Posterior mediastinal opening 01'48''

The posterior mediastinal pleura is opened and the proximal esophageal pouch will be freed from the azygos arch, which is left untouched.

6. Proximal pouch opening 01'59''

The opening of the proximal pouch is performed first on the muscular layer, then on the mucosal layer. The opening is carried out in a perfectly distal fashion. A first Vicryl 5/0 stitch is knotted. It is then passed taking care to largely grasp the mucosa of the proximal pouch as well as all planes of the distal pouch whose mucosa will be opened only after the first stitch has been placed. This strategy will prevent any tear of the lower esophageal pouch.

7. Anastomosis 02'47''

As soon as the mucosa of the lower esophageal pouch has been opened, a crown of posterior stitches is made once knotted endoluminally and intracorporeally. An 8 French trans-anastomotic probe is entered under thoracoscopic control. It is then pushed until reaching the stomach. A series of anterior stitches allows to complete the anastomosis. In the present case, the tension between the 2 esophageal fragments is acceptable. At the end of the procedure, the good position of the stomach into the abdomen is controlled.

8. Application of biological glue 04'13''

The eso-esophageal anastomosis is protected by the application of biological glue. The thoracic drain is withdrawn 24 hours postoperatively and oral feeding is started on the 3rd postoperative day. The first operative step during a type I esophageal atresia without tracheoesophageal fistula includes the total freeing of the gastrostomy and an explorative thoracoscopy that made it possible to re-approximate the 2 esophageal fragments in this patient. If this re-approximation had not been possible, it would have been necessary to adopt a more complex procedure with an abdominal approach. The child’s parents should be informed of the different steps of the operative strategy prior to surgery.