Thoracoscopic Division of a Vascular Ring

Abstract

Introduction:

Minimally invasive techniques are increasingly being used to effectively treat patent ductus arteriosus and vascular rings. ¹ This video shows an effective thoracoscopic resection of a vascular ring in a patient with a right-sided aortic arch.

Methods:

Our patient is a 12-year-old boy who presented with a several month history of worsening dysphagia. He underwent a computed tomography (CT) of chest and echocardiogram that showed a right-sided aortic arch with an aberrant subclavian artery off a diverticulum of Kommerrell and a ligamentum arteriosum, creating a vascular ring. We were unable to tell from the CT scan whether the ligamentum arteriosum still had a patent vessel, so we treated it as though it were patent during our operative resection. Because of his symptoms, he was taken to the operating room for a thoracoscopic resection of this vascular ring. Before starting the procedure, proximal and distal pulse oximeters and blood pressure cuffs were placed on the upper and lower extremities. The procedure was performed with single lung ventilation through a right mainstem intubation. He was positioned with his left side up to 40°, and the procedure was performed using three ports: a 4-mm camera port just posterior to the tip of the scapula and 3- and 5-mm working ports anterior and posterior to the camera port. The procedure was started by opening up the pleura overlying the approximate location of the ligamentum arteriosum using a 3-mm bipolar vessel sealer. The ligamentum arteriosum was dissected out using blunt dissection and the bipolar energy device, being on the constant lookout for the vagus and the recurrent laryngeal nerves. After dissecting out the ligamentum arteriosum circumferentially, a test clamp was performed to ensure that there was no difference between the proximal and distal pulse oximeters and blood pressures. The ligamentum arteriosum was then resected using a 5-mm stapler. After division of the ligamentum arteriosum, the surrounding fibrous tissue was resected to ensure relief of the anatomic obstruction of the trachea and esophagus.

Results:

The patient tolerated the procedure well and was discharged home on postoperative day 1. He had complete resolution of his dysphagia on his 2-week follow-up.

Conclusion:

Thoracoscopy is a safe and effective alternative to performing a vascular ring division.

SR: Ownership in JustRight Surgical; SA: no competing financial interests exist.

Runtime of video: 3 mins 38 secs

Presented at IPEG, April 13, 2018, in Seattle, Washington.