Utilization of a Transsternal Spinal Needle for Retrograde Suture Passage During Thoracoscopic Aortopexy

Abstract

Introduction:

Tracheomalacia is known to be associated with esophageal atresia (EA) and requires treatment if life-threatening. We describe a novel technique of thoracoscopic aortopexy.

Case presentation:

A 55-day-old male infant with a history of EA and tracheoesophageal fistula repair with subsequent severe gastroesophageal reflux presented after a life-threatening apneic event associated with feeding. Work-up revealed severe tracheomalacia. The patient underwent thoracoscopic aortopexy with a four-segment fixation of the ascending aorta and the base of the innominate artery. One 3.5-mm and two 5-mm trocars were placed. After partial thymectomy and exposure of the ascending aorta and innominate artery, a 2- 0 prolene suture on an RB-1 needle was passed through the vessels' adventitia. The needle was then cut off and a 20-gauge spinal needle was inserted at an angle through the sternum via a 2-mm stab wound. A single suture tail was passed retrograde through the spinal needle. The spinal needle was then removed and reinserted at a different angle through the same stab wound, and the second suture tail was passed retrograde. This procedure was repeated for the three other sutures, which were then tied under direct thoracoscopic visualization of the great vessels with concomitant bronchoscopic visualization of the trachea. After completion of the aortopexy, a laparoscopic Nissen fundoplication was performed.

Results:

The patient was discharged home 9 days later. Follow-up revealed appropriate growth and no feeding or respiratory difficulties.

Conclusion:

A transsternal spinal needle allows easy retrograde passage of sutures through the sternum and the use of conventional curved needles for the great vessels. Coupled with precise suture placement through a bridge of sternal bone, this technique provides excellent anterior fixation.