First Report of Robot-Assisted Thoracoscopic Posterior Tracheopexy to Treat Severe Tracheomalacia

Abstract

Introduction:

We have had increasing success with posterior tracheopexy to address posterior tracheomalacia directly through open and video-assisted thoracoscopic approach. We reported the first use of the robot-assisted thoracoscopic approach for posterior tracheopexy in a 3-minute video.

Materials and Methods:

A 5-year-old boy (25 kg) began at 6 months of age with recurrent episodes of spasmodic croup, requiring steroids, inhalers, and racemic epinephrine. He continued to have intermittent nocturnal events with barking coughs and respiratory distress, including multiple blue spells. Preoperative assessment with rigid dynamic bronchoscopy confirmed posterior intrusion type tracheomalacia affecting his middle and lower trachea as well as the carina, especially with coughing. In the operating room, after achievement of general anesthesia with single-lung ventilation, the patient was positioned in semiprone left lateral decubitus. A 4-mm trocar was inserted posterior and cephalad to the scapular tip for the thoracoscope, and later replaced with an 8.5-mm robotic camera port. Then, two 8-mm working robotic ports were inserted under thoracoscopic guidance. The right-hand robotic port was inserted into the third intercostal space along the anterior axillary line and the left-hand robotic port in the seventh intercostal space posterior to the scapula. A 5-mm port was placed anterior and caudad to the working ports and used for lung retraction. After retracting the lung and opening the overlying pleura, we divided the azygos vein between ligatures, resecting a small segment to use as autologous pledget material. The esophagus was dissected from the trachea and pushed to the left of the posterior mediastinum to accommodate the space required for the posterior tracheopexy. The anterior spinal ligament was then cleared, and the fatty tissue including lymph nodes and thoracic duct was pushed toward the left chest. The posterior tracheobronchopexy was performed from the thoracic inlet to the carina by placing five pledgeted (azygos) horizontal mattress sutures through the longitudinal midline portion of the posterior tracheal membrane and suturing them to the anterior longitudinal spinal ligament. Flexible bronchoscopic observation was used continuously throughout this process to confirm that sutures were not placed intraluminally and that the lumen was optimally opened without distortion. A chest tube was placed through one of the thoracoscopic ports on completion of the procedure.

Results:

The patient recovered uneventfully and was discharged from the hospital on the 5th postoperative day. He presented a noticeable improvement in respiratory symptoms; nonetheless, our bronchoscopic evaluation 3 months after the surgery demonstrated that anterior airway support was still required to prevent symptomatic dynamic anterior airway collapse. Therefore, the patient underwent subsequent anterior aortopexy and tracheopexy through ministernotomy to achieve optimal airway patency.

Conclusions:

The robot-assisted approach for thoracoscopic posterior tracheopexy is safe and feasible in selected patients with severe tracheomalacia. When compared with video-assisted thoracoscopic approach, we feel that the robotic platform allows for more facile suturing with the degree of required precision. Moreover, the robotic system allows for picture-in-picture bronchoscopic guidance, such that the view from the bronchoscope is available to the surgeon on the console in real time.

No competing financial interests exist.

Runtime of video: 3 mins

Previously presented at IPEG 2018 in Seattle, Washington.